Black/White Differences in Pressure Ulcer Incidence in Nursing Home Residents

Mona Baumgarten, PhD, David Margolis, MD, PhD, Carol van Doorn, PhD, Ann L. Gruber-Baldini, PhD, J. Richard Hebel, PhD, Sheryl Zimmerman, PhD, and Jay Magaziner, PhD

Objectives: To compare black and white nursing home residents with respect to the incidence of nursing home (NH)-acquired pressure ulcers (PUs) and to examine the role of resident characteristics and facility characteristics in explaining differences between the racial groups.

Design: Prospective cohort study conducted between 1992 and 1995.

Setting: Fifty-nine Maryland NHs.

Participants: A total of 1,938 residents (301 black, 1,637 white) aged 65 and older newly admitted to participating NHs.

Measurements: The outcome variable was the first occurrence of a Stage 2, 3, or 4 PU as determined based on medical record review. The predictor variable was race (black, white). Eight resident characteristics (age, sex, number of activity of daily living dependencies, bedfast, PU on admission to facility, incontinence, dementia, and whether the resident was on Medicaid) and three facility characteristics (number of beds, for-profit ownership status, and urban/nonurban location) were considered as possible confounding variables.

Results: The incidence of PUs was 0.38 per person-year in the NH. The rate for blacks was significantly higher than for whites (0.56 vs 0.35 per person-year) (P<.001). In multivariate analysis, controlling for eight resident characteristics and three facility characteristics, race was significantly associated with PU incidence (hazard ratio comparing blacks with whites=1.31, 95% confidence interval=1.021.66).

Conclusion: Blacks have a higher incidence of NH-acquired PUs than whites; resident characteristics appear to mediate the higher risk. Future research should aim to identify modifiable factors that explain differences between racial groups in PU risk and to develop solutions to prevent the suffering and cost associated with PUs. J Am Geriatr Soc 2004;52(8): 1293-1298.

Ethnic Differences in the Prevalence and Pattern of Dementia-Related Behaviors

Kaycee M. Sink, MD, Kenneth E. Covinsky, MD, MPH, Robert Newcomer, PhD, and Kristine Yaffe, MD

Objectives: To determine the prevalence of dementia-related behaviors in a large, multiethnic sample of community-dwelling patients with moderate to severe dementia and to determine whether differences in patient or caregiver characteristics could explain any differences in prevalence of these behaviors between white and nonwhite patients.

Design: Cross-sectional study.

Setting: Community-based.

Participants: A total of 5,776 Medicare patients (5,090 white, 469 black, 217 Latino; mean age 78.9) enrolled in the Medicare Alzheimer’s Disease Demonstration and Evaluation study at eight sites across the United States between 1989 and 1991.

Measurements: Trained interviewers collected information on patient demographic characteristics, cognitive and functional status, and caregiver characteristics such as relationship to patient, functional status, depression, and burden. Ethnicity was obtained by self-report. Caregivers were asked if the patient typically demonstrated any of eight dementia-related behaviors. To determine the independent association between ethnicity and dementia-related behaviors, logistic regression models were developed for each of the behaviors, adjusting for patient and caregiver characteristics.

Results: Overall, 92% of patients had one or more dementia-related behaviors. Sixty-one percent of black and 57% of Latino patients were reported to have four or more behaviors, compared with 46% of white patients (P<.001). The prevalence of specific behaviors ranged from 24% for combativeness to 67% for wandering. After multivariate adjustment, black patients were significantly more likely than whites to be constantly talkative (odds ratio (OR)=1.41, 95% confidence interval (CI)=1.111.80), to have hallucinations (OR=1.89, 95% CI=1.492.40) and episodes of unreasonable anger (OR=1.70, 95% CI=1.342.15), to wander (OR=1.40, 95% CI=1.081.81), and to wake their caregiver (OR=1.33, 95% CI=1.041.69). Latinos had a significantly higher likelihood than whites of having hallucinations (OR= 1.49, 95% CI=1.102.01), episodes of unreasonable anger (OR=1.59, 95% CI= 1.182.16), combativeness (OR=1.59, 95% CI=1.172.17), and wandering (OR= 1.59, 95% CI=1.212.26). For most behaviors, these adjusted ORs are similar in magnitude of effect and statistical significance to the unadjusted estimates.

Conclusion: Black and Latino community-dwelling patients with moderate to severe dementia have a higher prevalence of dementia-related behaviors than whites. Therefore, as the aging minority population grows, it will be especially important to target caregiver education, in-home support, and resources to minority communities. J Am Geriatr Soc 2004;52(8):1277-1283.

Prevalence and Outcomes of Low Mobility in Hospitalized Older Patients

Cynthia J. Brown, MD, Rebecca J. Friedkin, PhD, and Sharon K. Inouye, MD, MPH

Objectives: To estimate the prevalence of different levels of mobility in a hospitalized older cohort, to measure the degree and rate of adverse outcomes associated with different mobility levels, and to examine the physician activity orders and documented reasons for bedrest in the lowest mobility group.

Design: A prospective cohort study.

Setting: An 800-bed university teaching hospital.

Participants: Four hundred ninety-eight hospitalized medical patients, aged 70 and older.

Measurements: Using average mobility level, scored from 0 to 12, the low-mobility group was defined as having a score of 4 or less, intermediate as a score of higher than 4 to 8, and high as higher than 8. Outcomes were functional decline, new institutionalization, death, and death or new institutionalization.

Results: Low and intermediate levels of mobility were common, accounting for 80 (16%) and 157 (32%) study patients, respectively. Overall, any activity of daily living (ADL) decline occurred in 29%, new institutionalization in 13%, death in 7%, and death or new institutionalization in 22% of patients in this cohort. When compared with the high mobility group, the low and intermediate groups were associated with the adverse outcomes in a graded fashion, even after controlling for multiple confounders. The low-mobility group had an adjusted odds ratio (OR) of 5.6 (95% confidence interval (CI)=2.911.0) for ADL decline, 6.0 (95% CI=2.514.8) for new institutionalization, 34.3 (95% CI=6.3185.9) for death, and 7.2 (95% CI=3.614.4) for death or new institutionalization. The intermediate group had adjusted ORs of 2.5 (95% CI=1.54.1), 2.9 (95% CI= 1.46.0), 10.1 (95% CI=1.952.9), and 3.3 (95% CI=1.85.9) for ADL decline, new institutionalization, death, and death or new institutionalization, respectively. Bedrest was ordered at some point during hospitalization in 165 (33%) patients. For most patients, mobility was limited involuntarily (bedrest orders), and almost 60% of bedrest episodes in the lowest mobility group had no documented medical indication.

Conclusion: Low mobility and bedrest are common in hospitalized older patients and are important predictors of adverse outcomes. This study demonstrated that the adverse outcomes associated with low mobility and bedrest may be viewed as iatrogenic events leading to complications, such as functional decline. J Am Geriatr Soc 2004; 52(8):1263-1270.