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Background. Stopping driving has significant negative consequences for older adults, but there is no simple, reliable screening tool to predict driving cessation. We sought to determine if self-rated health (SRH) was an independent predictor of driving cessation among older adults. Methods. Data on SRH (poor, fair, good, very good, or excellent), medical diagnoses, physical performance, visual acuity, driving status, and other relevant covariates were collected from 649 community-dwelling older Alabama drivers during in-home interviews. Using multivariable logistic regression analyses, we estimated the association of SRH with driving cessation 2 years later. Results. Participants had a mean age of 74 years; 43% were women, 41% African American, and 48% rural. Overall, 36% reported poor to fair SRH at baseline, and 11% had stopped driving after 2 years. Compared to 8% of drivers with good to excellent SRH, 17% with poor to fair health stopped driving (adjusted odds ratio [OR], 1.93; 95% confidence interval [CI], 1.09-3.41; p = .025). Lower Short Physical Performance Battery (SPPB) scores (adjusted OR, 0.86; 95% CI, 0.78-0.95; p = .001) and older age (adjusted OR, 1.06 per year; 95% CI, 1.01-1.11; p = .010) were also associated with driving cessation. Receiver operating characteristics curves documented similar predictive discrimination (c statistics) for SRH (0.72), the SPPB (0.70), and a count of comorbidities based on the Charlson Comorbidity Index (0.73). Conclusions. Poor to fair SRH predicted incident driving cessation after 2 years in a cohort of older adults. SRH can be easily obtained during clinic visits to identify at-risk drivers.

Purpose: To describe a pilot initiative sponsored by the Veterans Health Administration (VHA) to improve the health and community tenure of frail older veterans living in rural counties 50-100 miles from two host VHA medical centers. Design and Methods: Veterans aged 75 and older who scored at risk of repeated hospital admission on the PRA-Plus telephone questionnaire were targeted and visited by evaluators who administered a comprehensive health questionnaire prior to being assessed at home by the Coordination and Advocacy for Rural Elders (CARE) program clinical teams. Guided by current state-of-the-art practices, the nurse--social worker teams performed in-home standardized assessments using the MDS-HC, developed patient-specific care plans, and mobilized family, community, and VHA resources to implement plans. Results: On average, eight problems were identified for each patient, most commonly falls risk, social needs, pain, and needs related to IADL disability. As a result of initial assessment, two thirds of CARE participants received referral/linkage to formal services, more than half to medical providers. Implications: Through CARE, the VHA is learning more about the unmet needs of older rural veterans. Further development and evaluation should guide the VHA toward providing efficient, effective community-based services to all frail older veterans. Key Words: Case management, Rural aging, MDS-HC

Background. As the number of older adult drivers increases, distinguishing safe from unsafe older adult drivers will become an increasing public health concern. We report on the medical and functional factors associated with vehicle crashes in a cohort of Alabama drivers, 55 years old and older. Methods. This prospective study involved 174 older adults, on whom demographic, medical, functional, and physical performance data were collected in 1991. Subjects were then followed through 1996 for incident vehicle crashes. Results. Sixty-one subjects experienced between one and four police-reported vehicle crashes during the study period. Following adjustment for age, race, days driven per week, and gender, Cox proportional-hazards models showed the following variables to be associated with crash involvement: reported difficulty with yardwork or light housework (relative risk [RR] = 2.1; 95% confidence interval [CI] 1.1, 4.0; p = .02), or opening ajar (RR = 3.1; 95% CI 1.4, 6.7; p = .004); at least one crash before 1991 (RR = 2.1; 95% CI 1.2, 3.7;p = .008); using hypnotic medication (RR = 2.9; 95% CI 1.3, 6.6;p = .0 1); self-reported stroke or transient ischemic attack (RR = 2.7; 95% CI 1.1, 6.6; p = .03); scoring within the depressed range on the Geriatric Depression Scale (RR = 2.5; 95% CI 1.1, 6.0; p = .03), and failing the useful field-of-view test (RR = 1.9; 95% CI 1.0, 3.5; p = .05). Conclusions. Variables related to function, medication use, affect, neurological disease, and visuocognitive skills were associated with vehicle crash involvement in this cohort. Our findings suggest that multifactorial assessments are warranted to identify at-risk older drivers.

Background. Acute gastroenteritis is a cause of considerable morbidity and mortality in the elderly population. A prospective assessment of acute diarrhea in three community-based long-stay homes is described. Methods. A cohort study of acute gastroenteritis was performed in three community-based nursing homes, involving 572 residents over an 8-month period. Diarrhea cases were enrolled on the basis of the acute onset of loose stools of [greater than or equal to] 24 hours, as well as one of the following: a rectal temperature of [greater than or equal to] 100 [degrees] F, dehydration, positive occult blood, [greater than or equal to] 48 hours duration, or as a part of any outbreak. Stool cultures for Clostridium difficile were performed on all NH 1 patients. Results. Fifty-three gastroenteritis cases were ascertained, consistent with incidence rates of 14.6, 36.4, and 6.7 cases/100 patient years in NH 1, NH 2, and NH 3, respectively. Requiring a Foley catheter (OR = 2.57; 95% CI, 0.93, 7.09) increased diarrhea risk. Six Clostridium difficile enteritis cases and an episode attributable to Aeromonas/Pleisomonas species were diagnosed. One C. difficile diarrhea case was imported from hospital to NH 1. Ten of 12 fecal excretors resided in close geographic clusters in NH 1, where a majority of the latter were mobile and incontinent of stool. Conclusions. Acute gastroenteritis was a common disease in the study nursing homes, for which specific risk factors were identified. A predominant role for Clostridium difficile in the taxonomy of nursing home diarrheas was suggested.

Summary Whether or not age by itself increases susceptibility to pneumococcal infections separate from the effects of chronic disease is controversial. To address this issue, data collected for a retrospective [...]

Delirium is defined by criteria of the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM-III) and its revised version (DSM-IIIR). These criteria include: acute onset with a fluctuating or changing course; memory deficits; disorientation; clouding of consciousness indicated by inability to shift, focus, or maintain attention; and abnormalities in psychomotor activities, perceptual abilities, speech, and sleep-wake cycle. Several studies have attempted to determine the prevalence, defined as disease frequency before admission, and incidence, which is number of cases developing in the hospital, of delirium, but these studies had various shortcomings. Older studies did not use a definition of delirium that was comparable to that of DSM-III and DSM-IIIR. When the DSM-II was used, the factors comprising the diagnosis of delirium were not described in operational terms. Finally, studies that use data from medical records to diagnose delirium are necessarily affected by the bias of the persons who recorded the information. An approach was developed to make the DSM-III criteria for delirium operational, and the prevalence and incidence of delirium were determined in 235 subjects aged 70 years and older. The patients were all admitted to general medicine and were identified by screening as having psychiatric disorders. They were seen by a psychiatrist, and the DSM-III criteria for delirium were applied to determine the prevalence and incidence of this delirium. The results show that delirium is prevalent among the elderly at admission, but the incidence of delirium developing in the hospital is lower than has been reported previously. (Consumer Summary produced by Reliance Medical Information, Inc.)