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BACKGROUND: The aim of this study was to examine the effects on functional and psychosocial parameters and long-term care utilization of a preventive home visit program for ambulatory frail Japanese elders. METHODS: Eligible participants (n = 323) were randomly assigned to intervention (n = 161) or control group (n = 162). Nurses and care managers provided structured preventive home visits to the intervention group participants every 6 months over 2 years. Activities of daily living (ADLs), instrumental activities of daily living (IADLs), depression, and social support were collected via mail questionnaire at baseline and at 12- and 24-month follow-up points. The utilization of long-term care insurance was documented over the period. RESULTS: Two-way analysis of covariance did not show significant outcome differences overall. In a pre-planned subgroup analysis for participants who had at least one ADL dependency at baseline, those in the intervention group (N = 105) were significantly less likely to deteriorate over 2 years in their function and depression than those in the control group (N = 100): ADLs (p = .0311), IADLs (p = .0114), depression (p = .0001). The total long-term care costs over 2 years in the intervention group (36,001 credits) were higher than in the control group (26,022 credits) (nonsignificant), and elders in the intervention group utilized significantly more community and institutional long-term care services than those in the control group over the period 7 months to 15 months after the intervention started. CONCLUSIONS: The results suggest that a preventive home visit program might be ineffective on functional and psychosocial status among ambulatory frail elders overall, although it might significantly improve ADLs, IADLs and depression for those with ADL dependency. [ABSTRACT FROM AUTHOR]

AIM: The aim of this article is to describe the program and study design of our preventive home visit model that targets the specific care needs of Japanese ambulatory frail elders living at home. METHODS: The program focused on ambulatory frail elders who were certified as being in the two lowest levels of care need in the Long-Term Care Insurance system and eligible for care, but who were currently not using long-term care services. To provide efficient community- based preventive care, we developed a program model composed of structured assessments and individualized care recommendations conducted by community care nurses or workers. The assessment protocol focused on locomotion, activities of daily living, social activities, health status, and possibility of abuse. Care needs were clarified every six months over two years. The effectiveness of the program is being assessed in a randomized controlled trial. RESULTS: A total of 243 elders were assigned randomly to the preventive home-visit intervention (n=122) or control group (n=121). Their mean age was 80 years, 76% were women, and 25% lived alone. Outcomes including ADLs, IADLs, depression, and social support were measured by postal questionnaire at baseline, and at 12- and 24-month follow-ups. Utilization of public health or long-term care insurance and service uses over the period is also being documented. CONCLUSIONS: The design's unique elements of regular evaluation of healthcare needs for targeted individuals within the long-term care insurance context will allow new understanding of the role and effectiveness of preventive home visits. [ABSTRACT FROM AUTHOR]

BACKGROUND: Patients with rheumatoid arthritis (RA) provide an important opportunity for understanding care of patients with a serious chronic condition. OBJECTIVES: We sought to characterize the complexity of care for patients with RA, including metrics describing the patient, the disease, and use of the health care system across time and place. METHODS: We undertook a prospective cohort study of 568 community-dwelling patients with RA by using observational data from clinically detailed telephone interviews at baseline and 2 years later in addition to medical record abstraction. Health status, comorbidity, use of disease-modifying antirheumatic drugs, visits, providers, provider types, encounter settings, and the discontinuity between patients and providers were studied. RESULTS: Within a 12-month window, 568 patients had 8686 outpatient encounters with the health care system with a mean of 3.41 unique providers per patient associated with a mean of 5 primary care and 6 rheumatologist visits. Half did not see a primary care physician, and 20% did not see a rheumatologist during 6-month periods despite their use of potentially toxic drugs, a mean of 4 comorbidities and progressive RA. Over the course of 24 months, 29% of patients changed their primary care provider, and 15% changed their rheumatologist. Patients were moderately impaired with mean SF-12 physical component score 37 (SD, 9). CONCLUSION: Patients with RA have frequent encounters with multiple providers and also frequent discontinuity of care. Recognizing the complexity of the care of patients with a chronic disease across multiple dimensions provides an opportunity to better understand challenges and opportunities in delivering high quality care. [ABSTRACT FROM AUTHOR]

Background: Prognostic information collected at hospital admission may be useful in defining care objectives and in deciding on therapy for older people. The aim of our study was to identify admission risk factors for in-hospital and postdischarge mortality.Methods: The study included 987 patients aged 70 years and older admitted to the geriatric ward of San Giovanni Battista Hospital in Torino during 1995 and 1996. Demographic, clinical, and functional variables were collected on admission to hospital and examined as potential risk factors for mortality during hospitalization and at 5 years of follow-up.Results: During their hospital stay, 147 patients (14.9%) died. Risk factors independently associated with in-hospital mortality included functional impairment (Activities of Daily Living [ADL]) (OR [odds ratio] 1.73, CI [confidence interval] 95% 1.02-2.95), dependence related to medical conditions (OR 2.18, CI 95% 1.39-3.42), cerebrovascular disease (OR 3.23, CI 95% 1.64-6.37), cancer (OR 4.52, CI 95% 1.99-10.24), albumin 3.0-3.4 g/dl (OR 4.51, CI 95% 2.76-7.35), albumin <3.0 g/dl (OR 6.83, CI 95% 3.59-13.0), creatinine 1.5-3 mg/dl (OR 2.23, CI 95% 1.36-3.65), creatinine >3 mg/dl (OR 2.55, CI 95% 1.10-5.93), and fibrinogen >/=452 mg/dl (OR 1.91, CI 95% 1.26-2.89). During the 5-year follow-up, 553 patients (67.7%) died. Variables independently associated with mortality in multivariate analysis were age 75-84 years (HR [hazard ratio] 1.40, CI 95% 1.10-1.78), >/=85 years (HR 2.08, CI 95% 1.59-2.72), male sex (HR 1.50, CI 95% 1.24-1.81), ADL dependency (HR 1.24, CI 95% 1.01-1.52), >/=5 errors on Short Portable Mental Status Questionnaire (HR 1.34, CI 95% 1.10-1.63), dependence on Dependence Medical Index (HR 1.36, CI 95% 1.10-1.67), presence of cancer (HR 2.58, CI 95% 1.80-3.71), hemoglobin /=2 (HR 1.49, CI 95% 1.14-1.95).Conclusions: A complete functional and clinical evaluation at hospital admission permits identification of patients at higher risk of early and long-term mortality. [ABSTRACT FROM AUTHOR]

Background: The Mini-Nutritional Assessment (MNA) is a validated assessment instrument for nutritional problems, but its length limits its usefulness for screening. We sought to develop a screening version of this instrument, the MNA-SF, that retains good diagnostic accuracy.Methods: We reanalyzed data from France that were used to develop the original MNA and combined these with data collected in Spain and New MEXICO: Of the 881 subjects with complete MNA data, 151 were from France, 400 were from Spain, and 330 were from New MEXICO: Independent ratings of clinical nutritional status were available for 142 of the French subjects. Overall, 73.8% were community dwelling, and mean age was 76.4 years. Items were chosen for the MNA-SF on the basis of item correlation with the total MNA score and with clinical nutritional status, internal consistency, reliability, completeness, and ease of administration.Results: After testing multiple versions, we identified an optimal six-item MNA-SF total score ranging from 0 to 14. The cut-point score for MNA-SF was calculated using clinical nutritional status as the gold standard (n = 142) and using the total MNA score (n = 881). The MNA-SF was strongly correlated with the total MNA score (r = .945). Using an MNA-SF score of > or = 11 as normal, sensitivity was 97.9%, specificity was 100%, and diagnostic accuracy was 98.7% for predicting undernutrition.Conclusions: The MNA-SF can identify persons with undernutrition and can be used in a two-step screening process in which persons, identified as "at risk" on the MNA-SF, would receive additional assessment to confirm the diagnosis and plan interventions. [ABSTRACT FROM AUTHOR]

Objective: To measure the effects of a specialized postfall assessment intended to detect causes and underlying risk factors for falls, and to recommend preventive and therapeutic interventions.Design: Randomized, controlled trial.Setting: A long-term residential care facility for elderly persons.Subjects: Within 7 days of a fall, 160 ambulatory subjects (mean age, 87 years) were randomly assigned to receive either a comprehensive postfall assessment (intervention group, n = 79) or usual care (control group, n = 81).Intervention: The postfall assessment included a detailed physical examination and environmental assessment by a nurse practitioner; laboratory tests; electrocardiogram; and 24-hour Holter monitoring. Probable cause or causes for the fall, identified risk factors, and therapeutic recommendations were given to the patient's primary physician.Measurements and Main Results: Through use of the assessment, many remediable problems (for example, weakness, environmental hazards, orthostatic hypotension, drug side effects, gait dysfunction) were detected. At the end of the 2-year follow-up period, the intervention group had 26% fewer hospitalizations (P less than 0.05) and a 52% reduction in hospital days (P less than 0.01) compared with controls. Patients in the intervention group had 9% fewer falls and 17% fewer deaths than controls by 2 years, but these trends were not statistically significant.Conclusions: Our study suggests that falls are a marker of underlying disorders easily identifiable by a careful postfall assessment, which in turn can reduce disability and costs. [ABSTRACT FROM AUTHOR]

A sensible approach to screening and more comprehensive assessment will help detect the predominant and treatable causes of disability and death in your elderly patients. Used appropriately, these interventions need not consume an inordinate amount of office time. [ABSTRACT FROM AUTHOR]

Background: Clinicians are often unaware of the many existing scales for identifying fall risk and are uncertain about how to select an appropriate one. Our purpose was to summarize existing fall risk assessment scales to enable more informed choices regarding their use.Methods: After a systematic literature search, 21 articles published from 1984 through 2000 describing 20 fall risk assessments were reviewed independently for content and validation by a panel of five reviewers using a standardized review form. Fourteen were institution-focused nursing assessment scales, and six were functional assessment scales.Results: The majority of the scales were developed for elderly populations, mainly in hospital or nursing home settings. The patient characteristics assessed were quite similar across the nursing assessment forms. The time to complete the form varied from less than 1 minute to 80 minutes. For those scales with reported diagnostic accuracy, sensitivity varied from 43% to 100% (median = 80%), and specificity varied from 38% to 96% (median = 75%). Several scales with superior diagnostic characteristics were identified.Conclusions: A substantial number of fall risk assessment tools are readily available and assess similar patient characteristics. Although their diagnostic accuracy and overall usefulness showed wide variability, there are several scales that can be used with confidence as part of an effective falls prevention program. Consequently, there should be little need for facilities to develop their own scales. To continue to develop fall risk assessments unique to individual facilities may be counterproductive because scores will not be comparable across facilities. [ABSTRACT FROM AUTHOR]

Background: Disability in instrumental activities of daily living (IADLs) or activities of daily living (ADLs) is an indicator of health risk. The inclusion of these items in population screens may be limited by variation in item performance across gender and age groups. Further, identification of shortened lists may encourage inclusion of these items in screens.Methods: We applied item response theory (IRT) methods to assess the responses of 9865 community-dwelling elders in the 1993 Medicare Current Beneficiary Survey to 11 IADL/ADL items. Items were classified as "receive help/not receive help" for the overall population and stratified by age and gender. We assessed the same IADL/ADL items using responses classified as "difficulty/no difficulty." After eliminating items that performed poorly, we performed all-subsets analyses to identify abbreviated sets of items that would select the highest proportion of persons with IADL/ADL disability.Results: Responses classified in receive help format showed consistency by gender and age group. Changing the response classification to difficulty/no difficulty influenced the reported order and relationship of IADL/ADL items. Receipt of help for any one of five items--shopping, doing light housework, walking, bathing, or managing finances--identified 93% of individuals receiving help with any IADL/ADL. A slightly different set of five items--walking, shopping, transferring, doing light housework, or bathing--identified 91% of persons reporting difficulty with any IADL or ADL.Conclusions: The relationship of IADL and ADL items to the underlying construct of disability was similar for men and women. The relationship was also similar for oldest-old and younger-old individuals. This study also identified abbreviated lists of disability items that can be used to efficiently screen community-dwelling elders for the presence of IADL/ADL disability. [ABSTRACT FROM AUTHOR]

Objectives: This randomized controlled trial studied the effects of a low- to moderate-intensity group exercise program on strength, endurance, mobility, and fall rates in fall-prone elderly men with chronic impairments.Methods: Fifty-nine community-living men (mean age = 74 years) with specific fall risk factors (i.e., leg weakness, impaired gait or balance, previous falls) were randomly assigned to a control group (n = 28) or to a 12-week group exercise program (n = 31). Exercise sessions (90 minutes, three times per week) focused on increasing strength and endurance and improving mobility and balance. Outcome measures included isokinetic strength and endurance, five physical performance measures, and self-reported physical functioning, health perception, activity level, and falls.Results: Exercisers showed significant improvement in measures of endurance and gait. Isokinetic endurance increased 21% for right knee flexion and 26% for extension. Exercisers had a 10% increase (p < .05) in distance walked in six minutes, and improved (p < .05) scores on an observational gait scale. Isokinetic strength improved only for right knee flexion. Exercise achieved no significant effect on hip or ankle strength, balance, self-reported physical functioning, or number of falls. Activity level increased within the exercise group. When fall rates were adjusted for activity level, the exercisers had a lower 3-month fall rate than controls (6 falls/1000 hours of activity vs 16.2 falls/1000 hours, p < .05).Discussion: These findings suggest that exercise can improve endurance, strength, gait, and function in chronically impaired, fall-prone elderly persons. In addition, increased physical activity was associated with reduced fall rates when adjusted for level of activity. [ABSTRACT FROM AUTHOR]

Background and Objectives: Studies indicate an expected population growth of almost fifty percent in Oklahomans aged 65 and older by 2030. According to the United Health Foundation, Oklahoma ranked 48th in overall senior health in 2017., Research Design and Methods: The Oklahoma Healthy Aging Initiative administered a Consumer Needs Assessment Survey by mail to a stratified random sample of the 475,518 registered voters aged 65 and older. The survey was anonymous and stratified by region. The survey contained six sections: introduction, health and health promotion, activities/recreation, information and assistance, caregiving and "about you.", Results: Nearly one in three (32%) of respondents indicated that they directly or indirectly provide care to another, with another 9% responding they maybe provide care, and the remaining 59% responding no . Nearly 10% of people who say they are not caregivers reported that they participate at least one day a week in caring for a sick or invalid spouse, family member, or friend living with them, indicating current estimates of the number of caregivers is low., Discussion and Implications: Those who report they are or are maybe caregivers tend to be more interested in community events and more interested in caregiver respite. In addition, maybe caregivers appear to be more interested in health improvement topics and classes, such as health and wellness, mental health, chronic disease, and computers when compared to both caregivers and non-caregivers. Our survey results indicate a need for caregivers to receive respite services as well as training courses in Oklahoma communities., Competing Interests: Conflict of Interest: None

Purpose: The purpose of this study was to compare and contrast health education needs of rural Oklahomans aged 65 and older compared to urban and sub-urban populations., Methods: Surveys were distributed to a list of registered voters age 65 and older in Oklahoma with a total of 1,248 surveys returned. Survey items asked about interests in services, classes and activities, plus current barriers to accessing and/or engaging in such programs., Findings: Survey respondents living in large rural towns (23.7%) and the urban core (21.5%) were significantly more likely than those in small rural towns (14.0%) or sub-urban areas (15.5%) to have attended a free health information event in the past year ( P =0.0393). Older Oklahomans in small towns and isolated rural areas reported more frequently than those in the urban core that they would participate in congregate meals at a center (small town/isolated rural: 14.4%, urban core: 7.2%) ( P =0.05). Lack of adequate facilities was more frequently reported by those residing in small town and isolated rural areas compared to urban core areas (16.4% vs. 7.8%, P =0.01). Finally, older Oklahomans in the large rural towns (0.6%) and small town and isolated rural locations (2.13%) less frequently reported use of senior information lines (Senior Infoline) than those in the urban core (6.0%) and in sub-urban areas (7.1%) ( P =0.0009)., Conclusions: Results of this survey provide useful data on senior interests and current barriers to community programs/activities have some unique trends among both urban and rural populations.

The growing senior population and persistent poor health status of seniors in Oklahoma compels a fresh look at what health promotion services would be well received. Surveys were distributed to a list of registered voters age 65 and older in Oklahoma with a total of 1,248 surveys returned (19.8%). Survey items asked about interests in services, classes, and activities, plus current barriers to accessing and/or engaging in such programs. To account for survey weighting, Rao-Scott Chi-Square Tests were performed to determine differences by demographic characteristics. We identified services, classes, and activities that were (and were not) of interest to seniors in Oklahoma with legal assistance (52.1%), exercise classes (46.6%), internet classes (40.7%), and indoor exercise activities (45.5%) receiving the highest level of interest. Barriers to interest in participating in programs included not wanting to go and not knowing availability of such services. The results of this survey provide useful data on health promotion gaps for seniors, interests and barriers to engaging in such activities, and guidance for statewide program development. Future program development needs to be focused on areas of interest for older adults, including legal assistance, exercise classes, and internet classes.

Among Americans aged 65 years and older, falls are the leading cause of injury death and disability, and finding effective methods to prevent older adult falls has become a public health priority. While research has identified effective interventions delivered in community and clinical settings, persuading older adults to adopt these interventions has been challenging. Older adults often do not acknowledge or recognize their fall risk. Many see falls as an inevitable consequence of aging. Health care providers can play an important role by identifying older adults who are likely to fall and providing clinical interventions to help reduce fall risks. Many older people respect the information and advice they receive from their providers. Health care practitioners can encourage patients to adopt effective fall prevention strategies by helping them understand and acknowledge their fall risk while emphasizing the positive benefits of fall prevention such as remaining independent. To help clinicians integrate fall prevention into their practice, the Centers for Disease Control and Prevention launched the STEADI (Stopping Elderly Accidents, Deaths, and Injuries) initiative. It provides health care providers in primary care settings with resources to help them screen older adult patients, assess their fall risk, and provide effective interventions., Competing Interests: Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© 2017 The Author(s).)

Background: The aim of this randomized controlled trial was to determine the effects on functional parameters of an updated preventive home visit program for frail older adults in the Japanese Long-term Care Insurance (LTCI) system., Methods: The program included home visits by nurses or care managers every 3 months for 24 months, with a systematic assessment of care needs to prevent functional decline. Eligible participants (N = 360) were randomly assigned to the visit (VG: n = 179) or control group (CG: n = 181). Functional parameters were gathered via mail questionnaires at baseline and at 12- and 24-month follow-ups. Care-need levels in the LTCI were obtained at 12-, 24-, and 36-month follow-ups and the utilization of the LTCI service through 36 months., Results: Participants in VG were significantly more likely to maintain their activities of daily living (ADL) functioning (p = .0113) and less likely to increase care-needs level, compared with CG participants, over 24 months. A generalized linear model showed that the estimate of the effect on increase in care-needs level (ie, functional decline) was -0.53 (p = .042) over 36 months., Conclusions: These results suggest that the updated preventive home visit program could be effective for the prevention of ADL and care-needs deterioration, and these effects could continue up to 1 year after program completion., (© The Author 2016. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Purpose: To determine the associative value of selected questions from the National Health Interview Survey (NHIS) for screening adults older than 18 years at risk of injurious falls., Methods: Data from adults 18 years of age and older were extracted from the NHIS for 2011 relevant to an injurious fall within the preceding year. A multivariate logistic regression model was used to determine associations of self-reported injurious falls with key social-demographic, health, and physical function variables. Outcomes were reported as odds ratio (OR) with 95% confidence intervals (CIs)., Results: Self-reported injurious fall within the preceding year was associated with difficulty climbing 10 steps without special equipment (OR, 3.22; 95% CI, 2.32-4.46), loss of dependence for an activity of daily living (OR, 1.85; 95% CI, 1.17-2.91), pain in legs and below the knees (OR, 1.68; 95% CI, 1.23-2.30), and moderate visual impairment (OR, 1.59; 95% CI, 1.18-2.15). Women were at greater risk than men and those aged 75 years and older (OR, 1.46; 95% CI, 1.02-2.09)., Conclusions: A subset of the NHIS questions are positively associated with injurious falls in the previous 12 months and may be of use in identifying adults at greater risk of future falls. The NHIS questions may serve to identify persons in need of targeted preventive services.

Aim: To describe the programme and research protocol of our updated preventive home visit programme for ambulatory frail older adults in the Japanese Long-Term Care Insurance system., Background: Our previous trials have shown that the nature of recommendations during preventive home visits is a key issue. The present programme has updated our previous one by including a unique structured assessment with treatment recommendations tied to an ongoing programme for quality assurance., Design: A randomized, controlled trial., Methods: Eligible participants (n = 360) will be randomly assigned to home visit (n = 179) and control (n = 181) groups in three suburban municipalities. Nurses provide recommendations based on structured assessments to participants in visit group every 3 months from September 2011-October 2013. The primary outcomes are parameters related to quality of life, including activities of daily living, instrumental activities of daily living, depression, cognitive capacity, daily-life satisfaction and self-efficacy for health promotion; these are collected by mail at baseline, 12 and 24 months. The secondary outcome is long-term care use over the study period. To evaluate the visit process, we are qualitatively analysing documentation data from the assessment sheet and chart., Conclusion: This study is collecting and analysing evidence regarding the process and outcomes of preventive home visits based on structured care-need assessments., Trial Registration: The study protocol was registered for the UMIN clinical registry approved by ICMJE (No. UMIN000006463, October 04, 2011)., (© 2014 John Wiley & Sons Ltd.)

The Fall Prevention Center of Excellence designed three progressive-intensity fall prevention program models, Increasing Stability Through Evaluation and Practice (InSTEP), to reduce risk in community-dwelling older adults. Each model included physical activity, medical risk, and home safety components and was implemented as a 12-week program for small class sizes (12-15 people) in community and senior centers. Change in fall rates and fall risk factors was assessed using a battery of performance tests, self-reports of function, and fall diaries in a 3-group within-subjects (N = 200) design measured at baseline, immediately postintervention, and at 3 and 9 months postintervention. Overall, participants experienced a reduction in falls, improved selfperception of gait and balance, and improved dynamic gait function. The medium-intensity InSTEP model significantly (p = .003) reduced self-reported falls in comparison with the other models. InSTEP is a feasible model for addressing fall risk reduction in community-dwelling older adults.

Background and Aims: Reducing health care costs through preventive geriatric care has become a high priority in Japan. We analyzed data from a randomized controlled trial to examine the effects of a preventive home visit program on health care costs among ambulatory frail elders., Methods: Structured preventive home visits by nurses or care managers were provided to the visit group every 6 months over 2 years. The enrolled participants (N = 323) were randomly assigned to either the visit group (N = 161) or the control group (N = 162). We analyzed the health care costs, including the costs for hospitalizations and outpatient clinic utilization for participants who had health care insurance from the local government (N = 307). The visit group included 154 individuals in the visit group and 153 people in the control group., Results: Total health care costs over the study period were not significantly different between groups, but at most monthly time points costs and those for outpatient clinic utilization in the visit group were lower than those in the control group. Hospitalizations, which accounted for more than ¥ 500,000 JPY per month, were less likely to occur more often among participants in the visit group (N = 71) than in the control group (N = 113) (OR = 0.63; p = 0.002)., Conclusions: These results suggest that a preventive home visit program may reduce monthly health care costs, primarily by reducing hospitalization costs.

Background: Falls are a common, serious, and often unrecognized problem facing older adults. The objective of this study was to provide an initial clinical and statistical validation for a public health strategy of fall risk self-assessment by older adults using a Fall Risk Questionnaire (FRQ)., Methods: Adults age 65+ (n=40) were recruited at a Los Angeles Veterans Affairs (VA) medical facility and at a local assisted living facility. Participants completed the FRQ self-assessment and results were compared to a "gold standard" of a clinical evaluation of risks using the American/British Geriatrics Society guidelines to assess independent predictors of falls: history of previous falls, fear of falling, gait/balance, muscle weakness, incontinence, sensation and proprioception, depression, vision, and medications. For the comparison, we used an iterative statistical approach, weighing items based on relative risk., Results: There was strong agreement between the FRQ and clinical evaluation (kappa=.875, p<.0001). Individual item kappa values ranged from .305-.832. After dropping one FRQ item (vision risk) because of inadequate agreement with the clinical evaluation (kappa=.139, p=.321), the final FRQ had good concurrent validity., Conclusions: The FRQ goes beyond existing screening tools in that it is based on both evidence and clinical acceptability and has been initially validated with clinical examination data. A larger validation with longitudinal follow-up should determine the actual strength of the FRQ in predicting future falls., (Published by Elsevier Ltd.)

Falls are a major public health problem for older adults, and community-based organizations play a key role in educating seniors about falls prevention (FP). We conducted a qualitative process evaluation at six sites to report community-based centers' perspectives on adoption, adaptation, and sustainability of an evidence-based multifactorial FP model. Wide dissemination of new health-oriented programs requires marketing to center directors, who must consider sustainability options. The diversity and independence of community-based organizations, together with current staffing and funding limitations, suggest that fidelity to multifactorial evidence-based interventions will be difficult to achieve.

Objective: To determine seniors' beliefs about falls and design a fall-risk self-assessment and educational materials to promote early identification of evidence-based fall risks and encourage prevention behaviors., Methods: Focus groups with community-dwelling seniors, conducted in two phases to identify perceptions about fall risks and risk reduction and to assess face validity of the fall-risk self-assessment and acceptability of educational materials., Results: Lay perception of fall risks was in general concordance with evidence-based research. Maintaining independence and positive tone were perceived as key motivators for fall prevention. Seniors intended to use information in the educational tool to stimulate discussions about falls with health care providers., Implications: An evidence-based, educational fall-risk self-assessment acceptable to older adults can build on existing lay knowledge about fall risks and perception that falls are a relevant problem and can educate seniors about their specific risks and how to minimize them.

Falls are a major health concern for elderly people and cause substantial health care costs. The authors used meta-analytic findings on the effectiveness of fall prevention interventions to determine cost-effectiveness of a proposed Medicare fall prevention program for people who experience a recent fall. Using published clinical trial data, the authors constructed a population-based economic model and estimated that, in the base case, the program could prevent a half million people from falling again within a year. From the model, under most circumstances the cost-effectiveness ratio is less than $1500 per person prevented from experiencing a recurrent fall. Paying for a fall prevention program to increase the use of evidence-based interventions would be a cost-effective use of Medicare dollars., (Copyright © 2010 Elsevier Inc. All rights reserved.)

Objective: To develop process-based quality indicators to improve perioperative care for elderly surgical patients., Background: The population is aging and expanding, and physicians must continue to optimize elderly surgical care to meet the anticipated increase in surgical services. We sought to develop process-based quality indicators applicable to virtually all disciplines of surgery to identify necessary and meaningful ways to improve surgical care and outcomes in the elderly., Methods: We identified candidate perioperative quality indicators for elderly patients undergoing ambulatory, or major elective or nonelective inpatient surgery through structured interviews with thought leaders and systematic reviews of the literature. An expert panel of physicians in surgery, geriatrics, anesthesia, critical care, internal, and rehabilitation medicine formally rated the indicators using a modification of the RAND/UCLA Appropriateness Methodology., Results: Ninety-one of 96 candidate indicators were rated as valid. They were categorized into 8 domains: comorbidity assessment, elderly issues, medication use, patient-provider discussions, intraoperative care, postoperative management, discharge planning, and ambulatory surgery. Of note, 71 (78%) of the indicators rated as valid address processes of care not routinely performed in younger surgical populations., Conclusions: Attention to the quality of care in elderly patients is of great importance due to the increasing numbers of elderly undergoing surgery. This project used a validated methodology to identify and rate process measures to achieve high quality perioperative care for elderly surgical patients.

Objectives: The aim of this study was to provide national annualized descriptive statistics of the hospital admissions for long-stay nursing home residents., Design: National, descriptive, secondary data analysis., Setting: National, Veterans Health Administration (VHA), 136 VHA nursing homes., Participants: Our study population consisted of 6554 VHA long-stay nursing home residents who had an annual assessment during FY 2005, identified from the Minimum Data Set (MDS). These residents were linked with the national VHA discharge dataset., Measurement: We provide descriptive statistics of the major diagnostic categories (MDC) and diagnosis related groups (DRG) for long-stay residents admitted to a VHA hospital where the source of admission was from the VHA nursing home., Results: Overall, 28.57% (1873/6554) of VHA long-stay residents were hospitalized. The top 5 MDC accounted for over 70% of the hospitalizations. The frequency of MDC associated with hospital admissions, in descending order, were respiratory system (25.33%), kidney and urinary tract (15.88%), circulatory (14.65%), digestive system (9.39%), and nervous system (5.16%). Nearly 25,000 bed days of care (BDC) were associated with these hospitalizations. The top 3 DRG (DRG 320- Med kidney & urinary tract, 89-Med simple pneumonia & pleurisy, 79-Med respiratory infections & inflammations) accounted for nearly 25% of all the hospitalizations and approximately 23% of the BDC., Conclusions: VHA nursing homes do not have the financial incentives that impact the decision to hospitalize that exist in the non-VHA sector. This unique feature of the VHA's nursing homes would allow one to study the issue of potentially preventable hospitalizations in long-stay residents without the confounding impact of Medicare and Medicaid payment incentives. Because of the importance of this policy issue in the national long-term care debate, further VHA studies may provide important empirically based policy input.

Dehydration in clinical practice, as opposed to a physiological definition, refers to the loss of body water, with or without salt, at a rate greater than the body can replace it. We argue that the clinical definition for dehydration, ie, loss of total body water, addresses the medical needs of the patient most effectively. There are 2 types of dehydration, namely water loss dehydration (hyperosmolar, due either to increased sodium or glucose) and salt and water loss dehydration (hyponatremia). The diagnosis requires an appraisal of the patient and laboratory testing, clinical assessment, and knowledge of the patient's history. Long-term care facilities are reluctant to have practitioners make a diagnosis, in part because dehydration is a sentinel event thought to reflect poor care. Facilities should have an interdisciplinary educational focus on the prevention of dehydration in view of the poor outcomes associated with its development. We also argue that dehydration is rarely due to neglect from formal or informal caregivers, but rather results from a combination of physiological and disease processes. With the availability of recombinant hyaluronidase, subcutaneous infusion of fluids (hypodermoclysis) provides a better opportunity to treat mild to moderate dehydration in the nursing home and at home.

Objectives: To estimate the risk and long-term prognostic significance of 30-day readmission postdischarge of a 4-year cohort of elderly veterans first admitted to Medicare hospitals for treatment of hip fractures (HFx), controlling for comorbidities., Design: Retrospective, national secondary data analysis., Setting: National Medicare and Veterans Health Administration (VHA) facilities., Participants: The study cohort was 41,331 veterans with a HFx first admitted to a Medicare eligible facility during 1999 to 2002., Measurements: HFxs were linked with all other Medicare and VHA inpatient discharge files to capture dual inpatient use. Logistic regression was used to examine the relationship between 30-day readmission and age, sex, inpatient length of stay, and selected Elixhauser comorbidities., Results: Approximately 18.3% (7,579/41,331) of HFx patients were readmitted within 30 days. Of those with 30-day readmissions, 48.5% (3,675/7,579) died within 1 year, compared with 24.9% (8,388/33,752) of those without 30-day readmissions. Readmission risk was significantly greater in the presence of specific comorbidities, ranging from 11% greater risk for patients with fluid and electrolyte disorders (95% confidence interval (CI)=1.04-1.20) to 43% for renal failure (95% CI=1.29-1.60). For this cohort, cardiac arrhythmias (24%), chronic pulmonary disease (28%), and congestive heart failure (16%) were common comorbidities, and all affected the risk of 30-day readmission., Conclusion: Patients with HFx with 30-day readmissions were nearly twice as likely to die within 1 year. Identification of several predictive comorbidities at discharge and examination of reasons for subsequent readmission suggests that readmission was largely due to active comorbid clinical problems. These comorbidity findings have implications for the current Centers for Medicare and Medicaid Services (CMS) pay-for-performance initiatives, especially those related to better coordination of care for patients with chronic illnesses. These comorbidity findings for elderly patients with HFx may also provide data to enable CMS and healthcare providers to more accurately differentiate between comorbidities and hospital-acquired complications under the current CMS initiative related to nonpayment for certain types of medical conditions and hospital acquired infections.

Background: Multidimensional preventive home visit programs aim at maintaining health and autonomy of older adults and preventing disability and subsequent nursing home admission, but results of randomized controlled trials (RCTs) have been inconsistent. Our objective was to systematically review RCTs examining the effect of home visit programs on mortality, nursing home admissions, and functional status decline., Methods: Data sources were MEDLINE, EMBASE, Cochrane CENTRAL database, and references. Studies were reviewed to identify RCTs that compared outcome data of older participants in preventive home visit programs with control group outcome data. Publications reporting 21 trials were included. Data on study population, intervention characteristics, outcomes, and trial quality were double-extracted. We conducted random effects meta-analyses., Results: Pooled effects estimates revealed statistically nonsignificant favorable, and heterogeneous effects on mortality (odds ratio [OR] 0.92, 95% confidence interval [CI], 0.80-1.05), functional status decline (OR 0.89, 95% CI, 0.77-1.03), and nursing home admission (OR 0.86, 95% CI, 0.68-1.10). A beneficial effect on mortality was seen in younger study populations (OR 0.74, 95% CI, 0.58-0.94) but not in older populations (OR 1.14, 95% CI, 0.90-1.43). Functional decline was reduced in programs including a clinical examination in the initial assessment (OR 0.64, 95% CI, 0.48-0.87) but not in other trials (OR 1.00, 95% CI, 0.88-1.14). There was no single factor explaining the heterogenous effects of trials on nursing home admissions., Conclusion: Multidimensional preventive home visits have the potential to reduce disability burden among older adults when based on multidimensional assessment with clinical examination. Effects on nursing home admissions are heterogeneous and likely depend on multiple factors including population factors, program characteristics, and health care setting.

Background: Nursing home populations may consist of both short- and long-stay residents, who have different resource use profiles. Differentiating between these two populations is important in any analysis of drug costs and use., Objective: The aim of this analysis was to provide national annualized estimates of drug acquisition costs and use of drugs excluded under Medicare Part D for dually eligible long-stay nursing home residents in the US., Methods: This was a national, descriptive, secondary data analysis. The study population consisted of 6554 Veterans Health Administration (VHA) long-stay nursing home residents (n=136 nursing homes), identified from the Minimum Data Set (MDS), who had an annual assessment during fiscal year (FY) 2005 linked with their 8,847,561 inpatient pharmacy claims. The study data generated were descriptive statistics of the annual drug acquisition costs and use of medications excluded under Medicare Part D. VHA therapeutic drug classes were obtained from FY 2005 national pharmacy claims linked at the individual resident level., Results: The excluded drugs accounted for 3 036 306 of the more than 8.8 million inpatient pharmacy claims, totalling $US3,406,756 or $US526 per resident (99% CI 490, 562). Non-opioid analgesics were received by 73.3% of the residents, totalling $US352,608 or $US73 per resident; 25.3% received antitussives, decongestants, or cold and cough medications, totalling $US27,220 or $US16 per resident; 63.8% received vitamins, totalling $US281,909 or $US67 per resident; 17.7% received benzodiazepines or sedative hypnotics, totalling $US76,083 or $US66 per resident; and 64.3% received laxatives or stool softeners, totalling $US298,326 or $US71 per resident. The total acquisition cost of all drugs was $US23,782,717 for 6554 VHA nursing home residents or $US3629 per resident (99% CI 3343, 3915)., Conclusion: The cost of Medicare Part D-excluded drugs represented a fraction of the total VHA drug costs for long-stay nursing home residents, accounting for only 14.3% of all drug costs and 34.3% of the more than 8.8 million inpatient pharmacy claims. More research is needed to account for the drug dispensing and administration costs associated with these excluded classes of drugs and their efficacy. Studies of VHA drug acquisition costs provide important policy-relevant data for the Medicare Part D national price negotiation debate, particularly in a US presidential election year.

The purpose of the study was to investigate the relationships between frequency of going outdoors and subsequent functional and psychosocial changes over a 20-month period. Data were collected from community-dwelling 107 frail elders who could walk independently but who still needed some assistance to live on their own. Functional and psychosocial status at baseline and follow-up were compared among three groups defined by the frequency of going outdoors: (1) four or more times a week, (2) one to three times a week and (3) less than once a week. At baseline, elders going outdoors more often were less functionally impaired, more socially active, and less depressed than elders going outdoors less often. There was a significant difference in change over time of activities of daily living (ADLs) (p=0.002) among the three groups, even when controlling for baseline differences, and the scores of those who went outdoors almost daily were least likely to decline. More of those going outdoors four or more times a week at baseline were still living at home at follow-up than those in the other two groups (p=0.048). These results suggest that the frequency of going outdoors can predict changes in ADLs over at least a 20-month period.