Highlights from the Journal of the American Geriatrics Society

Predictors of Adherence to the Use of Hip Protectors in Nursing Home Residents Andrea Warnke, PhD, Gabriele Meyer, Ralf Bender, PhD, and Ingrid Mühlhauser, MD. Objectives: To assess predictors of hip-protector use in nursing home residents under usual-care conditions and after intervention consisting of structured education of nurses and nursing home residents and provision of free hip protectors. Design: Nested cohort analyses within a cluster randomized, controlled trial with 18 months follow-up. Setting: Forty-nine nursing home clusters in Hamburg, Germany. Participants: Residents with at least one fall during the study period (intervention group, n=237; usual-care group, n=274). Measurements: Use of hip protector while falling. Regression analyses were performed for each of the two cohorts of fallers using the time to the first fall without hip protector as the dependent variable. Predefined nursing home cluster-related parameters (center, staffing ratio, proportion of registered nurses in nursing staff, hip-protector use before study period) and resident-related parameters (sex, history of falls and fractures, fear of falling, urinary incontinence, use of walking aid, degree of disablement) were considered as explanatory variables. Results: Under usual care, 97% of fallers (n=266), compared with 62% (n=148) in the intervention group, experienced at least one fall without hip protection. Using Cox proportional hazards models with and without frailty parameter (random cluster effect), the following predictors were identified: intervention group: use of walking aid, hazard ratio (HR)=1.53 (95% confidence interval (CI):0.98-2.39) and no urinary incontinence, HR= 1.47 (95% CI:1.03-2.09); usual care: nursing staff per 10 residents, HR= 0.78 (95% CI=0.63-0.96); high degree of disablement, HR=1.38 (95% CI= 1.06-1.80); strong fear of falling, HR=0.78 (95% CI=0.60-1.02). The nursing home cluster was a significant predictor in the control group (P=.029), but not in the intervention group (P=.100). Conclusion: Only a few and weak predictors of hip-protector use of questionable relevance could be identified in both groups. Future research should concentrate on the implementation of interventions of proven efficacy, such as provision of hip protectors combined with structured education of staff and residents. J Am Geriatr Soc 2004;52(3): 340-345. Effect of State Medicaid Reimbursement Rates on Hospitalizations from Nursing Homes Orna Intrator, PhD, and Vincent Mor, PhD Objectives: To estimate the effect of state Medicaid nursing home reimbursement rates on hospitalizations of nursing home residents. Design: Cross-sectional sample of nongovernment-owned nursing homes with 25 beds or more in one Metropolitan Statistical Area in each of 10 states in 1993, with 6 months follow-up on mortality and hospitalizations. Setting: Two hundred fifty-three nursing homes. Participants: Eight to 16 randomly selected residents from each facility, totaling 2,080. Measurements: Minimum Data Set assessments conducted by research nurses at baseline. A three-category 6-month outcome was defined as (1) any hospitalization; for those not hospitalized, (2) death versus (3) alive in the facility. Results: Using multinomial logistic regression, adjusted to survey design, controlling for resident and facility characteristics, a $10 increase in 1993 Medicaid reimbursement rate above the mean rate of approximately $75 resulted in a 9% reduction in a resident’s risk of hospitalization (P<.05). Conclusion: State Medicaid reimbursement rates appear to affect clinical decisions regarding the need for hospital admission and thresholds for nursing home use. The findings from this study reemphasize the importance of properly aligning state Medicaid and federal Medicare long-term care policies because, currently, states have no incentive to increase reimbursement rates to avoid hospitalization. J Am Geriatr Soc 2004;52(3):393-398. The National Pressure Ulcer Long-Term Care Study: Pressure Ulcer Development in Long-Term Care Residents Susan D. Horn, PhD, Stacy A. Bender, MS, RD, Maree L. Ferguson, PhD, RD, Randall J. Smout, MS, Nancy Bergstrom, RN, PhD, George Taler, MD, Abby S. Cook, BS, RD, Siobhan S. Sharkey, MBA, Anne Coble Voss, PhD, RD Objectives: To identify resident, treatment, and facility characteristics associated with pressure ulcer (PU) development in long-term care residents. Design: Retrospective cohort study with convenience sampling. Setting Ninety-five long-term care facilities participating in the National Pressure Ulcer Long-Term Care Study throughout the United States. Participants: A total of 1,524 residents aged 18 and older, with length of stay of 14 days or longer, who did not have an existing PU but were at risk of developing a PU, as defined by a Braden Scale for Predicting Pressure Sore Risk score of 17 or less, on study entry. Measurements: Data collected for each resident over a 12-week period included resident characteristics (eg, demographics, medical history, severity of illness using the Comprehensive Severity Index, Braden Scale scores, nutritional factors), treatment characteristics (nutritional interventions, pressure management strategies, incontinence treatments, medications), staffing ratios and other facility characteristics, and outcome (PU development during study period). Data were obtained from medical records, Minimum Data Set, and other written records (e.g., physician orders, medication logs). Results: Seventy-one percent of subjects (n=1,081) did not develop a PU during the 12-week study period; the remaining 29% of residents (n=443) developed a new PU. Resident, treatment, and facility characteristics associated with greater likelihood of developing a Stage I to IV PU included higher initial severity of illness, history of recent PU, significant weight loss, oral eating problems, use of catheters, and use of positioning devices. Characteristics associated with decreased likelihood of developing a Stage I to IV PU included new resident, nutritional intervention (e.g., use of oral medical nutritional supplements and tube feeding for >21 days), antidepressant use, use of disposable briefs for more than 14 days, registered nurse hours of 0.25 hours per resident per day or more, nurses’ aide hours of 2 hours per resident per day or more, and licensed practical nurse turnover rate of less than 25%. When Stage I PUs were excluded from the analyses, the same variables were significant, with the addition of fluid orders associated with decreased likelihood of developing a PU. Conclusion:A broad range of factors, including nutritional interventions, fluid orders, medications, and staffing patterns, are associated with prevention of PUs in long-term care residents. Research-based PU prevention protocols need to be developed that include these factors and target interventions for reducing risk factors. J Am Geriatr Soc 2004;52(3):359-367. Mechanisms of Unexplained Anemia in the Nursing Home Andrew S. Artz, MD, Dean Fergusson, MHA, PhD, Paul J. Drinka, MD, Melvin Gerald, MD, Rex Bidenbender, MD, Anthony Lechich, MD, Felix Silverstone, MD, Mark A. Mccamish, MD, PhD, Jinlu Dai, MD, PhD, Evan Keller, DVM, PhD, and William B. Ershler, MD Objectives: To characterize anemia in elderly nursing home residents. Design: Prospective multiinstitutional cohort study. Setting: Five nursing homes. Participants: From retrospective analysis, residents found to be anemic using chart review were prospectively randomized. Of the 81 residents enrolled, 60 were anemic. Measurements: Chart review for medical history and factors related to treatment or history of anemia, extensive laboratory evaluation for causes of anemia, and classification of anemia by two hematologists. Results: Among the 60 anemic residents, the causes of anemia were idiopathic (n=27), iron-deficiency (n=14), anemia associated with chronic disease (n=8), anemia of renal insufficiency (n=6), and other (n=5). The eryrthropoietin (EPO) response to anemia was lower in residents with idiopathic anemia (IA) than in those with iron-deficiency anemia, and this correlated with renal function as estimated using calculated creatinine clearance. In this elderly population, advancing age was not correlated with lower EPO response. Conclusion: IA is common in nursing home residents. A lower EPO response contributes to the high prevalence of anemia in this setting and may be due, in part, to occult renal dysfunction. J Am Geriatr Soc 2004;52(3):423-427. Alcohol Intake and Risk of Dementia Jose A. Luchsinger, MD, Ming-Xin Tang, PhD, Maliha Siddiqui, MPH, Steven Shea, MD, and Richard Mayeux, MD Objectives: To examine the association between intake of alcoholic beverages and risk of Alzheimer’s disease (AD) and dementia associated with stroke (DAS) in a cohort of elderly persons from New York City. Design: Cohort study. Setting: The Washington Heights Inwood–Columbia Aging Project. Participants: Nine hundred eighty community-dwelling individuals aged 65 and older without dementia at baseline and with data on alcohol intake recruited between 1991 and 1996 and followed annually. Measurements: Intake of alcohol was measured using a semiquantitative food frequency questionnaire at baseline. Subjects were followed annually, and incident dementia was diagnosed using Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria and classified as AD or DAS. Results: After 4 years of follow-up, 260 individuals developed dementia (199 AD, 61 DAS). After adjusting for age, sex, apolipoprotein E (APOE)-[epsiv]4 status, education, and other alcoholic beverages, only intake of up to three daily servings of wine was associated with a lower risk of AD (hazard ratio=0.55, 95% confidence interval=0.34–0.89). Intake of liquor, beer, and total alcohol was not associated with a lower risk of AD. Stratified analyses by the APOE-[epsiv]4 allele revealed that the association between wine consumption and lower risk of AD was confined to individuals without the APOE-[epsiv]4 allele. Conclusion:Consumption of up to three servings of wine daily is associated with a lower risk of AD in elderly individuals without the APOEe-4 allele. J Am Geriatr Soc 2004(4):540-546. Association Between Functional Status and Use and Effectiveness of Beta-Blocker Prophylaxis in Elderly Survivors of Acute Myocardial Infarction Gail Vitagliano, MD, Jeptha P. Curtis, MD, John Concato, MD, MPH, Alvan R. Feinstein, MD, Martha J. Radford, MD, and Harlan M. Krumholz, MD Objectives: To examine whether physical and cognitive impairments explain low use of beta-blockers in elderly patients and whether functionally impaired older adults have improved survival if a beta-blocker is prescribed at hospital discharge. Design: Cross-sectional and retrospective cohort study. Setting: Acute care hospitals in the United States. Participants: National cohort of 45,370 elderly acute myocardial infarction survivors, with no chart-documented contraindications to beta-blocker treatment. Measurements: The main outcome measures were beta-blocker prescription at hospital discharge and 1-year survival. Results: Fifty percent (n=22,683) of eligible patients were prescribed a beta-blocker at discharge. Older age and functional impairments (incontinence, mobility impairment, and cognitive impairment) were independently associated with decreased use of beta-blockers. The odds ratios for prescribing a beta-blocker at hospital discharge were 0.82 (95% confidence interval (CI)=0.77–0.86), 0.63 (95% CI=0.56–0.71), and 0.40 (95% CI=0.32–0.51) for persons with one, two, and three impairments, respectively, compared with those with no impairments. In survival analysis, patients prescribed a beta-blocker were 21% less likely than nonrecipients to die within 1 year of follow-up (relative risk=0.79, P=.0001). Similar survival benefit was observed in patients with and without functional impairments. Conclusion: This study shows a strong association between functional impairment and the use of beta-blockers after acute myocardial infarction in elderly patients. The results suggest that increasing use of beta-blockers in this group provides an opportunity to improve outcomes. J Am Geriatr Soc 2004;52(4): 495-501.