Susan H. Hirsch

Value of functional status as a predictor of mortality: Results of a prospective study☆

PURPOSE To assess the value of functional status questions in predicting mortality, we conducted a 4-year prospective longitudinal follow-up study of functionally impaired community-dwelling elderly persons. SUBJECTS AND METHODS A total of 282 elderly (aged 64 years or older) patients of 76 community-based physicians who were UCLA clinical faculty members were assessed at baseline and at an average of 51 months later using scales from the Functional Status Questionnaire. RESULTS By the end of the study, 24% of the sample had died. By means of a multivariate model, the following baseline characteristics were independently predictive of death: greater dysfunction on a scale of intermediate activities of daily living, male gender, living alone, white race, better quality of social interactions, and age. Initial baseline functional measures were also predictive of follow-up health status perceptions. CONCLUSION The assessment of information on physical functioning and the quality of social interactions provides prognostic information regarding mortality. Furthermore, of the independent predictors of death identified in this sample, only functional impairment and living alone are remediable. Whether improving functional status can reduce the risk of mortality remains to be determined.

A Randomized Clinical Trial of Outpatient Comprehensive Geriatric Assessment Coupled with an Intervention to Increase Adherence to Recommendations

BACKGROUND: Although comprehensive geriatric assessment (CGA) has been demonstrated to confer health benefits in some settings, its value in outpatient or office settings is uncertain.

Improving patient quality of life with feedback to physicians about functional status.

OBJECTIVE: To improve functional status among primary care patients.INTERVENTION: 1) Computer-generated feedback to physicians about the patient’s functional status, the patient’s self-reported “chief complaint,” and problem-specific resource and management suggestions; and 2) two brief interactive educational sessions for physicians.DESIGN: Randomized controlled trial.SETTING: University primary care clinic.PARTICIPANTS: All 73 internal medicine houseofficers and 557 of their new primary care patients.MEASURES: 1) Change in patient functional status from enrollment until six months later, using the Functional Status Questionnaire (FSQ); 2) management plans and additional information about functional status abstracted from the medical record; and 3) physician attitude about whether internists should address functional status problems.RESULTS: Emotional well-being scores improved significantly for the patients of the experimental group physicians compared with those of the control group physicians (p<0.03). Limitations in social activities indicated as “due to health” decreased among the elderly (>70 years of age) individuals in the experimental group compared with the control group (p<0.03). The experimental group physicians diagnosed more symptoms of stress or anxiety than did the control group physicians (p<0.001) and took more actions recommended by the feedback form (p<0.02).CONCLUSIONS: Computer-generated feedback of functional status screening results accompanied by resource and management suggestions can increase physician diagnoses of impaired emotional well-being, can influence physician management of functional status problems, and can assist physicians in improving emotional well-being and social functioning among their patients.

The relationship between expectations for aging and physical activity among older adults.

AbstractBACKGROUND: New strategies to increase physical activity among sedentary older adults are urgently needed. OBJECTIVE: To examine whether low expectations regarding aging (age-expectations) are associated with low physical activity levels among older adults. DESIGN: Cross-sectional survey. PARTICIPANTS: Six hundred and thirty-six English- and Spanish-speaking adults aged 65 years and above attending 14 community-based senior centers in the Los Angeles region. Over 44% were non-Latino whites, 15% were African American, and 36% were Latino. The mean age was 77 years (range 65 to 100). MEASUREMENTS: Self-administered written surveys including previously tested measures of age-expectations and physical activity level in the previous week. RESULTS: Over 38% of participants reported <30 minutes of moderate-vigorous physical activity in the previous week. Older adults with lower age-expectations were more likely to report this very low level of physical activity than those with high age-expectations, even after controlling for the independent effect of age, sex, ethnicity, level of education, physical and mental health-related quality of life, comorbidity, activities of daily living impairment, depressive symptoms, self-efficacy, survey language, and clustering at the senior center. Compared with the quintile of participants having the highest age-expectations, participants with the lowest quintile of age-expectations had an adjusted odds ratio of 2.6 (95% confidence intervals: 1.5, 4.5) of reporting <30 minutes of moderate-vigorous physical activity in the previous week. CONCLUSIONS: In this diverse sample of older adults recruited from senior centers, low age-expectations are independently associated with very low levels of physical activity. Harboring low age-expectations may act as a barrier to physical activity among sedentary older adults.

Life-sustaining treatment decisions for nursing home residents: who discusses, who decides and what is decided?

OBJECTIVE: To evaluate whether nursing home residents and their families reported discussions about life‐sustaining treatment with their physicians, the relationship between such discussions and orders to limit therapy, and predictors of physician‐patient communication about life‐sustaining treatment.

The Critical Shortage of Geriatrics Faculty

To estimate the adequacy of current and future supply of geriatrics faculty, we conducted a national survey to determine the current supply of geriatrics faculty in five specialties and compared these estimates to standards for optimal faculty supply in geriatrics. Finally, we generated a model to project future faculty supply based on both current training capacity and differing assumptions regarding future training capacity.

How Many Physicians Will Be Needed to Provide Medical Care for Older Persons? Physician Manpower Needs for the Twenty-First Century

To estimate the number of full‐time‐equivalent (FTE) physicians and geriatricians needed to provide medical care in the years 2000 to 2030, we developed utilization‐based models of need for non‐surgical physicians and need for geriatricians.

Primary Care of Long‐Stay Nursing Home Residents: Approaches of Three Health Maintenance Organizations

OBJECTIVE: To describe the innovative programs of three health maintenance organizations (HMOs) for providing primary care for long‐stay nursing home (NH) residents and to compare this care with that of fee‐for‐service (FFS) residents at the same NHs.

Cognitive Decline in High-Functioning Older Persons Is Associated with an Increased Risk of Hospitalization

Objectives: To examine hospital use for patients with evidence of cognitive decline indicative of early cognitive impairment.

Geriatrics in Residency Programs.

To determine how well geriatrics has been integrated into residency training, the authors surveyed a random 33% sample of all the 378 family practice (n = 126) and 420 internal medicine (n = 140) training programs in the United States in 1988. All the programs responded. On average, the internal medicine programs had more geriatrics faculty than did the family practice faculty, but these numbers were insufficient to meet current or future needs. Fewer than half of the residencies had geriatrics inpatient or ambulatory-care evaluation units, geriatrics consult services, geropsychiatry wards, or geriatrics clinics available as training sites. In contrast, nursing homes were available for 93% of the family practice programs and 58% of the internal medicine programs. A total of 80% of the family practice programs but only 36% of the internal medicine programs had geriatrics curricula in place. The authors conclude that integration of geriatrics content into residency training is far from universal, largely because of a shortage of faculty and clinical training sites.