Judith O. Harker

Development and Testing of a Five-Item Version of the Geriatric Depression Scale

OBJECTIVE: To develop and test the effectiveness of a 5‐item version of the Geriatric Depression Scale (GDS) in screening for depression in a frail community‐dwelling older population.

Randomized, Controlled Trial of a Nonpharmacological Intervention to Improve Abnormal Sleep/Wake Patterns in Nursing Home Residents

Objectives: Abnormal sleep/wake patterns are common in nursing home residents. Lifestyle and environmental factors likely contribute to these poor sleep patterns. The objective of this study was to test a multidimensional, nonpharmacological intervention to improve abnormal sleep/wake patterns in nursing home residents.

A proof-of-principle, prospective, randomized, controlled trial demonstrating improved outcomes in scheduled unsedated colonoscopy by the water method

BACKGROUND An observational study in veterans showed that a novel water method (water infusion in lieu of air insufflation) enhanced cecal intubation and willingness to undergo a repeat scheduled unsedated colonoscopy. OBJECTIVE To confirm these beneficial effects and significant attenuation of discomfort in a randomized, controlled trial (RCT). DESIGN Prospective RCT, intent-to-treat analysis. SETTING Veterans Affairs ambulatory care facility. PATIENTS Veterans undergoing scheduled unsedated colonoscopy. INTERVENTIONS During insertion, the water and traditional air methods were compared. MAIN OUTCOME MEASUREMENTS Discomfort and procedure-related outcomes. RESULTS Eighty-two veterans were randomized to the air (n = 40) or water (n = 42) method. Cecal intubation (78% vs 98%) and willingness to repeat (78% vs 93%) were significantly better with the water method (P < .05; Fisher exact test). The mean (standard deviation) of maximum discomfort (0 = none, 10 = most severe) during colonoscopy was 5.5 (3.0) versus 3.6 (2.1) P = .002 (Student t test), and the median overall discomfort after colonoscopy was 3 versus 2, P = .052 (Mann-Whitney U test), respectively. The method, but not patient characteristics, was a predictor of discomfort (t = -1.998, P = .049, R(2) = 0.074). The odds ratio for failed cecal intubation was 2.09 (95% CI, 1.49-2.93) for the air group. Fair/poor previous experience increased the risk of failed cecal intubation in the air group only. The water method numerically increased adenoma yield. LIMITATIONS Single site, small number of elderly men, unblinded examiner, possibility of unblinded subjects, restricted generalizability. CONCLUSIONS The RCT data confirmed that the water method significantly enhanced cecal intubation and willingness to undergo a repeat colonoscopy. The decrease in maximum discomfort was significant; the decrease in overall discomfort approached significance. The method, but not patient characteristics, was a predictor of discomfort. (Clinical trial registration number NCT00747084).

Water-aided colonoscopy: a systematic review

BACKGROUND Water-aided methods for colonoscopy are distinguished by the timing of removal of infused water, predominantly during withdrawal (water immersion) or during insertion (water exchange). OBJECTIVE To discuss the impact of these approaches on colonoscopy pain and adenoma detection rate (ADR). DESIGN Systematic review. SETTING Randomized, controlled trial (RCT) that compared water-aided methods and air insufflation during colonoscope insertion. PATIENTS Patients undergoing colonoscopy. INTERVENTION Medline, PubMed, and Google searches (January 2008-December 2011) and personal communications of manuscripts in press were considered to identify appropriate RCTs. MAIN OUTCOME MEASUREMENTS Pain during colonoscopy and ADR. RCTs were grouped according to whether water immersion or water exchange was used. Reported pain scores and ADR were tabulated based on group assignment. RESULTS Pain during colonoscopy is significantly reduced by both water immersion and water exchange compared with traditional air insufflation. The reduction in pain scores was qualitatively greater with water exchange as compared with water immersion. A mixed pattern of increases and decreases in ADR was observed with water immersion. A higher ADR, especially proximal to the splenic flexure, was obtained when water exchange was implemented. LIMITATIONS Differences in the reports limit application of meta-analysis. The inability to blind the colonoscopists exposed the observations to uncertain bias. CONCLUSION Compared with air insufflation, both water immersion and water exchange significantly reduce colonoscopy pain. Water exchange may be superior to water immersion in minimizing colonoscopy discomfort and in increasing ADR. A head-to-head comparison of these 3 approaches is required.

A Randomized Trial of a Screening, Case Finding, and Referral System for Older Veterans in Primary Care

OBJECTIVES: To test whether a system of screening, assessment, referral, and follow‐up provided within primary care for high‐risk older outpatients improves recognition of geriatric conditions and healthcare outcomes.

The Sepulveda GEU Study revisited: Long-term outcomes, use of services, and costs

The randomized controlled trial of the Geriatric Evaluation Unit (GEU) at the Sepulveda Veterans Hospital was the first to document the clinical and cost-effectiveness of hospital-based comprehensive geriatric assessment (CGA). Frail elderly inpatients were assigned randomly to the GEU for CGA, therapy, rehabilitation, and placement (N=63), or to standard hospital care (N=60). At one year, GEU patients had much lower mortality (24% vs 48%) and were less likely to have been discharged to a nursing home (NH) (13% vs 30%), or to have spent any time in NHs (27% vs 47%). GEU patients were more likely to improve in personal self-maintenance and morale. Further, controls had substantially more acute-care hospital days, NH days, and hospital readmissions, resulting in higher direct institutional care costs, especially after survival adjustment. Here, we report the results of long-term follow-up. There was a significant survival effect through two years. Despite prolongation of life, there was no indication that quality of life was worse for survivors in the GEU group. In fact, the proportion of persons independent in ⩾2 ADLs at two years was somewhat higher for GEU patients (0.44) than controls (0.33) (z=1.27; p=0.056). By three years, 43% of GEU subjects and 38% of controls were still alive. Over the entire 3-year period, the per capita direct cost difference was not significant, either before or after survival adjustment (unadjusted:

Depression in Older Patients Admitted for Postacute Nursing Home Rehabilitation

37,091 GEU vs

The yield, reliability, and validity of a postal survey for screening community-dwelling older people.

34,205 control; survival-adjusted:

The complexity of care for patients with rheumatoid arthritis: metrics for better understanding chronic disease care.

54,315 GEU vs

Effect of preventive home visits for ambulatory housebound elders in Japan: a pilot study

63,362 control; p=0.17). For patients who died during follow-up, the per capita health-care costs of the last year of life were significantly lower in GEU than control decedents (