From the Journal of the American Geriatrics Society

A Randomized Trial of a Multicomponent Home Intervention to Reduce Functional Difficulties in Older Adults Laura N. Gitlin, PhD, Laraine Winter, PhD, Marie P. Dennis, PhD, EdM, Mary Corcoran, PhD, OTR/L, Sandy Schinfeld, MPH, and Walter W. Hauck, PhD OBJECTIVES: To test the efficacy of a multicomponent intervention to reduce functional difficulties, fear of falling, and home hazards and enhance self-efficacy and adaptive coping in older adults with chronic conditions. DESIGN: A prospective, two-group, randomized trial. Participants were randomized to a treatment group or no-treatment group. SETTING: Urban community-living older people. PARTICIPANTS: Three hundred nineteen community-living adults aged 70 and older who reported difficulty with one or more activities of daily living. INTERVENTION: Occupational and physical therapy sessions involving home modifications and training in their use; instruction in strategies of problem-solving, energy conservation, safe performance, and fall recovery techniques; and balance and muscle strength training. MEASUREMENTS: Outcome measures included self-rated functional difficulties with ambulation, instrumental activities of daily living, activities of daily living, fear of falling, confidence performing daily tasks, and use of adaptive strategies. Observations of home hazards were also conducted. RESULTS: At 6 months, intervention participants had less difficulty than controls with instrumental activities of daily living (P=.04, 95% confidence interval (CI)=−0.28–0.00) and activities of daily living (P=.03, 95% CI=−0.24 to −0.01), with largest reductions in bathing (P=.02, 95% CI=−0.52 to −0.06) and toileting (P=.049, 95% CI=−0.35–0.00). They also had greater self-efficacy (P=.03, 95% CI=0.02–0.27), less fear of falling (P=.001, 95% CI=0.26–0.96), fewer home hazards (P=.05, 95% CI=−3.06–0.00), and greater use of adaptive strategies (P=.009, 95% CI=0.03–0.22). Benefits were sustained at 12 months for most outcomes. CONCLUSION: A multicomponent intervention targeting modifiable environmental and behavioral factors results in life quality improvements in community-dwelling older people who had functional difficulties, with most benefits retained over a year. J Am Geriatr Soc 2006;54(5):809-816. Risk Factors and Prediction of Postoperative Delirium in Elderly Hip-Surgery Patients: Implementation and Validation of a Medical Risk Factor Model Kees J. Kalisvaart, MD, PhD, Ralph Vreeswijk, RN, MSc, Jos F. M. de Jonghe, PhD, Tjeerd van der Ploeg, MMath, Willem A. van Gool, MD, PhD, and Piet Eikelenboom, MD, PhD OBJECTIVES: To evaluate risk factors for postoperative delirium in a cohort of elderly hip-surgery patients and to validate a medical risk stratification model. DESIGN: Prospective cohort study. SETTING: Medical school–affiliated general hospital in Alkmaar, the Netherlands. PARTICIPANTS: Six hundred three hip-surgery patients aged 70 and older screened for risk factors for postoperative delirium. MEASUREMENTS: Predefined risk factors for delirium were assessed on admission. One point was assigned for each of four risk factors present, resulting in three groups: low, intermediate, and high risk. Baseline screening and assessment included the Mini-Mental State Examination, the standardized Snellen test for visual impairment, chart review to determine Acute Physiological and Chronic Health Evaluation II score, and blood urea nitrogen to creatinine ratio. The primary outcome was postoperative delirium, as defined using Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, and Confusion Assessment Method criteria. All patients were screened daily for delirium. RESULTS: Incidence of delirium was 3.8% in the low-risk group (P<.001 in="" the="" intermediate-risk="" group="">P=.27, relative risk (RR)=3.0), and 37.1% in the high-risk group (P<.001 rr="9.8)." cognitive="" impairment="" at="" admission="" had="" the="" highest="" predictive="" value="" for="" postoperative="" delirium="" of="" determination="0.15)." contrary="" to="" previous="" findings="" age="" was="" an="" independent="" factor="" delirium.="" moreover="" four="" times="" as="" frequent="" in="" acute="" patients="" elective="" hip-replacement="" patients.="">CONCLUSION: The medical risk factor model is valid for elderly hip-surgery patients. Cognitive impairment, age, and type of admission are important risk factors for delirium in this surgical population. J Am Geriatr Soc 2006;54(5):817-822. Escherichia Coli O157: H7 Infection in Nursing Homes: Review of Literature and Report of Recent Outbreak SanGary Reiss, MD, Pamela Kunz, MD, Diana Koin, MD, and Emmet B. Keeffe, MD Escherichia coli O157:H7 is a well-described cause of hemorrhagic colitis in isolated cases and outbreaks. The postdiarrhea complications of this infection (thrombotic thrombocytopenic purpura and hemolytic uremic syndrome) have historically been linked to illness in children aged 5 to 10, but in an elderly, institutionalized population, E. coli O157:H7 is associated with high morbidity and mortality. This geriatric population is at high risk for developing gastrointestinal infections for a number of reasons, including age- and medication-related achlorhydria, antibiotic usage, and comorbid medical conditions. The combination of age-related risk factors with those associated with group living makes nursing facilities a high-risk environment for outbreaks of infectious diseases. E. coli O157:H7 may be more likely to cause disease outbreaks in this population because of the low inoculum required for clinical infection. Moreover, the prevalence of potential competing diagnoses, such as lower gastrointestinal bleeding from neoplastic or diverticular disease, complicates the diagnosis. Clinical presentation and laboratory studies are unpredictable and pose diagnostic challenges. This report reviews the literature on nursing home outbreaks of E. coli O157:H7 and presents an outbreak that occurred in an assisted living community in San Mateo County, California, in October 2003. The purpose of this literature review and report of an outbreak is to heighten awareness of the unique susceptibility of elderly, institutionalized patients for E. coli O157:H7 infection and its sequelae. J Am Geriatr Soc 2006;54(4):680-684. Are Patient Preferences for Life-Sustaining Treatment Really a Barrier to Hospice Enrollment for Older Adults with Serious Illness? David Casarett, MD, MA, Peter H. Van Ness, PhD, MPH, John R. O'Leary, MA, and Terri R. Fried, MD OBJECTIVES: To determine whether patient preferences are a barrier to hospice enrollment. DESIGN: Prospective cohort study. SETTING: Fifteen ambulatory primary care and specialty clinics and three general medicine inpatient units. PARTICIPANTS: Two hundred three seriously ill patients with cancer (n=65, 32%), congestive heart failure (n=77, 38%), and chronic obstructive pulmonary disease (n=61, 30%) completed multiple interviews over a period of up to 24 months. MEASUREMENTS: Preferences for high- and low-burden life-sustaining treatment and site of death and concern about being kept alive by machines. RESULTS: Patients were more likely to enroll in hospice after interviews at which they said that they did not want low-burden treatment (3 patients enrolled/16 interviews at which patients did not want low-burden treatment vs 47 patients enrolled/841 interviews at which patients wanted low-burden treatment; relative risk (RR)=3.36, 95% confidence interval (CI)=1.17–9.66), as were interviews at which patients said they would not want high-burden treatment (5/28 vs 45/826; RR=3.28, 95% CI=1.14–7.62), although most patients whose preferences were consistent with hospice did not enroll before the next interview. In multivariable Cox regression models, patients with noncancer diagnoses who desired low-burden treatment (hazard ratio (HR)=0.46, 95% CI=0.33–0.68) were less likely to enroll in hospice, and those who were concerned that they would be kept alive by machines were more likely to enroll (HR=5.46, 95% CI=1.86–15.88), although in patients with cancer, neither preferences nor concerns about receiving excessive treatment were associated with hospice enrollment. Preference for site of death was not associated with hospice enrollment. CONCLUSION: Overall, few patients had treatment preferences that would make them eligible for hospice, although even in patients whose preferences were consistent with hospice, few enrolled. Efforts to improve end-of-life care should offer alternatives to hospice that do not require patients to give up life-sustaining treatment, as well as interventions to improve communication about patients' preferences. J Am Geriatr Soc 2006;54(3):472-478. Pain in Severe Dementia: Self-Assessment or Observational Scales? Sophie Pautex, MD, Agnès Michon, MD, Monia Guedira, MD, Héloise Emond, MD, Paulette Le Lous, RN, Dimitrios Samaras, MD, Jean-Pierre Michel, MD, François Herrmann, MD, MPH, Panteleimon Giannakopoulos, MD, and Gabriel Gold, MD OBJECTIVES: To assess the performance of self-assessment scales in severely demented hospitalized patients and to compare it with observational data. DESIGN: Prospective clinical study. SETTING: Geriatrics hospital and a geriatric psychiatry service. PARTICIPANTS: All patients who met Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria for dementia, with a Mini-Mental State Examination score less than 11 and a Clinical Dementia Rating score of 3. MEASUREMENTS: Three self-assessment tools—the verbal, horizontal visual, and faces pain scales—were administered in randomized order. A nursing team independently completed an observational pain rating scale. Main outcomes were comprehension (ability to explain scale use and correctly indicate positions for no pain and extreme pain, on two separate occasions), inter- and intrarater reliability, and comparison of pain intensities measured by the different scales. RESULTS: Sixty-one percent of 129 severely demented patients (mean age 83.7, 69% women) demonstrated comprehension of at least one scale. Comprehension rates were significantly better for the verbal and the faces pain scales. For patients who demonstrated good comprehension, the inter- and intrarater reliability of the three self-assessment scales was high (intraclass correlation coefficient=0.88–0.98). Correlation between the three self-assessment scales was moderate to strong (Spearman correlation coefficient (r)=0.45–0.94; P<.001 observational="" rating="" correlated="" at="" least="" moderately="" with="" self-assessment="">r=0.25–0.63), although for patients reporting pain, the observational rating scale underestimated severity compared with all three self-assessment scales. CONCLUSION:M Clinicians should not apply observational scales routinely in severely demented patients, because many are capable of reliably reporting their own pain. J Am Geriatr Soc 2006; 54(7):1040-1045.