Apr-06

FROM THE JOURNAL OF THE AMERICAN GERIATRICS SOCIETY

Skilled Care Requirements for Elderly Patients After Coronary Artery Bypass Grafting
Brahmajee K. Nallamothu, MD, MPH, Mary A. M. Rogers, PhD, MS, Sanjay Saint, MD, MPH, Laurence J. McMahon, Jr., MD, MPH, Brant E. Fries, PhD, Samuel R. Kaufman, MSc and Kenneth M. Langa, MD, PhD

Objectives: To examine the extent to which elderly individuals use various skilled care facilities after coronary artery bypass grafting (CABG).

Design: Retrospective cohort study.

Setting: State of Michigan from 1997 to 1998.

Participants: Residents aged 65 and older enrolled in Medicare who underwent CABG.

Measurements: Cumulative incidence of admission within 100 days of hospital discharge, relative risk (RR) of admission, readmission or extended stay at a skilled care facility, and length of stay in a skilled care facility.

Results: Fifty percent of patients aged 80 and older used a skilled care facility after CABG, with most requiring admission to a skilled nursing facility (SNF) or readmission to an acute-care hospital within 100 days after discharge. Patients aged 80 and older had a significantly higher risk of admission to a SNF (adjusted RR=3.3, 95% confidence interval (CI)=2.8–4.0) than did those aged 65 to 69, as did patients aged 75 to 79 (adjusted RR=2.2, 95% CI=1.8–2.6) and those aged 70 to 74 (adjusted RR=1.5, 95% CI=1.3–1.8). The length of time spent in skilled care facilities significantly increased with age (mean days=13.3 for aged 65–69, 16.9 for 70–74, 19.6 for 75–79, and 22.9 for 80 and older; P<.001).

Conclusion: Older patients are more likely to be admitted to a SNF, be readmitted to an acute-care hospital, and have longer institutional stays after CABG. When balancing the risks and benefits of CABG, physicians, patients, families, and policy-makers need to carefully consider the likelihood of follow-up institutional care in elderly patients. J Am Geriatr Soc 2005;53(7):1133-1137.
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End-of-Life Care in Black and White: Race Matters for Medical Care of Dying Patients and their Families
Lisa C. Welch, PhD, Joan M. Teno, MD, MS, and Vincent Mor, PhD

Objectives: To compare the end-of-life medical care experienced by African-American and white decedents and their families.

Design: Cross-sectional, retrospective survey with weighted results based on a two-stage probability sampling design.

Setting: Hospitals, nursing homes, and home-based medical services across the United States.

Participants: Surrogates (N=1,447; primarily family members) for decedents from 22 states.

Measurements: Validated end-of-life care outcomes concerning symptom management, decision-making, informing and supporting families, individualized care, coordination, service utilization, and financial impact.

Results: Family members of African-American decedents were less likely than those of white decedents to rate the care received as excellent or very good (odds ratio (OR)=0.4). They were more likely to report absent (OR=2.4) or problematic (OR=1.9) physician communication, concerns with being informed (OR=2.5), and concerns with family support (OR=2.6). Family members of African Americans were less likely than those of whites to report that the decedent had treatment wishes (OR=0.3) or written advance care planning documents (OR=0.4). These differences persist when limiting the sample to respondents whose expectations for life-sustaining treatments matched treatments received. Family members of African-American decedents also were more likely to report financial hardship due to savings depletion (OR=2.1) or difficulty paying for care (OR=2.0) and that family/friends (OR=2.0) or home health workers (OR=1.9) provided home care.

Conclusion: This national study brings evidence that racial disparities persist into end-of-life care, particularly regarding communication and family needs. Results also suggest different home care patterns and levels of financial impact. J Am Geriatr Soc 2005;53(7):1145-1153.
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Relationship Between Patient Age and Duration of Physician Visit in Ambulatory Setting: Does One Size Fit All?
Agnes Lo, BSP, PharmD, Kathryn Ryder, MD, MS and Ronald I. Shorr, MD, MS

Objectives: To determine whether patient age, the presence of comorbid illness, and the number of prescribed medications influence the duration of a physician visit in an ambulatory care setting.

Design: A cross-sectional study of ambulatory care visits made by adults aged 45 and older to primary care physicians.

Setting: A probability sample of outpatient follow-up visits in the United States using the National Ambulatory Medical Care Survey (NAMCS) 2002 database.

Participants: Of 28,738 physician visits in the 2002 NAMCS data set, there were 3,819 visits by adults aged 45 and older included in this study for analysis.

Measurements: The primary endpoint was the time that a physician spent with a patient at each visit. Covariates included for analyses were patient characteristics, physician characteristics, visit characteristics, and source of payment. Visit characteristics, including the number of diagnoses and the number of prescribed medications, the major diagnoses, and the therapeutic class of prescribed medications, were compared for different age groups (45–64, 65–74, and ≥75) to determine the complexity of the patient’s medical conditions. Endpoint estimates were computed by age group and were also estimated based on study covariates using univariate and multivariate linear regression.

Results: The mean time±standard deviation spent with a physician was 17.9±8.5 minutes. There were no differences in the duration of visits between the age groups before or after adjustment for patient covariates. Patients aged 75 and older had more comorbid illness and were prescribed more medications than patients aged 45 to 64 and 65 to 74 (P<.001). Patients aged 75 and older were also prescribed more medications that require specific monitoring and counseling (warfarin, digoxin, angiotensin-converting enzyme inhibitors, diuretics, and levothyroxine) than were patients in other age groups (P<.001). Hypertension, coronary artery disease, atrial fibrillation, congestive heart failure, cerebrovascular disease, and transient ischemic attack were more common in patients aged 75 and older than in other age groups (P<.001). Despite these differences, there were no differences in unadjusted or adjusted duration of physician visit between the age groups.

Conclusion: Although patients aged 75 and older had more medical conditions and were at higher risk for drug-related problems than younger patients, the duration of physician visits was similar across the age groups. These findings suggest that elderly patients may require a multidisciplinary approach to optimize patient care in the ambulatory setting. J Am Geriatr Soc 2005;53(7):1162-1167.
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Functional Incidental Training: A Randomized, Controlled, Crossover Trial in Veterans Affairs Nursing Homes
Joseph G. Ouslander, MD, Patricia C. Griffiths, PhD, Eleanor McConnell, PhD, APRN, BC, Lisa Riolo, PhD, PT, Michael Kutner, PhD and John Schnelle, PhD

Objectives: To test the effects of a rehabilitative intervention directed at continence, mobility, endurance, and strength (Functional Incidental Training (FIT) in older patients in Department of Veterans Affairs (VA) nursing homes.

Design: Randomized, controlled, crossover trial.

Setting: Four VA nursing homes. Participants: All 528 patients in the nursing homes were screened; 178 were eligible, and 107 were randomized to an immediate intervention group (Group 1; n=52) and a delayed intervention group (Group 2; n=55).

Intervention: Trained research staff provided the FIT intervention, which included prompted voiding combined with individualized, functionally oriented endurance and strength-training exercises offered four times per day, 5 days per week, for 8 weeks. Group 1 received the intervention while Group 2 served as a control group; then Group 2 received the intervention while Group 1 crossed over to no intervention. A total of 64 subjects completed the intervention phase of the trial.

Measurements: Timed measures of walking or wheeling a wheelchair (mobility), sit-to-stand exercises, independence in locomotion and toileting as assessed using the Functional Independence Measure (FIM), one-repetition maximum weight for several measures of upper and lower body strength, frequency of urine and stool incontinence, and appropriate toileting ratios.

Results: There was a significant effect of the FIT intervention on virtually all measures of endurance, strength, and urinary incontinence but not on the FIM for locomotion or toileting. The effects of FIT were observed when Group 1 received the intervention and was compared with the control group and when Group 2 crossed over to the intervention. Group 1 deteriorated in all measures during the 8-week crossover period. Within-person comparisons also demonstrated significant effects on all measures in the 64 participants who completed the intervention; 43 (67%) of these participants were “responders” based on maintenance or improvement in at least one measure of endurance, strength, and urinary incontinence. No adverse events related to FIT occurred during the study period.

Conclusion: FIT improves endurance, strength, and urinary incontinence in older patients residing in VA nursing homes. Translating these positive benefits achieved under research conditions into practice will be challenging because of the implications of the intervention for staff workload and thereby the costs of care. J Am Geriatr Soc 2005;53(7):1091-1100.
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Reduction in Fear of Falling Through Intense Tai Chi Exercise Training in Older, Transitionally Frail Adults
Richard W. Sattin, MD, Kirk A. Easley, MS, Steven L. Wolf, PhD, FAPTA, Ying Chen, MS, and Michael H. Kutner, PhD

Objectives: To determine whether an intense tai chi exercise program could reduce fear of falling better than a wellness education (WE) program in older adults who had fallen previously and meet criteria for transitioning to frailty.

Design: Cluster-randomized, controlled trial of 48 weeks’ duration.

Setting: Ten matched pairs of congregate living facilities in the greater Atlanta area. Participants: Sample of 291 women and 20 men, aged 70 to 97.

Measurements: Activity-related fear of falling using the Activities-Specific Balance Confidence Scale (ABC) and the Fall Efficacy Scale at baseline and every 4 months for 1 year. Demographics, time to first fall and all subsequent falls, functional measures, Centers for Epidemiologic Studies Depression Scale, medication use, level of physical activity, comorbidities, and adherence to interventions.

Results: Mean ABC was similar in both cohort groups at the time of randomization but became significantly higher (decreased fear) in the tai chi cohort at 8 months (57.9 vs 49.0, P<.001) and at study end (59.2 vs 47.9, P<.001). After adjusting for covariates, the mean ABC after 12 months of intervention was significantly greater in the tai chi group than in the WE group, with the differences increasing with time (mean difference at 12 months=9.5 points, 95% confidence interval=4.8–14.2, P<.001).

Conclusion: Tai chi led to a significantly greater reduction in fear of falling than a WE program in transitionally frail older adults. The mean percentage change in ABC scores widened between tai chi and WE participants over the trial period. Tai chi should be considered in any program designed to reduce falling and fear of falling in transitionally frail older adults. J Am Geriatr Soc 2005;53(7):1168-1178.
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Effect of Blood Pressure and Diabetes Mellitus on Cognitive and Physical Functions in Older Adults: A Longitudinal Analysis of the Advanced Cognitive Training for Independent and Vital Elderly Cohort
Hsu-Ko Kuo, MD, MPH, Richard N. Jones, ScD, William P. Milberg, PhD, Sharon Tennstedt, PhD, Laura Talbot, PhD, EdD, RN, John N. Morris, PhD, and Lewis A. Lipsitz, MD

Objectives: To evaluate the effect of blood pressure (BP) and diabetes mellitus (DM) on cognitive and physical performance in older, independent-living adults.

Design: Longitudinal study with secondary data analysis from the Advanced Cognitive Training for Independent and Vital Elderly randomized intervention trial.

Setting: Six field sites in the United States.

Participants: Two thousand eight hundred two independent-living subjects aged 65 to 94.

Measurements: Cognitive functions in different domains and physical functions measured using activities of daily living, instrumental activities of daily living (IADLs), and the physical function subscale from the Medical Outcomes Study Short Form-36 (SF-36) Health Survey.

Results: After the first annual examination, hypertension was associated with a faster decline in performance on logical reasoning tasks (ability to solve problems following a serial pattern), whereas DM was associated with accelerated decline on the Digit Symbol Substitution Test (speed of processing). The reasoning and Digit Symbol Substitution test are executive function tasks thought to be related to frontal-lobe function. Hypertension and DM were associated with a significantly faster pace of decline on the SF-36 physical function component score. Individuals with DM had a faster pace of decline in IADL functioning than nondiabetic subjects. There was no evidence for an interaction between BP and DM on cognitive or physical function decline.

Conclusion: Hypertension and DM are associated with accelerated decline in executive measures and physical function in independent-living elderly subjects. Further research is needed to determine whether cardiovascular risk modification ameliorates cognitive and functional decline in elderly people. J Am Geriatr Soc 2005;53(7):1154-1161.