Development of a Protocol for Capillary Blood Glucose Testing in Nursing Home and Rehabilitation Settings
Scott L. Mader, MD, Kathleen A. Fuglee, RN, MN, CNS, CDE, Deanna S. Allen, RN, Lisa R. Werner, RN, BSN, Wendy A. Wanlass, MD, Keith J. Pagel, MD, Kay L. Beliel, Judy A. McEuen, RN, BSN, CDE, Elizabeth A. Stephens, MD, Nancy L. Allison, NP, CDE, Karen A. McWhorter, MN, RN, and Julie E. Vandling, RN, BSN

OBJECTIVES: To develop an algorithm to standardize capillary blood glucose (CBG) testing in nursing home and rehabilitation patients.

DESIGN: Descriptive study in which an interdisciplinary team from a nursing home, a rehabilitation center, and a diabetes mellitus care program developed and tested a protocol to standardize diabetes management parameters and CBG testing frequency.

SETTING: Department of Veterans Affairs nursing home and rehabilitation unit.

PARTICIPANTS: One hundred one patients admitted to the units during the 6-month study period who had orders for CBG testing.

INTERVENTION: Use of a standardized CBG testing protocol.

MEASUREMENTS: Use of management goal, use of CBG testing protocol, total CBG tests/month.

RESULTS: One hundred one subjects received orders for CBG testing; 72 (72%) received orders for a management goal, and 69 (69%) received orders to use the CBG protocol. Of these 69 patients, 22 met their CBG goals and were advanced to less-frequent CBG testing using the protocol, and 15 did not meet their CBG goals and were not advanced. An additional 15 patients were advanced to less-frequent CBG testing but not using the protocol. In all, 54 of 69 patients (78%) were advanced or could have been advanced by protocol to less-frequent CBG testing. Total CBG testing per month did not change before, during, or after the study period.

CONCLUSION: This protocol would be useful in long-term care facilities and in other congregate living settings where patients with diabetes mellitus have staff assisting with their diabetes management. Barriers to successful implementation are discussed. J Am Geriatr Soc 2006;54(7):1114-1118.

Characteristics of Frail Older Adult Drivers
David B. Carr, MD, Kellie L. Flood, MD, Karen Steger-May, MA, Kenneth B. Schechtman, PhD, and Ellen F. Binder, MD

OBJECTIVES: To determine the prevalence of driving in older adults with mild to moderate physical frailty and to compare characteristics of current frail older adult drivers with those of former drivers in the sample.

DESIGN: Retrospective study of frail older adults enrolled in randomized trials of exercise and hormone replacement therapy.

SETTING: Urban, academic medical center.

PARTICIPANTS: One hundred eighty-three sedentary community-dwelling men and women aged 75 and older with mild to moderate physical frailty, as defined by two of the following three criteria: modified Physical Performance Test (PPT) score between 18 and 32, peak oxygen uptake (VO₂) between 10 and 18 mL/kg per minute, and self-report of difficulty or assistance with one activity of daily living (ADL) or two instrumental ADLs. Participants were classified as current or former drivers.

MEASUREMENTS: Demographic characteristics, medical diagnoses, medication use, modified PPT score, and psychometric tests.

RESULTS: The majority (85%) of the participants were drivers. Former drivers were more likely to be older, be female, reside in congregate independent living for the elderly, have a higher incidence of arthritis and congestive heart failure, take sedating medications, have lower total ADL scores, have lower VO₂ peak scores, and have more impairment on tests of cognition and physical strength, although only age, type of residence, and grip strength were independent predictors of driving cessation in the regression analysis.

CONCLUSION: Despite the presence of physical frailty, many older adults choose to continue to drive. Further studies are needed to better understand the driving behaviors of frail older adults and explore opportunities for optimizing driving abilities. J Am Geriatr Soc 2006;54(7):1125-1129.

A Prospective, Longitudinal Study of the Functional Status and Quality of Life of Older Patients with Breast Cancer Receiving Adjuvant Chemotherapy
Arti Hurria, MD, Anju Hurria, BA, MPH, Enid Zuckerman, Katherine S. Panageas, Monica Fornier, MD, Gabriella D’Andrea, MD, Chau Dang, MD, Mark Moasser, MD, Mark Robson, MD, Andrew Seidman, MD, Violante Currie, MD, Catherine VanPoznak, MD, Maria Theodoulou, MD, Mark S. Lachs, MD, MPH, and Clifford Hudis, MD

OBJECTIVES: To examine the toxicity experienced by a cohort of older women receiving adjuvant chemotherapy for breast cancer and the longitudinal effect on their functional status and quality of life (QOL).

DESIGN: A geriatric assessment measuring functional status, comorbidity, mood, nutritional status, and QOL was performed before chemotherapy, at the end of chemotherapy, and 6 months later.

SETTING: This prospective longitudinal study was conducted at Memorial Sloan-Kettering Cancer Center, New York, New York.

PARTICIPANTS: Fifty patients aged 65 and older with Stage I to III breast cancer receiving any adjuvant chemotherapy; 49 were evaluable.

MEASUREMENTS: The chemotherapy regimen and the toxicity to chemotherapy were recorded. A geriatric assessment was performed before the start of chemotherapy, on completion of chemotherapy, and 6 months after completion of chemotherapy. QOL testing was performed at the same times.

RESULTS: Patients (mean age 68, range 65–84) received an anthracycline-based chemotherapy regimen (n=15) or cyclophosphamide 600 mg/m² intravenously (IV), methotrexate 40 mg/m² IV, 5-fluorouracil 600 mg/m² IV every 3 weeks for eight cycles (n=34). Grade 3 or 4 toxicity occurred in 53% (n=26), hematological toxicity in 27% (n=13), and nonhematological toxicity in 31% (n=15). Despite toxicity, there was no significant longitudinal change in functional status or QOL.

CONCLUSION: Despite toxicity from adjuvant chemotherapy, this cohort of relatively young older patients maintained their functional status and QOL from before chemotherapy to 6 months postchemotherapy. Subtle changes in higher-order functioning would require assessment using different geriatric assessment tools. J Am Geriatr Soc 2006;54(7):1119-1124.

Condom Versus Indwelling Urinary Catheters: A Randomized Trial
LSanjay Saint, MD, MPH, Samuel R. Kaufman, MA, Mary A. M. Rogers, PhD, Paul D. Baker, ARNP, Kathleen Ossenkop, ARN, and Benjamin A. Lipsky, MD

OBJECTIVES: To compare condom and indwelling urinary catheters in terms of infection risk and patient satisfaction.

DESIGN: A prospective, randomized, unblinded, controlled trial.

SETTING: An academically affiliated Veterans Affairs Medical Center.

PARTICIPANTS: Hospitalized men aged 40 and older who required a urinary collection device.

MEASUREMENTS: The incidence of adverse outcomes (bacteriuria, symptomatic urinary tract infection (UTI), or death) and patient device-related satisfaction as determined according to a questionnaire. Dementia status was recorded to assess effect modification by the presence of dementia.

RESULTS: Seventy-five subjects were randomized: 41 receiving an indwelling catheter and 34 a condom catheter. The incidence of an adverse outcome was 131/1,000 patient-days with an indwelling catheter and 70/1,000 patient-days with a condom catheter (P=.07). The median time to an adverse event was 7 days in the indwelling group and 11 days in the condom group. After adjusting for other risk factors, it was found that condom catheter use reduced adverse outcomes (P=.04). Patients without dementia who had an indwelling catheter were approximately five times as likely to develop bacteriuria or symptomatic UTI or to die (hazard ratio=4.84, 95% confidence interval=1.46–16.02) as those with a condom catheter (P=.01). Patients reported that condom catheters were more comfortable (P=.02) and less painful (P=.02) than indwelling catheters.

CONCLUSION: The use of condom catheters is less likely to lead to bacteriuria, symptomatic UTI, or death than the use of indwelling catheters. This protection is especially apparent in men without dementia. J Am Geriatr Soc 2006;54(7):1055-1061.

Association Between Advance Directives and Quality of End-of-Life Care: A National Study
Joan M. Teno, MD, MS, Andrea Gruneir, MSc, Zachary Schwartz, BA, Aman Nanda, and Terrie Wetle, PhD

OBJECTIVES: To examine the role of advance directives (ADs) 10 years after the Patient Self-Determination Act.

DESIGN: Mortality follow-back survey.

SETTING: People who died in a nursing home, hospital, or at home.

PARTICIPANTS: Bereaved family member or other knowledgeable informant.

MEASUREMENTS: Telephone interviewers that asked about the use of written ADs, use of life-sustaining treatment, and quality of care by asking whether staff provided desired symptom relief, treated the dying with respect, supported shared decision-making, coordinated care, and provided family with the needed information and emotional support.

RESULTS: Of the 1,587 people who died, 70.8% had an AD. Persons who died at home with hospice or in a nursing home were more likely to have an AD. In addition, those with an AD were less likely to have a feeding tube (17% vs 27%) or use a respirator in the last month of life (11.8% vs 22.0%). Bereaved family members who reported that the decedent did not have an AD were more likely to report concerns with physician communication (adjusted odds ratio (AOR)=1.4, 95% confidence interval (CI)=1.1–1.6) and with being informed about what to expect (AOR=1.2, 95% CI=1.0–1.3). No statistically significant differences were observed in other outcomes. Even in those with an AD, important quality concerns remained; one in four reported an unmet need in pain, one in two reported inadequate emotional support for the patient, and one in three stated inadequate family emotional support.

CONCLUSION: Bereaved family member report of completion of an AD was associated with greater use of hospice and fewer reported concerns with communication, yet important opportunities remain to improve the quality of end-of-life care. J Am Geriatr Soc 2007;55(2):189-194.

Clinical Presentation of Hypernatremia in Elderly Patients: A Case Control Study
Philippe Chassagne, MD, PhD, Laurent Druesne, MD, Corinne Capet, MD, Jean François Ménard, PhD, and Eric Bercoff, MD

OBJECTIVES: To assess early clinical signs and their prognostic value in elderly patients with hypernatremia.

DESIGN: Prospective, case control study of 150 patients with hypernatremia matched to 300 controls.

SETTING: Multicenter study including seven short- and long-term geriatric care facilities.

MEASUREMENTS: Clinical assessment of hydration status at bedside, such as abnormal skin turgor or dry oral mucosa. Secondary outcome measures: 30-day mortality rate and clinical indicators (assessed at the peak of natremia) associated with mortality.

RESULTS: Patients and controls were comparable in terms of drugs and underlying diseases, except for history of dementia, which was more frequent in patients than in controls. Patients were significantly more likely than controls to have low blood pressure, tachycardia, dry oral mucosa, abnormal skin turgor, and recent change of consciousness. Only three clinical findings were found in at least 60% of patients with hypernatremia: orthostatic blood pressure and abnormal subclavicular and forearm skin turgor. The latter two signs were significantly more frequent in patients with hypernatremia. Four other signs (tachycardia, abnormal subclavicular skin turgor, dry oral mucosa, and recent change of consciousness) had a specificity of greater than 79%. Using logistic regression, four signs were significantly and independently associated with hypernatremia: abnormal subclavicular and thigh skin turgor, dry oral mucosa, and recent change of consciousness. The mortality rate was 41.5% and was significantly higher in patients with hypernatremia. The status of consciousness when hypernatremia was diagnosed was the single prognostic indicator associated with mortality (odds ratio=2.3, 95% confidence interval=1.01–5.2).

CONCLUSION: Most of the classical signs of dehydration are irregularly present in patients with hypernatremia. Caregivers should carefully screen any variations in consciousness, because they may reveal severe hypernatremia. J Am Geriatr Soc 2006;54(8):1225-1230.

EDUCATION AND TRAINING
Chronic Low Back Pain in Older Adults: What Physicians Know, What They Think They Know, and What They Should Be Taught
Danelle Cayea, MD, MS, Subashan Perera, PhD, and Debra K. Weiner, MD

Chronic low back pain (CLBP) is a common and debilitating problem in older adults. Little exists in the literature about primary care physicians' (PCPs') knowledge of and confidence in managing this problem. A self-administered survey was mailed to PCPs in western Pennsylvania to measure knowledge of the evaluation and treatment of common contributors to CLBP in older adults, confidence in diagnosing these contributors through physical examination, and the association between confidence levels and knowledge. The survey combined items with an ordinal scale on which PCPs ranked their confidence in detecting various contributors to CLBP (e.g., fibromyalgia) using physical examination and patient vignettes followed by multiple choice questions designed to assess knowledge. One hundred fifty-three of 634 surveys were returned (24.1%). Overall, the majority of PCPs did not feel "very confident" in their ability to diagnose any of the contributors of CLBP listed (most items <40%). PCPs felt most confident in detecting scoliosis and least confident detecting myofascial pain of the piriformis muscle. There was a wide range in the number of respondents answering all questions related to a particular topic correctly (3.9% for sacroiliac joint syndrome to 70.4% for hip osteoarthritis). There was no relationship between knowledge scores and confidence ratings (P>.05 for all comparisons). The results point to a need for more PCP education about CLBP in older adults. It also suggests that accurate needs assessment should not rely on physician confidence ratings alone. J Am Geriatr Soc 2006;54(11):1772-1777.