摘要:

OBJECTIVE: To determine the effects of 11 months of exercise training and hormone replacement therapy (HRT), alone or in combination, on serum lipids and lipoproteins, in postmenopausal women.DESIGN: Controlled, prospective, 11‐month clinical trial. Healthy postmenopausal women (n = 71, age range 60–72 yrs) were assigned to four groups in a 2 × 2 design (control, exercise, HRT, exercise + HRT).SETTING: Large, midwestern urban community; subjects were recruited from the community‐at‐large. The exercise program was conducted at a university exercise facility.INTERVENTIONS: HRT consisted of conjugated estrogens at 0.625 mg/day and trimonthly medroxyprogesterone acetate 5 mg/day for 13 days. Exercise consisted of 2 months of low intensity exercise followed by 9 months of vigorous exercise for 45 min/day, 3 or more days/week, at 65–85% of maximal heart rate.MEASUREMENTS: Maximal aerobic power (V̇O2max), resting blood pressure, body composition, serum lipids and lipoproteins, and dietary intake at baseline and after 11 months.MAIN RESULTS: At the end of 11 months, subjects in the exercise group had decreased total cholesterol (TC;P<.01) and LDL‐cholesterol (LDL‐C;P<.05), but there was no change in HDL‐cholesterol (HDL‐C) or triglycerides. Women in the HRT group had decreased LDL‐C (P<.001) and increased HDL‐C (P<.01) and triglycerides (P<.01), but there was no change in TC. Exercise+HRT subjects had decreased TC (P<.05) and LDL‐C (P<.001), and increased HDL‐C (P<.001); exercise prevented the HRT‐related increase in triglycerides.CONCLUSIONS: Endurance exercise training and HRT have independent and complimentary effects on serum lipid profiles in healthy postmenopausal women. Such effects are likely to reduce the risk of cardiovascular morbidity in this population.J Am

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1996.tb00907.x

出版商:Blackwell Publishing Ltd    

年代:1996

数据来源: WILEY

摘要:

OBJECTIVE: Recent studies have suggested that vascular dementia in older persons is more common than previously hypothesized. A substantial proportion of dementia in old age may be an early manifestation of cerebrovascular disease (CVD), that eventually becomes clinically evident as an acute cerebrovascular accident. This study was aimed at assessing whether cognitive impairment and cognitive decline in older persons free of stroke are associated with higher risk of future stroke, independently of other risk factors.DESIGN: Population‐based prospective study.PARTICIPANTS: A total of 5024 subjects from the Established Populations for Epidemiologic Studies of the Elderly, who were alive and had no history of previous stroke at the sixth follow‐up visit. Subjects who had reported a stroke in a previous interview or with a diagnosis of cerebrovascular disease in a hospitalization record during the previous 3 years were excluded.MEASUREMENTS: Cognitive function was assessed by the Short Portable Mental Status Questionnaire (SPMSQ). Occurrence of a stroke was prospectively assessed by examining hospital discharge diagnoses and death certificates.RESULTS: During 19,533 person‐years of follow‐up, 259 strokes were recorded (13.3/1000 person‐years). Stroke incidence was lowest in those with normal SPMSQ score (12.1/1000 person‐years), intermediate in those with moderate impairment (16.3/1000 person‐years), and highest in those with severe impairment (30.9/1000 person‐years). Adjusting for age, education, smoking, history of hypertension, blood pressure, heart attack, diabetes, and disability, the relative risks of stroke for moderate and severe cognitive impairment were 1.2 (0.9–1.6) and 2.2 (1.2–3.8), respectively. The association between cognitive impairment and incident stroke was not mediated by hypertension or diabetes. Compared with subjects with stable or improved SPMSQ score in the previous 3 years, those who declined had higher risk of stroke.CONCLUSIONS: The elevated risk of subsequent strokes in older persons with cognitive impairment suggests that CVD may play a larger role in causing cognitive impairment then previously suspected. It remains to be demonstrated whether reducing modifiable risk factors for CVD decreases the burden of cognitive impairment in older persons without stroke.J Am Geriatr S

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1996.tb00908.x

出版商:Blackwell Publishing Ltd    

年代:1996

数据来源: WILEY

摘要:

BACKGROUND: Medicare's introduction of the Prospective Payment System for hospitals has shortened hospital stays and, as a consequence, has increased the use of post‐hospital care. Medicare coverage provides for various types of post‐hospital care. This paper examines the characteristics of patients, cities, and hospitals associated with discharge to these different types of post‐hospital care.METHODS: A total of 2248 consecutive Medicare patients having one of five diagnosis related groups (DRGs), who were about to be discharged from 52 hospitals in three cities in 1988–1989, were enrolled in the study. These DRGs comprised approximately one‐eighth of all Medicare hospital discharges and 40% of all Medicare‐paid post‐hospital care. Patients were interviewed in person before discharge and again 6 weeks after discharge. Clinical severity measures were developed from information abstracted from each patient's medical record. For each DRG, multinomial logit regression equations were developed to identify factors associated with the choice of one of four possible discharge locations: home with no formal care, home health care, nursing home care, or rehabilitation.RESULTS: Discharge location could be predicted correctly in 52 to 71% of cases, depending on the DRG. This level of predictive accuracy was significantly greater than relying on the modal discharge location, which accounted for 33 to 62% of cases. Most of the predictive power came from information gathered at the discharge interview. The variables associated significantly with the discharge location varied with the DRG and location examined. Living alone and functional dependency at discharge were the significant predictors found most often.CONCLUSIONS: Rather than assuming that everyone is discharged to the modal location, patient discharge location can be predicted. Much of the the explanation can be traced to a few variables such as functional status and living situation. The lack of greater accuracy suggests that factors other than those identified as important by clinical panels are involved in discharge planning for Medicare patients.J Am Geriatr Soc 44:

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1996.tb00909.x

出版商:Blackwell Publishing Ltd    

年代:1996

数据来源: WILEY

摘要:

OBJECTIVES: To develop and validate an instrument for stratifying older patients at the time of hospital admission according to their risk of developing new disabilities in activities of daily living (ADL) following acute medical illness and hospitalization.DESIGN: Multi‐center prospective cohort study.SETTING: Four university and two private non‐federal acute care hospitals.PATIENTS: The development cohort consists of 448 patients and the validation cohort consists of 379 patients who were aged 70 and older and who were hospitalized for acute medical illness between 1989 and 1992.MEASUREMENTS: All patients were evaluated on hospital admission to identify baseline demographic and functional characteristics and were then assessed at discharge and 3 months after discharge to determine decline in ADL functioning.RESULTS: Logistic regression analysis identified three patient characteristics that were independent predictors of functional decline in the development cohort: increasing age, lower admission Mini‐Mental Status Exam scores, and lower preadmission IADL function. A scoring system was developed for each predictor variable and patients were assigned to low, intermediate, and high risk categories. The rates of ADL decline at discharge for the low, intermediate, and high risk categories were 17%, 28%, and 56% in the development cohort and 19%, 31%, and 55% in the validation cohort, respectively. Patients in the low risk category were significantly more likely to recover ADL function and to avoid nursing home placement during the 3 months after discharge.CONCLUSION: Hospital Admission Risk Profile (HARP) is a simple instrument that can be used to identify patients at risk of functional decline following hospitalization. HARP can be used to identify patients who might benefit from comprehensive discharge planning, specialized geriatric care, and experimental interventions designed to prevent/reduce the development of disability in hospitalized older populations.J Am Geriatr Soc 44:251–25

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1996.tb00910.x

出版商:Blackwell Publishing Ltd    

年代:1996

数据来源: WILEY

摘要:

OBJECTIVE: To examine the roles played by changes in case‐mix, quality of care, and aggressiveness of care in explaining the 42% increase in mortality of the Medicaid nursing home population of Hennepin County, Minnesota, between 1984 and 1988.DESIGN: Retrospective chart review.SETTING: All nursing homes in Hennepin County, MN, that care for Medicaid patients.PATIENTS: A random sample of 1605 Medicaid nursing home residents from 1984 and 1988 stratified by year and by whether the resident died in that year. Sampling was disproportionate to allow approximately 400 individuals per stratum. A total of 1405 charts (87%) were reviewed; the remainder were either lost or destroyed.MAIN OUTCOME MEASURES: Measures included case‐mix (Charlson index, functional status, implicit reviewer assigned severity [range 1–4]), aggressiveness of care (orders limiting care), quality of care (process of care for tracer conditions [range 1–5], falls), and resident death.RESULTS: Implicitly rated severity of illness worsened between 1984 and 1988 (2.77 vs 2.91;P= .009), but other measures of case‐mix were unchanged. A greater percentage of residents had a DNR order in 1988 (12% in 1984 vs 37% in 1988;P<.001), and more received less aggressive care (31% vs 40%;P= .006). Overall process of care improved between 1984 and 1988 (2.88 vs 3.01;P<.05). With adjustment of the mortality rates and with logistic regression controlling for age and gender, changes in quality of care alone accounted for less than 5% of the mortality rate change between 1984 and 1988, case‐mix alone accounted for 49%, and aggressiveness of care alone accounted for nearly 100%.CONCLUSIONS: The nursing home population became sicker between 1984 and 1988, but process of care improved. These changes had a modest effect on the mortality rate. The increase in less aggressive care between 1984 and 1988 accounts for nearly all of the increase in mortality.J Am Geriatr Soc 44:25

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1996.tb00911.x

出版商:Blackwell Publishing Ltd    

年代:1996

数据来源: WILEY

摘要:

PURPOSE: To determine the natural history of weight change and the occurrence of clinically significant weight loss in subjects with Alzheimer's disease (AD).PATIENTS AND METHODS: Subjects with AD and cognitively normal older controls were recruited from 21 U.S. university medical centers that were participating in the Consortium to Establish a Registry for Alzheimer's Disease (CERAD). Annual assessments were performed. Subjects with AD (n = 362) and controls (n = 317) with two or more weight measurements taken a year or more apart were included in this analysis. The average period of follow‐up was>2 years for both subjects with AD and controls. Four variables describing different aspects of weight change were defined: ≥ 5% weight loss, percent weight change/year, maximum percent weight loss over 1 year, and standard deviation of measurements/subject.RESULTS: Nearly twice as many subjects with AD experienced a weight loss of 5% or more when compared with controls (menP= .003, womenP= .001). Surprisingly, a weight gain of 5% or more was also more common among AD cases. Overall, there was a tendency toward weight loss for both subjects with AD and controls, as measured by percent weight change/year. When other possible causes of weight loss were controlled using a multivariate model, a diagnosis of AD remained a significant predictor of ≥5% weight loss (P≪ .001), maximum percent weight loss over 1 year (P≪ .001), and standard deviation of measurements/subject (P≪ .001). A trend toward significance was noted for percent weight change/year (P= .07). Other than AD, very few of the possible confounders of this association remained significant predictors of weight change. In bivariate analysis, the severity of AD at entry correlated with percent weight change/year and standard deviation of measurements/subject. Additionally, the functional status of subjects with AD correlated with all four measures of weight change.CONCLUSION: Clinically important weight loss occurs more frequently among patients with AD than among cognitively normal control subjects. Instances of weight gain, periods of acute weight loss, and greater fluctuations in weight suggest that the natural history of weight change in AD may be characterized by dysfunction in body weight regulation. Further analysis is warranted regarding the relationship of severity of dementia, functional status, and other specific aspects of AD to weight change.J Am Geriatr Soc 44:26

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1996.tb00912.x

出版商:Blackwell Publishing Ltd    

年代:1996

数据来源: WILEY

摘要:

OBJECTIVE: To determine the circumstances of, incidence of, and risk factors for falls resulting in serious injuries in nonambulatory nursing home residents compared with those for ambulatory residents.DESIGN: Prospective cohort study with 1‐year follow‐upSETTING: Twelve community nursing homes in Tennessee.SUBJECTS: A total of 1228 residents, 65 years of age or older, of whom 725 (59%) were nonambulatory and 503 (41%) were ambulatory.MEASUREMENTS: Baseline data were obtained for potential risk factors for injurious falls. These included demographic characteristics, mental and physical function, vision, hearing, incontinence, and use of mechanical restraints and psychotropic drugs. Data were obtained from direct resident assessment, care provider interview, and the nursing home Minimum Data Set (MDS) (validated in a sample of residents).OUTCOME: There were 111 first falls resulting in serious injury (head injury with altered consciousness, fracture, joint dislocation or sprain, or sutured laceration) that received medical treatment (hospitalization, emergency room visit, physician visit, or on‐site radiological examination), ascertained from facility incident reports and nursing home charts.RESULTS: Nonambulatory residents had a substantially greater prevalence of mental and physical impairment. Circumstances of injurious falls in nonambulatory (n = 39 falls) and ambulatory (n = 72 falls) residents differed; those in the former group were more likely to involve equipment (87% vs 45%,P<.0001), occur while seated or during transferring (82% vs 21%,P<.0001), and from a chair/bed level (54% vs 6%,P<.0001). The incidence of injurious falls in nonambulatory residents (6.7 per 100 person‐years) was less than half that in ambulatory residents (17.0 per 100 person‐years,P<.0001). After controlling for other factors, the nonambulatory residents at highest risk were those not bed‐bound and with capacity for independent transfer (incidence density ratio (IDR) = 2.92, 95% CI = 1.07–7.99); the ambulatory residents at highest risk were baseline users of psychotropic drugs (IDR = 2.49, 95% CI = 1.43–4.33).CONCLUSIONS: In the study cohort, nonambulatory residents had 35% of injurious falls. Because the circumstances and risk factors of these events were substantially different from those for ambulatory residents, separate prevention strategies may be needed for this group. These data suggest that increasing the safety of transferring and of equipment are appropriate targets for interventions.J Am Geriatr Soc 4

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1996.tb00913.x

出版商:Blackwell Publishing Ltd    

年代:1996

数据来源: WILEY

摘要:

OBJECTIVE: To evaluate differences in functional status and burdens of medical conditions in Mexican American and non‐Hispanic white nursing home residents.DESIGN AND SETTING: Cross‐sectional survey of 17 nursing homes in south Texas.PARTICIPANTS: A total of 617 older nursing home residents, of whom 366 were Mexican American and 251 were non‐Hispanic white.MEASURES: Activities of Daily Living (ADL) status abstracted from standard nurses notes and Burden of Disease abstracted from medical records.RESULTS: Mexican American residents had greater numbers of ADL dependencies and poorer overall ADL scores than non‐Hispanic white residents. This poor functioning was not explained by age, gender, or marital or educational status. The average number of medical conditions was greater, and specific conditions, such as cerebrovascular disease, recent acute infections, diabetes, hypertension, and anemia, were more common in Mexican American residents compared with non‐Hispanic white residents. In models relating function with medical conditions and ethnic group, ADL scores and dependencies were significantly related to bowel and bladder incontinence, cerebrovascular disease, dementia, recent infections, and skin decubiti, but not to ethnic group.CONCLUSION: Mexican American nursing home residents are more functionally dependent than non‐Hispanic white residents. The difference in function is explained by a greater burden of medical conditions in the Mexican American residents.J Am Geriatr Soc 44:27

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1996.tb00914.x

出版商:Blackwell Publishing Ltd    

年代:1996

数据来源: WILEY

摘要:

OBJECTIVE: To study temporal trends and geographic variations in the use of surgery for spinal stenosis, estimate short‐term morbidity and mortality of the procedure, and examine the likelihood of repeat back surgery after surgical repair.DESIGN: Cohort study based on Medicare claims.SETTING: Hospital care.SUBJECTS: All Medicare beneficiaries 65 years of age or older who received a lumbar spine operation for spinal stenosis in 1985 or 1989 were followed through 1991 (10,260 patients from the 1985 cohort and 18,655 from the 1989 cohort).MAIN OUTCOME MEASURES: Two outcomes were measured: (1) rates of operation for spinal stenosis by state and (2) on an individual level, operative complications (cardiopulmonary, vascular, or infectious), postoperative mortality, and time between first operation and any subsequent reoperation.RESULTS: Rates of surgery for spinal stenosis increased eightfold from 1979 to 1992 for patients aged 65 and older and varied almost fivefold among US states. Mortality and operative complications increased with age and comorbidity. Complications were more likely for men and for individuals receiving spinal fusions. The 1989 cohort experienced a slightly higher probability of reoperation than the 1985 cohort for the first 3 years of follow‐up.CONCLUSIONS: A rapid increase in surgery rates for spinal stenosis was identified over a 14‐year period. The wide geographic variations and substantial complication rate from this elective surgical procedure (partly related to patient age) suggest a need for more information on the relative efficacy of surgical and nonsurgical treatments for this condition. The risks and benefits of particular surgical procedures for specific clinical and demographic subgroups as well as individual patient preferences regarding surgical risks and possible outcomes should also be evaluated further. These issues are likely to become increasingly important with the aging of the US population.J Am Geriatr Soc 44:285–29

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1996.tb00915.x

出版商:Blackwell Publishing Ltd    

年代:1996

数据来源: WILEY

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1996.tb00916.x

出版商:Blackwell Publishing Ltd    

年代:1996

数据来源: WILEY