Search

Background The Veterans Health Administration (VA) implemented the comprehensive life-sustaining treatment (LST) Decisions Initiative to provide training and standardize documentation of goals of care and LST preferences for seriously ill Veterans to improve end-of-life (EOL) outcomes. LST documentation is expected for all Home-Based Primary Care (HBPC) Veterans because they are at high risk of hospitalization and mortality. Methods A retrospective, cross-sectional analysis compared associations between Bereaved Family Survey (BFS) EOL care ratings and LST documentation. Participants were Veterans who died August 1, 2018 through September 30, 2019 in one of 55 VA HBPC programs. Regression modeling generated odds for key BFS outcomes. LST template completion rate was plotted by month to understand the interaction between time, LST completion rate, and EOL care family ratings. Results LST preferences were documented for 39% of HBPC Veterans. Family members rated overall EOL care as excellent for 53% of Veterans but significant divergence in BFS ratings occurred during the last 7 months of the study with 60% of family members of LST completers rating care as excellent compared with 48% for Veterans lacking LST documentation (p = 0.003). The adjusted odds of rating overall care in the final month of life as excellent was higher among those with a completed LST template (1.64 95% CI 1.19, 2.26). Conclusions Higher rates of LST documentation were associated with more favorable ratings of EOL but not in initial months following implementation of the comprehensive initiative; however, LST documentation rates were lower than expected among HBPC Veterans. Following an initial period of implementation of a comprehensive national initiative to promote Veteran choice about care during serious illness, documented LST preferences were associated with better family ratings of EOL care. HBPC clinicians may improve the bereaved family experience by using LSDTI tools and training to elicit and document preferences.

While repeat falls are common in post-acute care (PAC), risk factors have not been fully elucidated. The objective of thids study is to evaluate the contribution of cognitive function to repeat falls in older PAC Veterans. Data were collected from medical records for 91 single and 30 repeat fallers over 5 consecutive years (2011–2016). After controlling for demographic and medical factors, lower Mini-Mental State Exam (MMSE) score was associated with increased odds of repeat falls. MMSE scores below 20 (with age held constant at the mean) were associated with a greater than 50% chance of a repeat fall (compared to 24.7% base rate). Admission for a neurologic reason further increased risk. PAC Veterans who experience a fall have an increased risk of repeat falls with concomitant cognitive dysfunction and/or admission for neurologic reasons. Results support tailoring multi-component interventions for those with cognitive dysfunction utilizing standardized mental status screening upon admission.

PURPOSE/OBJECTIVE Evaluate the reliability and validity of the Hopkins Rehabilitation Engagement Scale (HRERS) in a postacute rehabilitation sample. We hypothesized that HRERS items would comprise a single factor, and would demonstrate adequate internal consistency and temporal stability, and significant relationships with key constructs. Research Method and Design: Retrospective medical record review between 2016 and 2017 of older veterans (N = 107) admitted to a community living center postacute care (CLC-PAC) rehabilitation hospital unit to address targeted physical therapy rehabilitation goals. Inclusion criteria included availability of two HRERS administrations at Time 1 (admission) and Time 2 (approximately one-month follow-up or physical therapist/CLC-PAC discharge). RESULTS Across timepoints, HRERS items reflect a single factor of engagement, and the scale has good internal consistency at admission (Time 1, α = .759) and follow-up (Time 2, α = .877). The temporal stability of HRERS across ratings was r = .56 (p < .001). Increased pain rating (r = -.309, p < .01) and depressive symptoms (-.287, p < .01) at admission correlates with subsequent physical therapist (PT) engagement (HRERS Time 2). Low admission PT engagement correlates with less frequent PT attendance (r = -.242, p < .01) and greater number of consults placed during the CLC stay (r = -.222, p < .05). CONCLUSIONS/IMPLICATIONS HRERS is a reliable and valid measure of PT engagement in older CLC-PAC Veterans. Findings support the administration of the HRERS at more than one timepoint during rehabilitation to inform interventions targeting select behavioral health factors such as pain and depression. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Background Telehealth is increasingly used for rehabilitation and exercise but few studies include older adult participants with comorbidities and impairment, particularly cognitive. Using Veterans Administration Video Connect (VVC), the aim of the present study is to present the screening, recruitment, baseline assessment, and initial telehealth utilization of post-hospital discharge Veterans in a VVC home-telehealth based program to enhance mobility and physical activity. Methods Older adult Veterans (n = 45, mean age 73), recently discharged from the hospital with physical therapy goals, were VVC-assessed in self-report and performance-based measures, using test adaptations as necessary, by a clinical pharmacy specialist and social worker team. Results Basic and instrumental ADL disabilities were common as were low mobility (Short Portable Performance Battery) and physical activity levels (measured by actigraphy). Half had Montreal Cognitive Assessment (MoCA) scores in the mild cognitive impairment range ( Conclusions Disabled older post-hospital discharged Veterans with physical therapy goals can be VVC-assessed and enrolled into a mobility/physical activity intervention. A substantial proportion required technical support, including in-person support for many. Yet, VVC seems feasible in those with mild cognitive impairment, assuming the presence of an able caregiver. Modifications of assessment tools were needed for the VVC interface, and while appearing feasible, will require further study. Trial registration ClinicalTrials.gov NCT 04045054 05/08/2019.

Background Process mapping is often used in quality improvement work to examine current processes and workflow and to identify areas to intervene to improve quality. Our objective in this paper is to describe process maps as a visual means of understanding modifiable behaviors and activities, in this case example to ensure that goals of care conversations are part of admitting a veteran in long-term care settings. Methods We completed site visits to 6 VA nursing homes and reviewed their current admission processes. We conducted interviews to document behaviors and activities that occur when a veteran is referred to a long-term care setting, during admission, and during mandatory VA reassessments. We created visualizations of the data using process mapping approaches. Process maps for each site were created to document the admission activities for each VA nursing home and were reviewed by the research team to identify consistencies across sites and to identify potential opportunities for implementing goals of care conversations. Results We identified five consistent behaviors that take place when a veteran is referred and admitted in long-term care. These behaviors are assessing, discussing, decision-making, documenting, and re-assessing. Conclusions Based on the process maps, it seems feasible that the LST note and order template could be completed along with other routine assessment processes. However, this will require more robust multi-disciplinary collaboration among both prescribing and non-prescribing health care providers. Completing the LST template during the current admission process would increase the likelihood that the template is completed in a timely manner, potentially alleviate the perceived time burden, and help with the provision of veteran-centered care.

Background User-centered design (UCD) methods are well-established techniques for creating useful artifacts, but few studies illustrate their application to clinical feedback reports. When used as an implementation strategy, the content of feedback reports depends on a foundational audit process involving performance measures and data, but these important relationships have not been adequately described. Better guidance on UCD methods for designing feedback reports is needed. Our objective is to describe the feedback report design method for refining the content of prototype reports. Methods We propose a three-step feedback report design method (refinement of measures, data, and display). The three steps follow dependencies such that refinement of measures can require changes to data, which in turn may require changes to the display. We believe this method can be used effectively with a broad range of UCD techniques. Results We illustrate the three-step method as used in implementation of goals of care conversations in long-term care settings in the U.S. Veterans Health Administration. Using iterative usability testing, feedback report content evolved over cycles of the three steps. Following the steps in the proposed method through 12 iterations with 13 participants, we improved the usability of the feedback reports. Conclusions UCD methods can improve feedback report content through an iterative process. When designing feedback reports, refining measures, data, and display may enable report designers to improve the user centeredness of feedback reports.

This comprehensive clinical guideline addresses pain issues that arise in care of patients commonly seen in post-acute and long-term care settings, including very old and frail individuals with multiple chronic medical and psychiatric conditions, short-stay patients needing posthospitalization care, and younger adults with chronic diseases and disabilities. Its sections proceed along the steps of the clinical process, and hence include pain definition, recognition, and assessment; diagnosis and cause-effect analysis; identification of care objectives; selection of interventions from the wide range or potential options, including a discussion of appropriate and rational use of opioids; and monitoring of the progress and outcomes of management decisions. The guideline emphasizes treating pain in the context of each patient's overall condition and not as a separate issue. It includes discussion of such challenging issues as responsibilities and capabilities of the staff and practitioners, what to do when patients persistently experience high pain levels despite substantial doses of analgesics, and how best to address the expectations of relevant regulations and surveyor guidelines. By including numerous hypertext links within the document, the CPG facilitates finding related information in different sections as well as external references and resources that provide additional support.

OBJECTIVEThe impact of healthcare system integration on infection prevention programs is unknown. Using catheter-associated urinary tract infection (CAUTI) prevention as an example, we hypothesize that US Department of Veterans Affairs (VA) nursing homes have a more robust infection prevention infrastructure due to integration and centralization compared with non–VA nursing homes.SETTINGVA and non-VA nursing homes participating in the AHRQ Safety Program for Long-Term Care collaborative.METHODSNursing homes provided baseline information about their infection prevention programs to assess strengths and gaps related to CAUTI prevention via a needs assessment questionnaire.RESULTSA total of 353 of 494 nursing homes from 41 states (71%; 47 VA and 306 non-VA facilities) responded. VA nursing homes reported more hours per week devoted to infection prevention-related activities (31 vs 12 hours; PPP=.014) and with nursing personnel (85% vs 56%, P=.003). However, fewer VA nursing homes reported having policies for appropriate catheter use (64% vs 81%; P=.004) and catheter insertion (83% vs 94%; P=.004).CONCLUSIONSAmong nursing homes participating in an AHRQ-funded collaborative, VA and non-VA nursing homes differed in their approach to CAUTI prevention. Best practices from both settings should be applied universally to create an optimal infection prevention program within emerging integrated healthcare systems.Infect Control Hosp Epidemiol 2017;38:287–293

Objectives: Evaluate the relative contribution of cognitive test performance to post-acute care (PAC) length of stay (LOS) and rehospitalization while controlling for key demographic, medical, and functional outcomes. Methods: Retrospective medical record review of 160 older Veterans, including cognitive test performance (Addenbrooke’s Cognitive Examination–Revised [ACE-R]), on admission to a Veterans Administration Hospital Community Living Center (CLC) PAC. Results: Individuals with impaired scores on the ACE-R had a longer LOS (10 median days longer; U = 2,547.00, p = .028). Of those rehospitalized, 71.4% ( n = 20) screened positive for cognitive impairment. Key medical factors explained the largest amount of variance in CLC-PAC LOS (29.8%), followed by admission ADL (activities of daily living) dependency (4.6%) and ACE-R total score (3.30%). Discussion: Cognitive screening should be considered on PAC admission, with impairment on ACE-R predicting geriatric rehabilitation outcomes such as risk of increased LOS and rehospitalization.

Context As part of its Life-Sustaining Treatment (LST) Decisions Initiative, the Veterans Health Administration (VA) in January 2017 began requiring electronic documentation of goals of care and preferences for Veterans with serious illness and at high risk for life-threatening events. Objectives To evaluate whether goals of “to be comfortable” were associated with greater palliative care (PC) use and lesser acute care use. Methods We identified Veterans with VA inpatient or nursing home stays overlapping July 2018–January 2019, with LST templates documented by January 31, 2019, and who died by April 30, 2019 (N = 18,163). From template documentation, we identified a “to be comfortable” goal. Using VA and Medicare data, we determined PC use (consultations and hospice) and hospital, intensive care unit, and emergency department use 7 and 30 days before death. Multivariate logistic regression examined the associations of interest. Results Sixty-four percent of the 18,163 Veterans had comfort-care goals; 80% with comfort care goals received hospice and 57% PC consultations (versus 57% and 46%, respectively, for decedents without comfort-care goals). In adjusted analyses, comfort care documented on the LST template prior to death was associated with significantly lower odds of hospital, intensive care unit, and emergency department use near the end of life. In the last 30 days of life, Veterans with a comfort care goal had 44% lower odds (adjusted odds ratio 0.57; 95% CI: 0.51, 0.63) of being hospitalized. Conclusion Findings support the VA's commitment to honoring of Veterans' preferences post introduction of its Life Sustaining Treatment Decisions Initiative.

The program "Implementing Goals of Care Conversations with Veterans in VA LTC Settings" is proposed in partnership with the US Veterans Health Administration (VA) National Center for Ethics in Health Care and the Geriatrics and Extended Care Program Offices, together with the VA Office of Nursing Services. The three projects in this program are designed to support a new system-wide mandate requiring providers to conduct and systematically record conversations with veterans about their preferences for care, particularly life-sustaining treatments. These treatments include cardiac resuscitation, mechanical ventilation, and other forms of life support. However, veteran preferences for care go beyond whether or not they receive life-sustaining treatments to include issues such as whether or not they want to be hospitalized if they are acutely ill, and what kinds of comfort care they would like to receive.Three projects, all focused on improving the provision of veteran-centered care, are proposed. The projects will be conducted in Community Living Centers (VA-owned nursing homes) and VA Home-Based Primary Care programs in five regional networks in the Veterans Health Administration. In all the projects, we will use data from context and barrier and facilitator assessments to design feedback reports for staff to help them understand how well they are meeting the requirement to have conversations with veterans about their preferences and to document them appropriately. We will also use learning collaboratives-meetings in which staff teams come together and problem-solve issues they encounter in how to get veterans' preferences expressed and documented, and acted on-to support action planning to improve performance.We will use data over time to track implementation success, measured as the proportions of veterans in Community Living Centers (CLCs) and Home-Based Primary Care (HBPC) who have a documented goals of care conversation soon after admission. We will work with our operational partners to spread approaches that work throughout the Veterans Health Administration.

Heart failure (HF) often presents as dyspnea either with exertion and/or recumbency. Patients also experience dependent swelling and fatigue. Measurement of the left ventricular ejection fraction (LVEF) identifies HF patients who may respond to pharmacologic therapy and/or electrophysiologic device implantation. Angiotension converting enzyme inhibitors, beta blockers, and aldosterone inhibitors can significantly lower the mortality and morbidity of HF in patients with an LVEF less than 35%. Cardiac defibrillators and biventricular pacemakers can also improve outcomes in selected patients with a decreased LVEF. The authors provide a guide for therapeutic decisions based on the inclusion criteria of the major clinical trials.

Background The program “Implementing Goals of Care Conversations with Veterans in VA LTC Settings” is proposed in partnership with the US Veterans Health Administration (VA) National Center for Ethics in Health Care and the Geriatrics and Extended Care Program Offices, together with the VA Office of Nursing Services. The three projects in this program are designed to support a new system-wide mandate requiring providers to conduct and systematically record conversations with veterans about their preferences for care, particularly life-sustaining treatments. These treatments include cardiac resuscitation, mechanical ventilation, and other forms of life support. However, veteran preferences for care go beyond whether or not they receive life-sustaining treatments to include issues such as whether or not they want to be hospitalized if they are acutely ill, and what kinds of comfort care they would like to receive. Methods Three projects, all focused on improving the provision of veteran-centered care, are proposed. The projects will be conducted in Community Living Centers (VA-owned nursing homes) and VA Home-Based Primary Care programs in five regional networks in the Veterans Health Administration. In all the projects, we will use data from context and barrier and facilitator assessments to design feedback reports for staff to help them understand how well they are meeting the requirement to have conversations with veterans about their preferences and to document them appropriately. We will also use learning collaboratives—meetings in which staff teams come together and problem-solve issues they encounter in how to get veterans’ preferences expressed and documented, and acted on—to support action planning to improve performance. Discussion We will use data over time to track implementation success, measured as the proportions of veterans in Community Living Centers (CLCs) and Home-Based Primary Care (HBPC) who have a documented goals of care conversation soon after admission. We will work with our operational partners to spread approaches that work throughout the Veterans Health Administration. Electronic supplementary material The online version of this article (doi:10.1186/s13012-016-0497-0) contains supplementary material, which is available to authorized users.

Objectives To evaluate the differential value of a self-reported health and safety awareness measure relative to other medical, psychosocial, and cognitive factors in predicting level of care (LOC) needs after hospital discharge. Design Retrospective medical record review. Setting Community living center postacute care (CLC-PAC) unit at a Veterans Affairs hospital. Participants A total of 175 veterans admitted to the Veterans Affairs hospital or directly to the CLC-PAC from home. Methods Cognitive status was assessed with the Mini-Mental State Examination, Digit Span Backward subtest, Trail Making Test (Part B), and Hopkins Verbal Learning Test-Revised. Self-report of health and safety awareness was measured with the Independent Living Scales Health and Safety (ILS-HS) subscale. Additional demographic and admission-related variables were coded, along with medical comorbidity, with the Charlson Comorbidity Index and depression using the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision Depression Checklist. Main Outcome Measurements Increased level of care was collected from social work and occupational therapy notes and defined as increased assistance with activities of daily living or nursing home placement comparing prehospitalization with CLC-PAC discharge. Results A total of 19% (n = 34) of residents required increased LOC on CLC-PAC discharge. The ILS-HS was a significant predictor of increased LOC above and beyond age and Mini Mental Status Examination score; for each standard deviation decrease in ILS-HS, there was an increased likelihood of greater LOC (odds ratio 0. 54, 95% confidence interval 0.35-0.83). Other neuropsychological tests (memory, executive functioning) did not significantly improve the model. Conclusions The inclusion of the ILS-HS to a standard cognitive screen (Mini Mental Status Examination) can improve prediction of increased LOC. Although select aspects of memory and executive functioning independently contribute to increased LOC prediction, the ILS-HS likely measures a unique aspect of cognitive functioning that may be specific to discharge planning needs in CLC-PAC residents. Level of Evidence II

To test whether changes in sympathetic nervous system (SNS) activity or insulin sensitivity contribute to the heterogeneous blood pressure response to aerobic exercise training, we used compartmental analysis of [3H]norepinephrine kinetics to determine the extravascular norepinephrine release rate (NE2) as an index of systemic SNS activity and determined the insulin sensitivity index (SI) by an intravenous glucose tolerance test, before and after 6 mo of aerobic exercise training, in 30 (63 ± 7 yr) hypertensive subjects. Maximal O2consumption increased from 18.4 ± 0.7 to 20.8 ± 0.7 ml · kg−1· min−1( P = 0.02). The average mean arterial blood pressure (MABP) did not change (114 ± 2 vs. 114 ± 2 mmHg); however, there was a wide range of responses (−19 to +17 mmHg). The average NE2did not change significantly (2.11 ± 0.15 vs. 1.99 ± 0.13 μg · min−1· m−2), but there was a significant positive linear relationship between the change in NE2and the change in MABP ( r = 0.38, P = 0.04). SIincreased from 2.81 ± 0.37 to 3.71 ± 0.42 μU × 10−4· min−1· ml−1( P = 0.004). The relationship between the change in SIand the change in MABP was not statistically significant ( r = −0.03, P = 0.89). When the changes in maximal O2consumption, percent body fat, NE2, and SIwere considered as predictors of the change in MABP, only NE2was a significant independent predictor. Thus suppression of SNS activity may play a role in the reduction in MABP and account for a portion of the heterogeneity of the MABP response to aerobic exercise training in older hypertensive subjects.

Heart failure (HF) often presents as dyspnea either with exertion and/or recumbency. Patients also experience dependent swelling and fatigue. Measurement of the left ventricular ejection fraction (LVEF) identifies HF patients who may respond to pharmacologic therapy and/or electrophysiologic device implantation. Angiotension converting enzyme inhibitors, beta blockers, and aldosterone inhibitors can significantly lower the mortality and morbidity of HF in patients with an LVEF less than 35%. Cardiac defibrillators and biventricular pacemakers can also improve outcomes in selected patients with a decreased LVEF. The authors provide a guide for therapeutic decisions based on the inclusion criteria of the major clinical trials.

Comprehensive health care for older adults is complex, involving multiple comorbidities and functional impairments of varying degrees and numbers. In response to this complexity and associated barriers to care, home-based care models have become prevalent. The home-based primary care (HBPC) model, based at a Michigan Department of Veterans Affairs Medical Center, and the Michigan Waiver Program (MWP) that includes home-based care are 2 of these. Although both models are formatted to address barriers to effective and efficient health care, there are differences in disease prevalence and functional performance between groups. The objective of this study was to explore the differences between the 2 groups, to shed some light on potential trends that could suggest areas for resource allocation by service providers.Using a retrospective analysis of data collected using the interRAI-home care, we examined a cross-sectional representation of clients enrolled in HBPC and MWP in 2008.The HBPC sample had 89 participants. The MWP database contained 9324 participants from across the State of Michigan and were weighted to be comparable to the HBPC population in sex and age, and to simulate the HBPC sample size.Veterans were more independent in basic activities of daily living performance, but there was no difference in the rate of reported falls between the 2 groups. Veterans had more pain and a higher prevalence of coronary artery disease (z = 7.0; P.001), Chronic obstructive pulmonary disease (z = 3.9; P.001), and cancer (z = 8.5; P.001). There was no statistically significant difference between the 2 groups in terms of the prevalence of geriatric syndromes. Scores on subscales of the interRAI-home care indicated a lower risk of serious health decline and adverse outcomes for MWP compared with HBPC clients (1.4 ± 1.1 vs 0.9 ± 0.1; z = 2.5; P = .012). Veterans receiving home-based care through the Veterans Affairs Medical Center were more burdened by chronic disease and had higher degrees of loneliness than their MWP counterparts- factors, which may increase their likelihood of hospitalizations. MWP participants had more cases of cerebrovascular accident (z = 2.1; P = .039), as well as a higher rate of diagnosed dementias (z = 2.7; P = .006). Though not different, stress among caregivers in both groups, and depression in clients of both groups were substantial. Overall, sleep, pain, coronary artery disease, chronic obstructive pulmonary disease, and cancer are significant issues for Veteran clients, and clients treated through MWP home-care in Michigan have higher than national average rates of dementias, diabetes, hypertension, and coronary artery disease.With expanded home care models of service on the horizon, comparisons such as the one presented here could identify more efficient and effective service, with potential for improved client health outcomes.

The purpose of this study was to test the hypothesis that there is homologous upregulation of arterial alpha-adrenergic responsiveness during suppression of sympathetic nervous system (SNS) activity in humans. 10 subjects (19-28 yr) were studied during placebo and when SNS activity was suppressed by guanadrel. Changes in forearm blood flow (FABF) mediated by the intraarterial infusion of norepinephrine (NE), angiotensin II (AII), and phentolamine were measured by plethysmography. During guanadrel compared with placebo, plasma NE levels (1.28 +/- 0.09-0.85 +/- 0.06 nM; P = 0.0001) and the extra vascular NE release rate derived from [3H]NE kinetics were lower (7.1 +/- 0.7-4.0 +/- 0.2 nmol/min per m2; P = 0.0004), suggesting suppression of SNS activity. During guanadrel, there was increased sensitivity in the FABF response to NE (analysis of variance P = 0.03). In contrast, there was no difference in the FABF response to AII (analysis of variance P = 0.81), suggesting that the upregulation observed to NE was homologous. The increase in FABF during phentolamine was similar during guanadrel compared with placebo (guanadrel: 141 +/- 37 vs. placebo; 187 +/- 27% increase; P = 0.33), suggesting that there was at least partial compensation to maintain constant endogenous arterial alpha-adrenergic tone. We conclude that there is homologous upregulation of arterial alpha-adrenergic responsiveness in humans when SNS activity is suppressed by guanadrel.

Decreased adrenergic responsiveness in human aging could be a result of downregulation mediated by the age-related increase in sympathetic nervous system (SNS) tone. If so, suppression of SNS tone in elderly subjects should upregulate adrenergic responsiveness into the range observed for younger subjects. To test this hypothesis, we examined alpha 1 (phenylephrine)- and alpha 2 (clonidine)-adrenergic agonist-mediated venoconstriction in a group of 15 older healthy subjects (age 59-73 yr) during placebo and when SNS tone was suppressed by guanadrel (15 mg twice daily for 3 wk). During guanadrel compared with placebo 1) there were decreases in plasma norepinephrine (NE) levels (1.47 +/- 0.07 to 0.80 +/- 0.06 nM; P less than 0.001) and in the extravascular NE release rate derived from [3H]NE kinetics (11.8 +/- 1.4 to 6.1 +/- 1.0 nmol.min-1.m-2; P = 0.01), suggesting suppression of SNS tone; 2) there was an augmented clonidine-mediated venoconstriction response [analysis of variance (ANOVA) P = 0.01]; and 3) there was no detectable change in phenylephrine-mediated venoconstriction (ANOVA P = 0.60). When compared with previous results from young subjects, maximal alpha 2-adrenergic venoconstriction during guanadrel was decreased in the elderly compared with the young, although their response appeared to be appropriately upregulated by the decrease in SNS tone. The lack of an age-related decrease in alpha 1-adrenergic venoconstriction, together with the lack of upregulation of this response during guanadrel, suggests that regulation of this alpha 1-adrenergic response is impaired in the older group.

Heart failure caused by systolic dysfunction affects more than 5 million adults in the United States and is a common source of outpatient visits to primary care physicians. Mortality rates are high, yet a number of pharmacologic interventions may improve outcomes. Other interventions, including patient education, counseling, and regular self-monitoring, are critical, but are beyond the scope of this article. Angiotensin-converting enzyme inhibitors and beta blockers reduce mortality and should be administered to all patients unless contraindicated. Diuretics are indicated for symptomatic patients as needed for volume overload. Aldosterone antagonists and direct-acting vasodilators, such as isosorbide dinitrate and hydralazine, may improve mortality in selected patients. Angiotensin receptor blockers can be used as an alternative therapy for patients intolerant of angiotensin-converting enzyme inhibitors and in some patients who are persistently symptomatic. Digoxin may improve symptoms and is helpful for persons with concomitant atrial fibrillation, but it does not reduce cardiovascular or all-cause mortality. Serum digoxin levels should not exceed 1.0 ng per mL (1.3 nmol per L), especially in women.

Results of recent studies from high-volume academic centers suggest that coronary artery bypass grafting (CABG) is becoming safer to perform in octogenarians. Similar data from community-based facilities do not exist.To assess the clinical and economic outcomes of nonemergency CABG in 338 octogenarians at 27 community-based facilities across the United States.Retrospective cohort analysis.Multivariate analyses were used to compare (1) in-hospital mortality rates, (2) rates of discharge to extended-care facilities, (3) lengths of stay, and (4) in-hospital costs between octogenarians and younger patients.Of 338 patients 80 years or older, the in-hospital mortality rate was higher (4.7% vs 2.1%; P = .002), the rate of discharge to extended-care facilities was greater (24.9% vs 4.8%; P.001), the length of stay was longer (9.6 vs 7.9 days; P.001), and in-hospital costs were higher ($20,188 vs $18,196; P.001) compared with patients younger than 80 years. After adjusting for several covariates, we found that octogenarians were at significantly greater risk of experiencing in-hospital deaths (odds ratio, 4.6; P = .001), of being discharged to extended-care facilities (odds ratio, 28.4; P.001), and of having longer lengths of stay (difference, 0.7 days; P = .002) than were patients aged 50 to 59 years.At these 27 community-based facilities, the in-hospital mortality for nonemergency CABG in octogenarians was 4.7%; however, nearly 25% of surviving octogenarians were discharged to extended-care facilities.

The majority of older hypertensive humans are sodium sensitive and they are characterized by increased alpha-adrenergic responsiveness relative to their level of sympathetic nervous system (SNS) activity. To test the hypothesis that heightened SNS activity and/or increased alpha-adrenergic receptor responsiveness during sodium loading may play a role in the sodium-dependent increase in blood pressure in older sodium-sensitive hypertensives, we used compartmental analysis of [3H]norepinephrine (NE) kinetics to determine the release rate of NE into an extravascular compartment (NE2) as an index of systemic SNS activity and determined forearm blood flow responses to graded intrabrachial artery NE and angiotensin II (ANG II) infusions and platelet membrane alpha2-receptor properties in 24 older (age 64 +/- 7 years) hypertensive subjects. Subjects were studied at the end of 1 week of a low (20 mmol/day)- and again at the end of 1 week of a high (200 mmol/day)-sodium diet. Subjects were categorized as sodium sensitive (SS) if they had a > or = 5 mm Hg increase in mean arterial blood pressure (MABP) with dietary sodium loading (n = 16), or sodium-resistant (SR) if their MABP increased by < 5 mm Hg (n = 8). Neither dietary sodium intake nor sodium-sensitivity status significantly affected arterial plasma NE levels, NE2, or other NE kinetic parameters. Forearm blood flow responses to NE or to ANG II, and platelet alpha2-receptor properties were similar between the SS and SR groups. These results suggest that the sodium-dependent increase in MABP that characterizes SS hypertension among older humans is not because of an increase in systemic SNS activity or increased arterial adrenergic receptor responsiveness.

The purpose of the study was to determine if exercise-induced vasodilation was associated with an increase in forearm plasma levels of nitric oxide (NO) biomarkers (NO 2 - + NO 3 - and L-citrulline). Twelve healthy subjects (27 ± 6 yrs) performed incremental rhythmic forearm exercise with the nondominant hand for 6 min each at 15, 30 and 45% of maximal voluntary contraction (MVC). Forearm blood flow (FBF) was determined in the exercise arm using venous occlusion plethysmography. Blood samples were obtained from the antecubital vein of the exercise and nonexercise arms for the measurement of NO biomarkers. In the exercise arm, FBF increased by a mean of 150%, 335% and 585% above baseline at 15, 30 and 45% of MVC, respectively. (ANOVA, P = 0.0001). Venous plasma NO 2 - + NO 3 - levels increased from 24±4 μmol/L at baseline, to 29±5, 32±4 and 35±4 μmol/L (ANOVA, P = 0.0001). Venous plasma L-citrulline levels increased from 31 ± 5 μmol/L at baseline to 58±10, 87±7 and 141± 15 μmol/L (ANOVA, P = 0.0001). There was a linear relationship between FBF and venous plasma NO 2 - + NO 3 - (slope= 0.38±0.10, P = 0.0007) and between L-citrulline, (slope = 5.1±1.3, P = 0.0004). Venous plasma levels of NO 2 - + NO 3 - and L-citrulline in the nonexercise arm were unchanged. These results demonstrate that exercise-induced vasodilation in the forearm is associated with forearm plasma levels of NO 2 - + NO 3 - and L-citrulline, in vivo markers of NO production.

To assess the effects of a multimedia educational intervention about advance directives (ADs) and cardiopulmonary resuscitation (CPR) on the knowledge, attitude and activity toward ADs and life-sustaining treatments of elderly veterans.Prospective randomized controlled, single blind study of educational interventions.General medicine clinic of a university-affiliated Veterans Affairs Medical Center (VAMC).One hundred seventeen Veterans, 70 years of age or older, deemed able to make medical care decisions.The control group (n = 55) received a handout about ADs in use at the VAMC. The experimental group (n = 62) received the same handout, with an additional handout describing procedural aspects and outcomes of CPR, and they watched a videotape about ADs.Patients' attitudes and actions toward ADs, CPR and life-sustaining treatments were recorded before the intervention, after it, and 2 to 4 weeks after the intervention through self-administered questionnaires. Only 27.8% of subjects stated that they knew what an AD is in the preintervention questionnaire. This proportion improved in both the experimental and control (87.2% experimental, 52.5% control) subject groups, but stated knowledge of what an AD is was higher in the experimental group (odds ratio = 6.18, p.001) and this effect, although diminished, persisted in the follow-up questionnaire (OR = 3.92, p =. 003). Prior to any intervention, 15% of subjects correctly estimated the likelihood of survival after CPR. This improved after the intervention in the experimental group (OR = 4.27, p =.004), but did not persist at follow-up. In the postintervention questionnaire, few subjects in either group stated that they discussed CPR or ADs with their physician on that day (OR = 0.97, p = NS).We developed a convenient means of educating elderly male patients regarding CPR and advance directives that improved short-term knowledge but did not stimulate advance care planning.

Background There are important interactions between the renin-angiotensin system and the sympathetic nervous system. Therapy with angiotensin-converting enzyme (ACE) inhibitors may suppress sympathetic nervous system activity. Objective To test the hypothesis that long-term ACE inhibition by ramipril will suppress sympathetic nervous system activity and up-regulate α-adrenergic receptor responsiveness in older patients with hypertension. Methods This placebo-controlled, double-blind randomized study was conducted at the University Hospital, General Clinical Research Center, University of Michigan Medical Center. Fifteen healthy older patients with mild to moderate hypertension received 8 weeks of ramipril therapy with doses ranging from 5 mg to 20 mg. The following measurements were obtained: plasma norepinephrine levels; norepinephrine kinetic parameters derived from plasma norepinephrine and 3H-norepinephrine levels obtained during infusion and disappearance of 3H-norepinephrine, including the extravascular norepinephrine release rate, norepinephrine clearance, spillover fraction, and volume of distribution; forearm blood flow; platelet membrane α2-receptor binding characteristics, and adenylyl cyclase activity. Results Although plasma norepinephrine levels increased in the subjects treated with ramipril, there were no significant differences from baseline in the rate of norepinephrine appearance into the vascular compartment (P = .76) or in the rate of norepinephrine release into the extravascular compartment (P = .92). In addition, no differences were observed in other norepinephrine kinetic parameters (norepinephrine spillover fraction, norepinephrine volume of distribution, or clearance) between the ramipril and placebo groups. Consistent with this, there was no apparent change in measures of vascular or platelet α-adrenergic receptor responsiveness. Conclusions Ramipril therapy did not suppress systemic sympathetic nervous system activity, alter other norepinephrine kinetic parameters, or alter α-adrenergic responsiveness in older patients with hypertension. Clinical Pharmacology & Therapeutics (1999) 65, 420–427; doi

We have previously demonstrated in normotensive humans an age-associated increase in sympathetic nervous system (SNS) activity combined with appropriate downregulation of α-adrenergic responsiveness. Impaired downregulation of α-adrenergic responsiveness, despite a comparable level of SNS activity, could contribute to higher blood pressure in older hypertensive humans. We measured arterial plasma norepinephrine (NE) levels and the extravascular NE release rate (NE2) derived from [3H]NE kinetics (to assess systemic SNS activity), and platelet and forearm arterial adrenergic responsiveness in 20 normotensive (N) and in 24 hypertensive (H), otherwise healthy, older subjects (60–75 yr). Although plasma NE levels were similar (N 357 ± 27 vs. H 322 ± 22 pg/ml; P = 0.37), NE2tended to be greater in the hypertensive group (H 2.23 ± 0.21 vs. N 1.64 ± 0.20 μg ⋅ min−1⋅ m−2; P = 0.11), and the NE metabolic clearance rate was greater (H 1,100 ± 30 vs. N 900 ± 50 ml/m2; P = 0.004). In the hypertensive group, there was a greater α-agonist-mediated inhibition of platelet membrane adenylyl cyclase activity and a NE- but not ANG II-mediated decrease in forearm blood flow. Compared with normotensive subjects, in older hypertensive subjects 1) NE metabolic clearance rate is increased, 2) systemic SNS activity tends to be increased, and 3) arterial and platelet α-adrenergic responsiveness is enhanced. These results suggest that heightened SNS activity coupled with enhanced α-adrenergic responsiveness may contribute to elevated blood pressure in older hypertensive humans.

The purpose of this study was to determine whether sodium-resistant hypertensives are more insulin resistant and whether dietary sodium restriction improves insulin sensitivity in older hypertensives. Insulin sensitivity was assessed by a frequently sampled intravenous glucose tolerance test to determine the insulin sensitivity index (SI) after 1 wk each of low- (20 mmol ⋅ l−1 ⋅ day−1) and high- (200 mmol ⋅ l−1 ⋅ day−1) sodium diets in 21 older (63 ± 2 yr) hypertensives. Subjects were grouped on the difference in mean arterial blood pressure (MABP) between diets [sodium sensitive (SS): ≥5-mmHg increase in MABP on the high-sodium diet ( n = 14); sodium resistant (SR): I. An analysis of variance indicated a significant ( P = 0.0002) group effect, with SS individuals having lower fasting plasma insulins on the low- (13 ± 2 vs. 27 ± 3 μU/ml) and high- (12 ± 2 vs. 22 ± 3 μU/ml) sodium diets compared with SR individuals. Similarly, there was a significant ( P= 0.0002) group effect in regard to SI, with SS individuals having significantly higher SI on the low- (3.26 ± 0.60 vs. 0.91 ± 0.31 μU × 10−4 ⋅ min−1 ⋅ ml−1) and high- (3.45 ± 0.51 vs. 1.01 ± 0.30 μU × 10−4 ⋅ min−1 ⋅ ml−1) sodium diets compared with SR individuals. We conclude that SR individuals exhibit a greater degree of insulin resistance than SS individuals and that dietary sodium restriction fails to improve insulin sensitivity regardless of sodium sensitivity status.

We tested the hypotheses that 1) there is an age-associated decrease in arterial alpha-adrenergic responsiveness and 2) there is upregulation of this response during suppression of sympathetic nervous system (SNS) activity. We measured forearm blood flow (FABF) by plethysmography during brachial artery infusions of the alpha-adrenergic agonist norepinephrine (NE) and the nonadrenergic agonist angiotensin II (ANG II) in 15 young and 14 older healthy human subjects. Among the old (O) relative to the young (Y) we identified greater plasma NE levels (Y: 1.29 +/- 0.07 nM vs. O: 2.14 +/- 0.17 nM; P = 0.0001); a decrease in NE-mediated reduction in FABF [analysis of variance (ANOVA) P = 0.04]; and, in contrast, no difference in ANG II-mediated reduction in FABF (ANOVA P = 0.43). In the nine older subjects studied during guanadrel (G) to suppress SNS activity, we identified decreased plasma NE levels [placebo (P): 2.11 +/- 0.24 nM vs. G: 1.09 +/- 0.09 nM; P = 0.002], increased NE-mediated FABF response (ANOVA P = 0.01), and no difference in FABF response to ANG II (ANOVA: P = 0.69) compared with P. We conclude that there is appropriate desensitization of arterial alpha-adrenergic responsiveness among the older relative to the young subjects that is specific for the alpha-adrenergic system. Among the older subjects there is homologous upregulation of this response when SNS activity is suppressed.

BACKGROUND The purpose of this study was to determine whether age is a predictor of sensitivity to the peripheral effects of insulin on carbohydrate metabolism independent of the potential influences of the level of sympathetic nervous system (SNS) activity and blood pressure (BP). METHODS In 60 human subjects (age range 19-78 years), insulin sensitivity, SI, was determined from glucose and insulin levels obtained during an intravenous glucose tolerance test, and plasma norepinephrine (NE) levels were measured to estimate SNS activity. RESULTS There were age-associated increases in plasma NE level (r = .585; p < .001) and mean arterial BP (r = .516; p < .001), and an age-associated decline in SI (r = -.352; p = .04). However, in stepwise multiple regression analysis, body mass index (BMI) and mean arterial BP were the only independent predictors of SI, accounting for 43% of the variance in SI; age, plasma NE level, plasma epinephrine level, and fasting plasma glucose did not enter the model. Although these results suggest an age-associated decline in insulin sensitivity, this decline appears to be associated with BMI and mean arterial BP rather than aging per se. In addition, the age-associated increase in SNS activity was not found to be an independent predictor of insulin sensitivity. CONCLUSION This study demonstrates that in addition to BMI, blood pressure should be considered as another confounding factor in studies of insulin sensitivity in human aging.

We have previously found that elderly humans have increased plasma norepinephrine (NE) levels and reduced alpha 2-adrenergic receptor-mediated inhibition of platelet membrane adenylyl cyclase activity. One possible mechanism for the latter finding is a decrease of high affinity platelet alpha 2-adrenergic receptor density in the elderly. To test this possibility, we used the alpha 2-adrenergic receptor agonist radioligand [3H]bromoxidine to define platelet alpha 2-adrenergic receptor high affinity binding sites in 31 young (age 19-31 yr) and 25 older (age 61-75 yr) normal human subjects. Plasma NE levels were higher (1.65 +/- 0.44 vs 1.12 +/- 0.37 nM; p = .0001) and epinephrine (EPI)-mediated adenylyl cyclase inhibition was lower in the older group (40 +/- 2 vs 50 +/- 2% inhibition at 10(-4) M EPI; p = .04). Although total platelet alpha 2-adrenergic receptor density was similar ([3H]yohimbine Bmax: Young: 140 +/- 10 vs Old: 135 +/- 9 fmol/mg protein; p = .71), receptor density for [3H]bromoxidine was significantly lower in the older group (30 +/- 3 vs 42 +/- 4 fmol/mg protein; p = .02). We conclude that there is an age-associated decrease in high affinity platelet alpha 2-adrenergic receptor density in humans which may contribute to the age-associated reduction in receptor-mediated inhibition of adenylyl cyclase.

he purpose of this study was to test the hypothesis that heightened sympathetic nervous system (SNS) activity contributes to the mechanism by which hypertension is associated with insulin resistance in humans. We performed frequently sampled intravenous glucose tolerance tests to determine tissue sensitivity to metabolic effects of insulin (SI) and measured plasma norepinephrine (NE) levels in 21 normotensive and 14 hypertensive Caucasian subjects. Compared with the normotensive subjects, hypertensive subjects had decreased SI (5.4 +/- 0.5 vs. 4.0 +/- 0.7 x 10(-5) x min-1 x pM-1; P = 0.03) but similar plasma NE levels (normotensive: 1.82 +/- 0.12 vs. hypertensive: 1.73 +/- 0.16 nM; P = 0.23). In a multiple regression model, only body mass index (BMI) and mean arterial blood pressure (MABP) were significant independent predictors of SI [SI = (-0.513)(BMI) + (-0.058)(MABP) + 23.6; r = 0.748; P = 0.0001]; age, plasma glucose, epinephrine, and NE level did not enter this model. As an additional test of this hypothesis, seven hypertensive subjects were restudied after 10 days of guanadrel therapy to determine whether SI would increase during suppression of SNS activity by guanadrel. Despite a significant reduction in plasma NE levels with guanadrel (baseline: 1.63 +/- 0.18 vs. guanadrel: 0.99 +/- 0.14 nM; P = 0.01), there was no significant change in SI (baseline: 2.97 +/- 0.78 vs. guanadrel: 2.41 +/- 0.54 x 10(-5).min-1 x pM-1; analysis of variance P = 0.57). We conclude that, in the Caucasian population we studied, heightened SNS activity is not essential for the insulin resistance observed in hypertensive humans.