Breast Cancer Screening in Women Aged 80 and Older: Results from a National Survey
Mara A. Schonberg, MD, MPH, Ellen P. McCarthy, PhD, MPH, Roger B. Davis, ScD, Russell S. Phillips, MD, and Mary B. Hamel, MD, MPH

Objectives: To estimate the national rates of mammography screening in women aged 80 and older and examine the relationship between health status and screening within the previous 2 years.

Design: Population-based survey.

Setting: United States.

Participants: Eight hundred eighty-two women aged 80 and older who responded to the 2000 National Health Interview Survey, representing an estimated 3.83 million noninstitutionalized women nationally.

Measurements: Screening mammography, disease burden, and functional status were assessed using a questionnaire.

Results: Of the 882 women, 41.5% were aged 85 and older; 19.6% had two or more significant diseases; and 12.1% were dependent in at least one activity of daily living (ADL). More than half (50.8%) had received a screening mammogram within the previous 2 years. Women with two or more significant diseases were less likely to have received screening than those without significant disease, but the difference was not statistically significant (43.9% vs 54.0%, P=.152). Women dependent in at least one ADL were less likely to receive screening mammography than women without functional impairment (37.2% vs 55.9%, P<.001). After adjustment, the likelihood of screening remained lower in women with two or more significant diseases (adjusted odds ratio (AOR)=0.63, 95% confidence interval (CI)=0.40-1.05) and in women with at least one ADL dependency (AOR=0.44, 95% CI=0.22-0.88). Of 294 women likely to have life expectancies of less than 5 years because of poor health, 39.4% received screening mammography.

Conclusion: More than half of women aged 80 and older in the United States receive screening mammograms. Nearly 40% of women very unlikely to benefit because of poor health received screening mammography. J Am Geriatr Soc 2004;52(10):1688-1695.

The Relationship Between Number of Medications and Weight Loss or Impaired Balance in Older Adults
Joseph V. Agostini, MD, Ling Han, MD, MS, and Mary E. Tinetti, MD

Objectives: To examine the relationship between cumulative medication exposure and risk of two common manifestations of adverse drug effects: weight loss and impaired balance.

Design: Cross-sectional and longitudinal cohort.

Setting: Urban Connecticut community.

Participants: Eight hundred eighty-five community-dwelling residents aged 72 and older.

Measurements: Weight loss (≥10 pounds) and balance, a composite of four balance measures.

Results: Participants took a mean±standard deviation of 2.2±1.9 medications (range 015). After adjustment for age, depressive symptoms, cognitive impairment, vision and hearing impairments, number of chronic diseases, and number of hospitalizations in the previous year, the adjusted odds ratio (OR) for weight loss was 1.48 (95% confidence interval (CI)=0.85-2.59) for those taking one to two medications, 1.96 (95% CI=1.08-3.54) for three to four medications, and 2.78 (95% CI=1.38-5.60) for five or more medications. For impaired balance, adjusted ORs were 1.44 (95% CI=0.94-2.19), 1.72 (95% CI= 1.09-2.71), and 1.80 (95% CI=1.02-3.19), respectively.

Conclusion: A greater number of medications were associated with increased risk of adverse drug outcomes, after extensive adjustment for chronic illness. Clinicians should consider the adverse effects of total drug use and not merely the benefits or risks of individual medications for specific diseases. J Am Geriatr Soc 2004;52(10):1719-1723.

Comparison of Routine Glove Use and Contact-Isolation Precautions to Prevent Transmission of Multidrug-Resistant Bacteria in a Long-Term Care Facility
William E. Trick, MD, Robert A. Weinstein, MD, Patricia L. DeMarais, MD, Wanda Tomaska, RN, Catherine Nathan, MS, Sigrid K. McAllister, BS, MT, Jeffrey C. Hageman, MHS, Thomas W. Rice, PhD, Glennis Westbrook, BS, MT, and William R. Jarvis, MD

Objectives: To compare routine glove use by healthcare workers for all residents, without use of contact-isolation precautions, with contact-isolation precautions for the care of residents who had vancomycin-resistant enterococci or methicillin-resistant Staphylococcus aureus isolated from a clinical culture.

Design: Random allocation of two similar sections of the skilled-care unit to one of the infection-control strategies during an 18-month study period.

Setting: Skilled-care unit of a 667-bed acute- and long-term care facility.

Participants: All residents present or admitted to the skilled-care unit from June 1, 1998, through December 7, 1999.

Measurements: Resident acquisition of four antimicrobial-resistant organisms (methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci, or extended-spectrum -lactamase-producing Klebsiella pneumoniae or Escherichia coli). All isolates were strain typed. The facility level costs associated with each strategy were estimated.

Results: Resident acquisition of antimicrobial-resistant organisms was no different in the glove-use and isolation-precautions sections (31 episodes (1.5 per 1,000 resident-days) vs 38 episodes (1.6 per 1,000 resident-days)). Acquisition of either of two prevalent K. pneumoniae strains was more likely (P=.06) in residents in the isolation-precautions section. The estimated costs of contact-isolation precautions were 40% greater than those of routine glove use.

nConclusion: There was a similar frequency of transmission of antimicrobial-resistant bacteria in the two study sections; there was evidence for resident-to-resident K. pneumoniae transmission in the isolation-precautions section. Routine glove use for healthcare workers, which decreases resident social isolation and healthcare facility costs, may be preferable in many long-term care facilities. J Am Geriatr Soc 2004;52(12):2003-2009.

Indicators of Recurrent Hospitalization for Pneumonia in the Elderly
Ali A. El Solh, MD, MPH, Thomas Brewer, DO, Mifue Okada, MD, Omar Bashir, MBBS, and Michael Gough, BSc

Objectives: To identify modifiable risk factors of late unplanned readmissions for elderly with community-acquired pneumonia.

Design: A case-control study.

Setting: Three university-affiliated tertiary-care hospitals.

Participants: Two hundred four case-control pairs. Case patients referred to all patients readmitted with pneumonia 30 days to 1 year after discharge. Control subjects were matched for age, admission date, and residence before admission.

Measurements: Baseline sociodemographic information, clinical data, activity of daily living (ADL) information, and Charlson Comorbidity Index score were obtained. The Pneumonia Severity Index was calculated with swallowing dysfunction and pattern and extent of radiographic abnormalities, antimicrobial coverage, and total duration recorded.

Results: Median time to readmission was 123 days (interquartile range=65-238 days). Readmission was not associated with increased severity or length of hospital stay. In a Cox proportional hazards regression model, swallowing dysfunction (hazard ratio (HR)=2.15, 95% confidence interval (CI)=1.46-2.97), current smoking (HR=2.04, 95% CI= 1.48-2.82), use of tranquilizers (HR=1.5, 95% CI=1.02-2.22), and lower ADL scores (HR=1.06, 95% CI=1.02-1.10) were independently associated with readmission for pneumonia. The receipt of angiotensin-converting enzyme inhibitors (HR=0.46, 95% CI=0.27-0.78) and prior pneumococcal vaccination (HR=0.59, 95% CI=0.42-0.82) had a protective effect.

Conclusion: Although there are limited effective measures to improve functional status, preventive strategies that include smoking cessation and pneumococcal vaccination should be actively pursued. Routine evaluation of swallowing dysfunction and use of pharmacological agents to improve the cough reflex deserve further evaluation in multicenter controlled trials. J Am Geriatr Soc 2004;52(12): 2010-2015.