ADVANCED DEMENTIA IN THE NH
Nursing homes are important providers of end-of-life care to persons with advanced dementia. The authors used data from the Minimum Data Set (June 1, 1994, to December 31, 1997) to identify persons 65 years and older who died with advanced dementia (n = 1609) and terminal cancer (n = 883) within 1 year of admission to any New York State nursing home. Variables from the Minimum Data Set assessment completed within 120 days of death were used to describe and compare the end-of-life experiences of these two groups. At nursing home admission, only 1.1% of residents with advanced dementia were perceived to have a life expectancy of less than 6 months; however, 71.0% died within that period. Before death, 55.1% of demented residents had a do-not-resuscitate order, and 1.4% had a do-not-hospitalize order. Nonpalliative interventions were common among residents dying with advanced dementia: tube feeding, 25.0%; laboratory tests, 49.2%; restraints, 11.2%; and intravenous therapy, 10.1%. Residents with dementia were less likely than those with cancer to have directives limiting care but were more likely to experience burdensome interventions: do-not-resuscitate order (adjusted odds ratio [OR], 0.12; 95% confidence interval [CI], 0.09-0.16), do-not-hospitalize order (adjusted OR, 0.33; 95% CI, 0.16-0.66), tube feeding (adjusted OR, 2.21; 95% CI, 1.51-3.23), laboratory tests (adjusted OR, 2.53; 95% CI, 2.01-3.18), and restraints (adjusted OR, 1.79; 95% CI, 1.23-2.61). Distressing conditions common in advanced dementia included pressure ulcers (14.7%), constipation (13.7%), pain (11.5%), and shortness of breath (8.2%). The authors concluded that nursing home residents dying with advanced dementia are not perceived as having a terminal condition, and most do not receive optimal palliative care. Management and educational strategies are needed to improve end-of-life care in advanced dementia.

Mitchell SL, Kiely DK, Hamel MB. Dying with advanced dementia in the nursing home. Arch Intern Med 2004;164:321-326.

CLINICAL GUIDELINES FOR DM IN THE ELDERLY
Increasingly, adults are living to an advanced age. While many enjoy good health, nearly 50% of adults older than 65 years have three or more chronic medical conditions. Furthermore, within any age-sex cohort, older adults exhibit widely heterogeneous health status—ranging from robust to frail. This heterogeneity and individual medical complexity makes care for older patients particularly challenging and requires both careful medical judgment and a clear understanding of the patient’s personal values and goals. Most current healthcare guidelines are disease-specific and do not address this complexity and heterogeneity, thus limiting their utility for guiding physicians in the care of older adult patients. The “Guidelines for Improving the Care of Older Persons with Diabetes Mellitus” are the first guidelines to specifically address this complexity and provide guidance to physicians who must prioritize therapies and goals for older adults with diabetes, comorbid medical conditions, and geriatric syndromes. By providing a rationale for prioritizing recommendations and the inclusion of geriatric syndromes that impact the patient’s overall health and diabetic care, these guidelines may serve as a model for the development of other guidelines targeting older adults with complex health status.

Durso SC. Using clinical guidelines designed for older adults with diabetes mellitus and complex health status. JAMA 2006;295:1935-1940.

FISH CONSUMPTION AND COGNITIVE DECLINE
Dietary intake of fish and the omega-3 fatty acids have been associated with lower risk of Alzheimer’s disease and stroke. The objective of this prospective cohort study was to examine whether intakes of fish and the omega-3 fatty acids protect against age-related cognitive decline. The study included residents age 65 years and older in a geographically defined Chicago, Illiois, community who participated in the Chicago Health and Aging Project. Main outcome measureÊwas change in a global cognitive score estimated from mixed models. The global score was computed by summing scores of 4 standardized tests. In-home cognitive assessments were performed 3 times over 6 years of follow-up. Results of the study showed that cognitive scores declined on average at a rate of 0.04 standardized units per year (SU/y). Fish intake was associated with a slower rate of cognitive decline in mixed models adjusted for age, sex, race, education, cognitive activity, physical activity, alcohol consumption, and total energy intake. Compared with a decline rate in score of –0.100 SU/y among persons who consumed fish less than weekly, the rate was 10% slower (–0.090 SU/y) among persons who consumed 1 fish meal per week and 13% slower (–0.088 SU/y) among persons who consumed 2 or more fish meals per week. The fish association was not accounted for by cardiovascular-related conditions or fruit and vegetable consumption but was modified after adjustment for intakes of saturated, polyunsaturated, and trans fats. There was little evidence that the omega-3 polyunsaturated fatty acids were associated with cognitive change. The authors concluded that fish consumption may be associated with slower cognitive decline with age. Further study is needed to determine whether fat composition is the relevant dietary constituent.

Morris MC, Evans DA, Tangney CC, et al. Fish consumption and cognitive decline with age in a large community study. Arch Neurol 2005;62:1849-1853.

REGIMENS FOR HEART FAILURE
Polypharmacy—the concurrent prescription of multiple medications—is a salient consideration in the care of older patients with heart failure. Little is known, however, about the complexity and financial burden of medical therapy in this population. This study examined chronic medications prescribed at hospital discharge to patients age 65 years or older hospitalized for heart failure in 2 cohorts separated by 27 months (April 1998–March 1999, nÊ=Ê31Ê602; July 2000–June 2001, nÊ=Ê30Ê774). Three utilization measures were assessed: the number of drugs, the estimated number of doses per day, and the estimated annual costs using the same cost standard (2003 average wholesale prices) for both samples. Utilization associated with population characteristics and between time frames was assessed in multivariable models. ResultsÊshowed that in 1998-1999, the mean number of drugs was 6.8, representing 10.1 doses daily at a cost of $3142/y, increasing to 7.5 drugs, 11.1 doses daily and $3823/y in 2000-2001 (P <.001 for all comparisons). After adjustment, the number of drugs increased by 12% and costs by 24% between samples. Factors associated with greater complexity and cost included diabetes (1.6 additional drugs and $1094/y additional cost), prior revascularization (1.3 drugs, $1154/y), and chronic lung disease (1.2 drugs, $814/y). Younger age and white race were also associated with more drugs and higher costs. The authors concluded that the drug treatment of older patients with heart failure is characterized by rapidly increasing complexity and cost. Efforts should be directed toward optimizing the complex drug regimens of elderly patients with heart failure and multiple comorbidities.

Masoudi FA, Baillie CA, Wang Y, et al. The complexity and cost of drug regimens of older patients hospitalized with heart failure in the United States, 1998-2001. Arch Intern Med 2005;165:2069-2076.