Patricia L. Blanchette

Self-Reported Driving, Cognitive Status, and Physician Awareness of Cognitive Impairment

OBJECTIVES: To assess self‐reported driving rates in older people and correlate these data with cognitive status and physician recognition of cognitive impairment.

Factors Associated with Physician Decision-Making in Starting Tube Feeding

BACKGROUND Because tube-feeding decisions are sometimes difficult, we examined physician, institutional, and patient factors associated with these decisions. METHODS Primary care physicians (n = 388) likely to manage nursing home patients in Hawaii were surveyed. Respondents indicated the factors of great importance in tube feeding decisions based on a vignette of a poststroke patient failing to thrive and family disagreement with advance directives. chi(2) and multiple logistic regression analyses were used to examine associations between physician demographics and factors of importance to physicians and their decisions based on the vignette. RESULTS Starting tube feeding (chosen by 31% of respondents) was associated with internal medicine specialty (odds ratio [OR] 2.5, 95% confidence interval [CI] 1.4-4.6), and placing great importance on family preference (OR 5.4, 95% CI 3.0-9.8) and liability (OR 2.5, 95% CI 1.3-4.8). After 3 months without improvement, 58% chose to withdraw tube feeding. Continuing tube feeding was associated with placing great importance on family wishes (OR 3.0, 95% CI 1.8-5.1) and liability (OR 1.7, 95% CI 1.0-2.9). Placing great importance on the living will was associated with decreased likelihoods of starting (OR 0.1, 95% CI 0.04-0.3) and continuing (OR 0.1, 95% CI 0.04-0.3) tube feeding. CONCLUSIONS The decision to start or withhold tube feeding is associated with the individual physicians perception of the importance of patient wishes versus family wishes and liability concerns. Physician awareness of the influence of these factors on medical decisions may improve the decision-making process.

Weight loss in patients with Alzheimer's disease.

Abstract Weight loss occurs frequently in patients with Alzheimers disease (AD). This article will review why weight loss is so important in AD patients and what the ramifications are. This includes not only the negative effects of weight loss but possible benefits of weight gain. There is some evidence that weight loss manifests before AD. Structural, genetic, and neurochemical factors are discussed. There are possible risk factors and predictors which could herald weight loss in AD. Olfactory changes which occur in AD patients may make the food less appealing. Changes in food consumption may occur in AD leading to decreased energy intake. At the same time there is more evidence that increased energy expenditure is not the cause of weight loss in AD. Lastly we will go over possible treatment strategies. This includes environmental changes, food alterations, oral supplementations, and medications. A Medline literature search was conducted from 2000 to present using key search words of weight loss and Alzheimers disease. Studies that were included were prospective designs, observational studies, review articles and their references.

Using standardized patients to assess the geriatrics medicine skills of medical students, internal medicine residents, and geriatrics medicine fellows.

Purpose. Medical schools and residency programs are placing additional emphasis on including clinical geriatrics competencies within their curricula. An eight-station, Geriatric Medicine Standardized Patient Examination (GSPX) was studied as a method to assess bedside geriatrics clinical skills over the continuum of medical education from medical school through residency and fellowship training. Method. The GSPX was administered to 39 medical students, 49 internal medicine residents, and 11 geriatrics medicine fellows in 2001–02. Reliability of standardized patient (SP) checklists and rating scales used to assess examinees’ performance was measured by Cronbachs alpha. Validity was measured by surveying the examinees’ assessment of fairness, individual case length, difficulty, and believability, and by faculty standard setting for each level of trainee. Results. Reliability was high (α = .89). All levels of examinees found the SPs to be believable, station lengths to be adequate, and rated the GSPX as a fair assessment. Students rated the cases as more difficult. Previous experience with similar real patients increased significantly with level of training (Pearson’s r = .48, p < .0001). Faculty set passing scores that increased from students to residents to fellows. However, GSPX scores decreased with level of training (r = −.25, p = .01). Conclusion. The GSPX is a reliable measure of geriatrics medicine skills with adequate face validity for examinees at all levels. However, GSPX scores did not increase with level of training, suggesting that a single form of the examination cannot be used across the continuum of training. Potential modifications to the GSPX that might provide more discrimination between levels of training are currently being explored.

Strength and influence of geriatrics departments in academic health centers.

The United States is establishing new medical schools and increasing class size by 30% in response to the predicted increased needs of the baby boom generation, which will retire soon and live longer than prior generations. Society in general and the medical profession in particular are ill equipped to care for the special needs of the elderly. Since the early 1980s, departments of geriatric medicine have been developed in the United States. However, the prevailing U.S. system for the training of physicians in geriatrics is through sections, divisions, or institutes. This article reviews the advantages and disadvantages of departments of geriatrics, using case examples from three (University of Oklahoma College of Medicine, Florida State University College of Medicine, and University of Hawaii at Mãnoa John A. Burns School of Medicine) of the extant 11 medical schools in the United States with departments of geriatrics. Commonalities among the three departments include a seat at the planning table in academic life, equal treatment and collaboration with other departments in academic and research program development, and direct access to key decision makers and opportunities for negotiation for funds. Each department has outreach to all undergraduate medical students through its training program. All three departments were launched through the investment of significant resources obtained both internally and externally. The challenge for the future will be to definitively demonstrate the efficacy of the department model versus the more prevalent section, division, and institute approach to training physicians to care for the elderly.

Tetanus immunity in long-term care facilities

OBJECTIVES: To investigate the correlates of tetanus immunity in the elderly residing in a long‐term care facility in Hawaii.

CURRICULUM DEVELOPMENT IN GERIATRIC MEDICINE FOR OBSTETRICS AND GYNECOLOGY RESIDENTS

elderly adults contributes to survival. The level proposed by Oates et al. below which BP should not be lowered in the oldest old is the upper limit of currently accepted recommendations for prevention and management of hypertension. From Figures 1 and 2 in their article, it appears that survival significantly decreases when systolic BP is less than 110 mmHg /or diastolic BP is less than 60 mmHg. It would be interesting to know whether systolic BP within the range 120 to 140 mmHg and diastolic BP within the range 60 to 90 mmHg affect survival. Such data were not provided. In our prospective cohort study of 179 low-level care residents (mean age 83.2 7.0; 80% women), the total 5year mortality rate was 116.1 per 1,000 person-years, whereas subjects with systolic BP less than 120 mmHg and especially with diastolic BP less than 65 mmHg had the highest mortality rates (171.4 and 194.8 per 1,000 personyears, respectively). Absolute postprandial systolic BP less than 120 mmHg was significantly associated with all-cause mortality (relative risk (RR) 5 1.69, 95% confidence interval (CI) 5 1.04–2.78; P 5.04). Second and more important is the fact that, in clinical practice, older populations present a spectrum of BP disorders, of which hypertension is not only highly prevalent but is also frequently associated with orthostatic hypotension (OH) and postprandial hypotension (PPH), syndromes known to increase morbidity and mortality. Oates et al. linked shortened survival in older veterans to orthostasis induced or worsened by antihypertensive treatment. Data on the prevalence of coexistent supine hypertension and OH or PPH are scarce, and the management of such conditions has not been well established. In our study, 46.9% of subjects had hypertension, 22.9% OH, and 38.5% PPH. In patients with hypertension 26.2% also had OH, 54.8% PPH, and 15.5% both. Of older patients admitted to a medical ward, OH was found in 24%, PPH in 34%, and both in 10%. In 100 consecutive patients (mean age 71.6 9.4) with OH, supine hypertension was present in 84% and PPH in 83%. Although OH and PPH are often considered to be adverse drug effects of antihypertensive therapy, a study of octoand nonagenarians did not find associations between antihypertensive agents, including angiotensin-converting enzyme inhibitors, diuretics, betablockers, and calcium channel blockers and OH, PPH, or falls. Moreover, hypertension was positively associated with PPH (RR 5 4.3, 95% CI 5 2.1–8.6; Po.001), and antihypertensive therapy ameliorated the postprandial decline in BP. Taken together with observations of other researchers, our data suggest that, in the oldest patients with hypertension coexisting with PPH or OH, antihypertensive therapy is beneficial as long as low BP (o120/ 65 mmHg) is avoided to prevent cerebral hypoperfusion and other target organ damage. The capacity to maintain optimal systemic, cerebral, and splanchnic blood flow is of fundamental biological significance, contributing to survival. Increasing evidence suggests that low BP, especially PPH and OH, are risk factors for poor clinical outcomes. Impaired BP homeostasis in older people often presents as a combination of resting hypertension with PPH or OH. Therefore, BP control must take into account the spectrum of individual hemodynamic abnormalities. The rule ‘‘the lower BP, the better’’ is not applicable to the older population, although the ‘‘baby should not be thrown out with the bath water’’, and it should be recognized that antihypertensive therapy is beneficial in the oldest old and can ameliorate PPH and OH as long as absolute BP is not too low.