Ann L. Gruber-Baldini

Dementia as a risk factor for falls and fall injuries among nursing home residents.

Objectives: To compare rates of falling between nursing home residents with and without dementia and to examine dementia as an independent risk factor for falls and fall injuries.

Cluster-Randomized Trial of a Mobile Phone Personalized Behavioral Intervention for Blood Glucose Control

OBJECTIVE To test whether adding mobile application coaching and patient/provider web portals to community primary care compared with standard diabetes management would reduce glycated hemoglobin levels in patients with type 2 diabetes. RESEARCH DESIGN AND METHODS A cluster-randomized clinical trial, the Mobile Diabetes Intervention Study, randomly assigned 26 primary care practices to one of three stepped treatment groups or a control group (usual care). A total of 163 patients were enrolled and included in analysis. The primary outcome was change in glycated hemoglobin levels over a 1-year treatment period. Secondary outcomes were changes in patient-reported diabetes symptoms, diabetes distress, depression, and other clinical (blood pressure) and laboratory (lipid) values. Maximal treatment was a mobile- and web-based self-management patient coaching system and provider decision support. Patients received automated, real-time educational and behavioral messaging in response to individually analyzed blood glucose values, diabetes medications, and lifestyle behaviors communicated by mobile phone. Providers received quarterly reports summarizing patient’s glycemic control, diabetes medication management, lifestyle behaviors, and evidence-based treatment options. RESULTS The mean declines in glycated hemoglobin were 1.9% in the maximal treatment group and 0.7% in the usual care group, a difference of 1.2% (P = 0.001) over 12 months. Appreciable differences were not observed between groups for patient-reported diabetes distress, depression, diabetes symptoms, or blood pressure and lipid levels (all P > 0.05). CONCLUSIONS The combination of behavioral mobile coaching with blood glucose data, lifestyle behaviors, and patient self-management data individually analyzed and presented with evidence-based guidelines to providers substantially reduced glycated hemoglobin levels over 1 year.

The Clinically Important Difference on the Unified Parkinson's Disease Rating Scale

OBJECTIVE To determine the estimates of minimal, moderate, and large clinically important differences (CIDs) for the Unified Parkinsons Disease Rating Scale (UPDRS). DESIGN Cross-sectional analysis of the CIDs for UPDRS total and motor scores was performed on patients with Parkinson disease (PD) using distribution- and anchor-based approaches based on the following 3 external standards: disability (10% on the Schwab and England Activities of Daily Living Scale), disease stage (1 stage on the Hoehn and Yahr Scale), and quality of life (1 SD on the 12-Item Short Form Health Survey). SETTING University of Maryland Parkinson Disease and Movement Disorders Center, Patients Six hundred fifty-three patients with PD. RESULTS A minimal CID was 2.3 to 2.7 points on the UPDRS motor score and 4.1 to 4.5 on the UPDRS total score. A moderate CID was 4.5 to 6.7 points on the UPDRS motor score and 8.5 to 10.3 on the UPDRS total score. A large CID was 10.7 to 10.8 points on the UPDRS motor score and 16.4 to 17.8 on the UPDRS total score. CONCLUSIONS Concordance among multiple approaches of analysis based on subjective and objective data show that reasonable estimates for the CID on the UPDRS motor score are 2.5 points for minimal, 5.2 for moderate, and 10.8 for large CIDs. Estimates for the UPDRS total score are 4.3 points for minimal, 9.1 for moderate, and 17.1 for large CIDs. These estimates will assist in determining clinically meaningful changes in PD progression and response to therapeutic interventions.

Nursing home facility risk factors for infection and hospitalization: importance of registered nurse turnover, administration, and social factors.

OBJECTIVES: Determine the relationship between a broad array of structure and process elements of nursing home care and (a) resident infection and (b) hospitalization for infection.

Cognitive impairment in hip fracture patients: timing of detection and longitudinal follow-up.

Objectives: To examine the prevalence, incidence, persistence, predictors, and outcomes of cognitive impairment after hip fracture.

The evolution of disability in Parkinson disease

The objectives of this study are to assess the level of disease severity associated with disability in Parkinson disease (PD) and the sequence of loss of independence in basic and instrumental activities of daily living (ADLs and IADLs). Six hundred eighteen patients with PD were evaluated for disease severity with the Unified PD Rating Scale (UPDRS) and for disability with the Older Americans Resource and Services Disability Subscale (OARS). The association between patient‐reported disability on ADLs and IADLs and level of disease severity on the total UPDRS was examined cross‐sectionally. Disability, with loss of independent function is reported between total UPDRS scores 30 to 40, and HY stages II to III. Difficulty with daily activities, without loss of independent function is reported earlier, at UPDRS <20 and HY I to II. Difficulty with walking is initially reported, followed by problems with a number of gait‐dependent activities including housework, dressing, transferring in and out of bed, and traveling in the community. The transition from HY stage II to III marks a pivotal milestone in PD, when gait and balance impairment results in disability in many gait‐dependent activities. The onset of disability in PD can be identified by asking patients about their walking, housework, dressing, and traveling. While individual patients vary in progression, the benchmarks of disability in this study provide guidance when counseling patients about prognosis. Better understanding of the stages of disability may facilitate the development of novel outcome measures in clinical trials in PD.

The validity of the minimum data set in measuring the cognitive impairment of persons admitted to nursing homes

OBJECTIVES: This study examined the construct validity of two cognitive scales from the federally mandated Minimum Data Set (MDS) of the nursing home Resident Assessment Instrument.

Behavioral Symptoms in Residential Care/Assisted Living Facilities: Prevalence, Risk Factors, and Medication Management

Objectives: To examine the prevalence, correlates, and medication management of behavioral symptoms in elderly people living in residential care/assisted living (RC/AL) facilities.

Short-Term Dynamics of Disability and Well-Being*

For persons with serious chronic morbidity, disability is a very dynamic process as morbidity advances or retreats, and as interventions succeed or fail. This article studies trajectories of function (cognitive, emotional, social, physical, and global well-being) over a year for 165 persons whose chronic morbidity prompted a hospital stay. Changes in functioning from hospital admission to one year post-discharge are analyzed; functional statuses were measured nine times in that period. Both intra-individual and inter-individual changes are studied by means of a combination of visual and statistical techniques. (1) Individuals: After the hospital stay, functions typically improve in the first month, stabilize for several months, then begin to fluctuate and worsen. Individual trajectories are very changeful over a year, yet there is short-run continuity (from one measurement point to the next). (2) Groups: Persons with fracture of hip show the most striking and protracted improvements over the year, compared to persons with other conditions. Chances of functional recovery are highest for persons with just one chronic condition; those chances decline as comorbidity increases. Having many social contacts is associated with initial high function that is maintained over the year; having few contacts is associated with stable low function. The analyses point to the scientific value of short remeasurement intervals for persons with severe or multiple morbidity.

The DSM-5 criteria, level of arousal and delirium diagnosis: Inclusiveness is safer

Delirium is a common and serious problem among acutely unwell persons. Alhough linked to higher rates of mortality, institutionalisation and dementia, it remains underdiagnosed. Careful consideration of its phenomenology is warranted to improve detection and therefore mitigate some of its clinical impact. The publication of the fifth edition of the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM-5) provides an opportunity to examine the constructs underlying delirium as a clinical entity. Altered consciousness has been regarded as a core feature of delirium; the fact that consciousness itself should be physiologically disrupted due to acute illness attests to its clinical urgency. DSM-5 now operationalises `consciousness’ as `changes in attention’. It should be recognised that attention relates to content of consciousness, but arousal corresponds to level of consciousness. Reduced arousal is also associated with adverse outcomes. Attention and arousal are hierarchically related; level of arousal must be sufficient before attention can be reasonably tested. Our conceptualisation of delirium must extend beyond what can be assessed through cognitive testing (attention) and accept that altered arousal is fundamental. Understanding the DSM-5 criteria explicitly in this way offers the most inclusive and clinically safe interpretation.BackgroundDelirium is a common and serious problem among acutely unwell persons. Alhough linked to higher rates of mortality, institutionalisation and dementia, it remains underdiagnosed. Careful consideration of its phenomenology is warranted to improve detection and therefore mitigate some of its clinical impact. The publication of the fifth edition of the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM-5) provides an opportunity to examine the constructs underlying delirium as a clinical entity.DiscussionAltered consciousness has been regarded as a core feature of delirium; the fact that consciousness itself should be physiologically disrupted due to acute illness attests to its clinical urgency. DSM-5 now operationalises `consciousness’ as `changes in attention’. It should be recognised that attention relates to content of consciousness, but arousal corresponds to level of consciousness. Reduced arousal is also associated with adverse outcomes. Attention and arousal are hierarchically related; level of arousal must be sufficient before attention can be reasonably tested.SummaryOur conceptualisation of delirium must extend beyond what can be assessed through cognitive testing (attention) and accept that altered arousal is fundamental. Understanding the DSM-5 criteria explicitly in this way offers the most inclusive and clinically safe interpretation.