PREDICTORS OF NURSING FACILITY ADMISSION: A 12-Year Epidemiological Study in the United States

Ashok J. Bharucha, MD, Rajesh Pandav, MBBS, MPH, Changyu Shen, BS, Hiroko H. Dodge, PhD, and Mary Ganguli, MD, MPH

Objectives: To identify predictors of institutionalization in a community-based cohort of older adults.

Design: Prospective, longitudinal. After initial assessment at study entry, surviving participants were reassessed in a series of approximately biennial waves until October 2001; baseline for the current analysis was Wave 2 (1989–91).

Setting: Largely rural, blue-collar community in the mid-Monongahela Valley of southwestern Pennsylvania.

Participants: A population-based cohort of 1,147 adults, aged 66 and older (mean 74.1) at baseline, who were not already institutionalized and who had complete data on all variables of interest.

Measurements: Cox proportional hazards models were used to identify predictors of institutionalization from among selected variables measured at baseline, including age, sex, education, marital status, living arrangements, ability to perform instrumental activities of daily living (IADLs), depressive symptoms, number of prescription medications (as an index of overall morbidity), self-reported social support, hospitalization during the preceding year, and cognitive functioning. Dementia was defined according to the operational criteria of the Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised, and by a Clinical Dementia Rating of 0.5 or greater, based on a standardized clinical assessment. The outcome variable was institutionalization, defined as entry into in a nursing home.

Results: Significant predictors of institutionalization were dementia (hazard ratio (HR)=5.09, 95% confidence interval (CI)=2.92–8.84), measured as a time-dependent variable; older age (HR=1.06, 95% CI= 1.03–1.10); IADL disability (HR=1.31, 95% CI=1.15–1.50); worse/less social support (HR=1.27, 95% CI=1.10–1.46); and number of prescription medications (HR=1.21, 95% CI=1.11–1.32), measured at baseline. The interaction between number of prescription drugs and dementia was also significant, suggesting that prescription medication count had less effect on institutionalization in those with dementia than in those without.

Conclusion: Dementia emerged as the most potent risk factor for institutionalization in this 12-year community-based epidemiological study. Medical burden conferred greater vulnerability to institutionalization in nondemented persons than in those with dementia. J Am Geriatr Soc 2004;52(3):434-439.

ETHICS, PUBLIC POLICY, AND MEDICAL ECONOMICS

Screening and Cognitive Impairment: Ethics of Forgoing Mammography in Older Women

Barrie L. Raik, MD, Franklin G. Miller, PhD, and Joseph J. Fins, MD

Mammographic screening for breast cancer in cognitively impaired women poses significant ethical questions. Many women with dementia should not be screened because of the greater harm than benefits and the difficulty in obtaining informed consent. This article reviews the current controversy about mammography and then suggests a risk/benefit analysis for this vulnerable population. Autonomy, decision-making capacity, and the roles of surrogates and physicians are considered, as are ageism and the risk of undertreatment. The harm of overdiagnosis and subsequent overtreatment for women who are cognitively impaired, have comorbidity and a limited life span are outlined. In these cases, the burdens of mammography outweigh the benefits. For women with early cognitive impairment and longer life expectancies, the potential benefits may outweigh the harms. A decision-making process by the patient, proxy, and practitioner that takes account of foreseeable risks and benefits, patient capacity and preferences, and the effect of this screening intervention on quality of life is outlined. J Am Geriatr Soc 2004;52(3):440-444.

STROKE PROPHYLAXIS IN INSTITUTIONALIZED ELDERLY PATIENTS WITH ATRIAL FIBRILIATION

Elaine Lau, BSc Phm, PharmD, Tammy J. Bungard, BSP, PharmD, and Ross T. Tsuyuki, BSc (Pharm), PharmD, MSc

Objectives: To identify patterns and predictors of antithrombotic use and to evaluate the appropriateness of antithrombotic therapy for stroke prophylaxis in institutionalized elderly patients with atrial fibrillation.

Design: Retrospective study.

Setting: Seventeen long-term care institutions in Edmonton, Alberta.

Subjects: Two hundred sixty-five long-term care residents, aged 65 and older, with atrial fibrillation.

Measurements: The proportion of patients who were prescribed warfarin, acetylsalicylic acid (ASA), both, or neither was determined. Odds ratios were calculated to identify risk factors for stroke and bleeding that are predictive of the receipt of anticoagulant therapy. Appropriateness of therapy was evaluated based on whether patients were prescribed antithrombotic therapy in accordance with their risk factors for stroke and bleeding.

Results: Warfarin was prescribed for 49% of patients, ASA for 22%, both for 8%, and neither for 20%. Nearly all patients (97%) were considered to be at high risk for stroke, with age being the predominant risk factor (88% >75), whereas about half were considered to be at low risk for bleeding. Multivariate analyses did not find any associations between individual risk factors for bleeding and anticoagulant treatment, with the exception of recent surgery (odds ratio=0.59, 95% confidence interval=0.37–0.94). Overall, 54.8% of patients received appropriate antithrombotic therapy. Of patients who were optimal candidates for anticoagulation, 60% received appropriate therapy (warfarin with or without ASA).

Conclusion: Although warfarin was the most appropriate treatment in nearly all of this population at high risk for stroke, it was prescribed in fewer than two-thirds of patients. Antithrombotic therapy was not always prescribed in accordance with patients’ risk factors for stroke and bleeding. There is a need for systematic identification of appropriate candidates for anticoagulation in the long-term care setting. J Am Geriatr Soc 2004;52(3):428-433.

CLINICAL INVESTIGATION

Increases in Serum Non-High-Density Lipoprotein Cholesterol May Be Beneficial in Some High-Functioning Older Adults: MacArthur Studies of Successful Aging

Arun S. Karlamangla, PhD, MD, Burton H. Singer, PhD, David B. Reuben, MD, and Teresa E. Seeman, PhD

Objectives: To examine the association between changes in serum non-high-density lipoprotein cholesterol (non-HDL-C) over a 2.5-year period and risk of adverse health outcomes in the following 4.5 years in high-functioning older adults.

Design: Prospective cohort, established in 1988, with a follow-up in 1991 and 1995.

Setting: Population-based, community-dwelling men and women.

Participants: A random sample (n=267) from the MacArthur cohort (N=1,189). The cohort represented the highest-functioning tertile of 4,030 screened candidates aged 70 to 79.

Measurements: Change in non-HDL-C between 1988 and 1991 was measured as a predictor of health outcomes between 1991 and 1995, including all-cause mortality, and among survivors, incident heart attack or stroke, development of new disability in basic activities of daily living, and decline in performance on the Short Portable Mental Status Questionnaire.

Results: More-positive change in non-HDL-C between 1988 and 1991 was associated with fewer adverse outcomes between 1991 and 1995. In individuals whose total cholesterol at baseline was in the middle two quartiles (195–244Êmg/dL), each 10-mg/dL increase in the 1988-to-1991 change in non-HDL-C was associated with an adjusted mortality odds ratio (OR) of 0.67 (95% confidence interval (CI)=0.51–0.88). In individuals without cardiovascular disease at baseline, the adjusted OR for new physical disability was 0.79 (95% CI=0.65–0.95) and for cognitive decline was 0.81 (95% CI=0.67–0.98).

Conclusion: Increases in cholesterol over time have beneficial associations in some older adults. The role of cholesterol changes in the health of older individuals needs further exploration. J Am Geriatr Soc 2004;52(4):487-494.

PERIODONTAL DISEASE AND WEIGHT LOSS IN OLDER ADULTS

Robert J. Weyant, DMD, DrPH, Anne B. Newman, MD, MPH, Stephen B. Kritchevsky, PhD, Walter A. Bretz, DDS, DrPH, Patricia M. Corby, DMD, Dianxu Ren, MS, MD, Lisa Weissfeld, PhD, Susan M. Rubin, MPH, and Tamara Harris, MD, MS

Objectives: To determine the association between periodontal disease and weight loss in an elderly cohort.

Design: A longitudinal design was used with participants from the Health, Aging and Body Composition (Health ABC) cohort study to determine the association between periodontal disease status and weight loss of at least 5% of baseline body weight over a period of 2 years.

Setting: Participants were examined in research clinics in Pittsburgh, Pennsylvania, and Memphis, Tennessee.

Participants: A randomly selected subset of 1,053 individuals from the Health ABC examination, aged 65 and older, ambulatory and community-dwelling at baseline.
nMeasurements: Periodontal disease was measured as mean pocket depth and attachment loss, extent (percentage) of pockets with at least 6 mm probing depth, extent of bleeding on probing, and tissue inflammation.

Results: In logistic regression models adjusting for variables that may explain weight loss, extent of periodontal pockets with at least 6 mm probing depth showed a significant association with weight loss (odds ratio= 1.53, 95% confidence interval=1.32–1.77).

Conclusion: Periodontal disease may be causally related to weight loss in the elderly and thus may increase risk of morbidity and mortality. J Am Geriatr Soc 2004;52(4):547-553.

ETHICS, PUBLIC POLICY, AND MEDICAL ECONOMICS
Who Are the Uninsured Elderly in the United States?

James W. Mold, MD, MPH, George E. Fryer, PhD, and Cynthia H. Thomas, MSW

Because of the Medicare program, a common assumption is made that virtually all older Americans have health insurance coverage. Data from the 2000 National Health Interview Survey were analyzed to estimate the number of people aged 65 and older without health insurance; their stated reasons for being uninsured; and the associations between lack of insurance and sociodemographic variables, health status, and access to and use of healthcare services.

In 2000, there were approximately 350,000 older Americans with no health insurance. Those without insurance were more likely to be younger, Hispanic, nonwhite, unmarried (widowed, divorced, or never married), poor, and foreign-born. They were less likely to hold U.S. citizenship. Despite relatively high rates of chronic medical conditions, they were unlikely to receive outpatient or home healthcare services. The most common reason given for lack of insurance was its cost.
This study reveals important gaps in the availability of health insurance for the elderly, gaps that are likely to affect an increasing number of older Americans in the coming decade. J Am Geriatr Soc 2004; 52(4):601-606.