Susan L. Mitchell

Increased gait unsteadiness in community-dwelling elderly fallers

OBJECTIVE To test the hypothesis that quantitative measures of gait unsteadiness are increased in community-dwelling elderly fallers. STUDY DESIGN Retrospective, case-control study. SETTING General community. PARTICIPANTS Thirty-five community-dwelling elderly subjects older than 70 years of age who were capable of ambulating independently for 6 minutes were categorized as fallers (age, 82.2 +/- 4.9 yrs [mean +/- SD]; n = 18) and nonfallers (age, 76.5 +/- 4.0 yrs; n = 17) based on history; 22 young (age, 24.6 +/- 1.9 yrs), healthy subjects also participated as a second reference group. MAIN OUTCOME MEASURES Stride-to-stride variability (standard deviation and coefficient of variation) of stride time, stance time, swing time, and percent stance time measured during a 6-minute walk. RESULTS All measures of gait variability were significantly greater in the elderly fallers compared with both the elderly nonfallers and the young subjects (p < .0002). In contrast, walking speed of the elderly fallers was similar to that of the nonfallers. There were little or no differences in the variability measures of the elderly nonfallers compared with the young subjects. CONCLUSIONS Stride-to-stride temporal variations of gait are relatively unchanged in community-dwelling elderly nonfallers, but are significantly increased in elderly fallers. Quantitative measurement of gait unsteadiness may be useful in assessing fall risk in the elderly.

A National Study of the Location of Death for Older Persons with Dementia

Objectives: To describe where older Americans with dementia die and to compare the state health system factors related to the location of dementia‐related deaths with those of cancer and all other conditions in this population.

End-of-life transitions among nursing home residents with cognitive issues.

BACKGROUND Health care transitions in the last months of life can be burdensome and potentially of limited clinical benefit for patients with advanced cognitive and functional impairment. METHODS To examine health care transitions among Medicare decedents with advanced cognitive and functional impairment who were nursing home residents 120 days before death, we linked nationwide data from the Medicare Minimum Data Set and claims files from 2000 through 2007. We defined patterns of transition as burdensome if they occurred in the last 3 days of life, if there was a lack of continuity in nursing homes after hospitalization in the last 90 days of life, or if there were multiple hospitalizations in the last 90 days of life. We also considered various factors explaining variation in these rates of burdensome transition. We examined whether there was an association between regional rates of burdensome transition and the likelihood of feeding-tube insertion, hospitalization in an intensive care unit (ICU) in the last month of life, the presence of a stage IV decubitus ulcer, and hospice enrollment in the last 3 days of life. RESULTS Among 474,829 nursing home decedents, 19.0% had at least one burdensome transition (range, 2.1% in Alaska to 37.5% in Louisiana). In adjusted analyses, blacks, Hispanics, and those without an advance directive were at increased risk. Nursing home residents in regions in the highest quintile of burdensome transitions (as compared with those in the lowest quintile) were significantly more likely to have a feeding tube (adjusted risk ratio, 3.38), have spent time in an ICU in the last month of life (adjusted risk ratio, 2.10), have a stage IV decubitus ulcer (adjusted risk ratio, 2.28), or have had a late enrollment in hospice (adjusted risk ratio, 1.17). CONCLUSIONS Burdensome transitions are common, vary according to state, and are associated with markers of poor quality in end-of-life care.

Open-loop and closed-loop postural control mechanisms in Parkinson's disease: increased mediolateral activity during quiet standing.

Stabilogram-diffusion analysis was used to gain insights into how idiopathic Parkinsons disease (IPD) affects the postural control mechanisms involved in maintaining erect stance. Twenty-two subjects with IPD and twenty-four healthy elderly subjects were studied under eyes-open, quiet-standing conditions. The postural control mechanisms in the parkinsonian subjects, compared to the healthy elderly, were characterized by an increase in the effective stochastic activity in the mediolateral direction. Mediolateral posturographic measures were also associated with a history of falls and poor performance on clinical measures of balance. It is hypothesized that the increase in mediolateral activity in subjects with IPD may reflect an attempt to maintain potentially stabilizing movements during quiet standing in the face of impaired movement in the anteroposterior direction. This study supports the notion that mediolateral instability is an important posturographic marker of functional balance impairment in the elderly.

Video decision support tool for advance care planning in dementia: randomised controlled trial

Objective To evaluate the effect of a video decision support tool on the preferences for future medical care in older people if they develop advanced dementia, and the stability of those preferences after six weeks. Design Randomised controlled trial conducted between 1 September 2007 and 30 May 2008. Setting Four primary care clinics (two geriatric and two adult medicine) affiliated with three academic medical centres in Boston. Participants Convenience sample of 200 older people (≥65 years) living in the community with previously scheduled appointments at one of the clinics. Mean age was 75 and 58% were women. Intervention Verbal narrative alone (n=106) or with a video decision support tool (n=94). Main outcome measures Preferred goal of care: life prolonging care (cardiopulmonary resuscitation, mechanical ventilation), limited care (admission to hospital, antibiotics, but not cardiopulmonary resuscitation), or comfort care (treatment only to relieve symptoms). Preferences after six weeks. The principal category for analysis was the difference in proportions of participants in each group who preferred comfort care. Results Among participants receiving the verbal narrative alone, 68 (64%) chose comfort care, 20 (19%) chose limited care, 15 (14%) chose life prolonging care, and three (3%) were uncertain. In the video group, 81 (86%) chose comfort care, eight (9%) chose limited care, four (4%) chose life prolonging care, and one (1%) was uncertain (χ2=13.0, df=3, P=0.003). Among all participants the factors associated with a greater likelihood of opting for comfort care were being a college graduate or higher, good or better health status, greater health literacy, white race, and randomisation to the video arm. In multivariable analysis, participants in the video group were more likely to prefer comfort care than those in the verbal group (adjusted odds ratio 3.9, 95% confidence interval 1.8 to 8.6). Participants were re-interviewed after six weeks. Among the 94/106 (89%) participants re-interviewed in the verbal group, 27 (29%) changed their preferences (κ=0.35). Among the 84/94 (89%) participants re-interviewed in the video group, five (6%) changed their preferences (κ=0.79) (P<0.001 for difference). Conclusion Older people who view a video depiction of a patient with advanced dementia after hearing a verbal description of the condition are more likely to opt for comfort as their goal of care compared with those who solely listen to a verbal description. They also have more stable preferences over time. Trial registration Clinicaltrials.gov NCT00704886.

Satisfaction with end-of-life care for nursing home residents with advanced dementia.

OBJECTIVES: To identify factors associated with satisfaction with care for healthcare proxies (HCPs) of nursing home (NH) residents with advanced dementia.

Natural history of feeding-tube use in nursing home residents with advanced dementia.

OBJECTIVES Despite the evidence that feeding-tube use in persons with advanced dementia is not associated with improved outcomes, there remains striking variation in their use. Yet, little is known about the national incidence of feeding-tube insertions, the circumstances of their insertion, and post-insertion health care use. DESIGN Secondary analysis of Minimum Data Set merged onto Medicare Claims Files. SETTING AND PARTICIPANTS Nursing home residents (NHR) without a feeding tube. MEASUREMENTS NHR were followed for up to 1 year to see whether a feeding tube was inserted and then followed for 1 year after insertion to examine health care use and survival. RESULTS The incidence of feeding-tube insertion was 53.6/1000 residents. Most (68.1%) feeding-tube insertions were performed in an acute care hospital with the most common reasons for admission being pneumonia, dehydration, and dysphagia. One year post-insertion mortality was 64.1% with median survival of 56 days. Within 1 year, 19.3% of those who had a feeding tube inserted required a tube replacement or repositioning within a median 145 days after the initial insertion. Over 1 year, tube feeding was associated with an average of 9.1 hospitalized days per person, 1.0 hospitalizations, 0.3 emergency room visits that did not result in a hospital admission. CONCLUSION Most feeding tubes are inserted in an acute care hospital. Feeding-tube insertions are also associated with poor survival and significant rate of health care use after insertion.

Comfort feeding only: a proposal to bring clarity to decision-making regarding difficulty with eating for persons with advanced dementia.

Feeding and eating difficulties leading to weight loss are common in the advanced stages of dementia. When such problems arise, family members are often faced with making a decision regarding the placement of a percutaneous endoscopic gastrostomy tube. The existing evidence based on observational studies suggests that feeding tubes do not improve survival or reduce the risk of aspiration, yet the use of feeding tubes is prevalent in patients with dementia, and the majority of nursing home residents do not have orders documenting their wishes about the use of artificial hydration and nutrition. One reason is that orders to forgo artificial hydration and nutrition get wrongly interpreted as “do not feed,” resulting in a reluctance of families to agree to them. Furthermore, nursing homes fear regulatory scrutiny of weight loss and wrongly believe that the use of feeding tubes signifies that everything possible is being done. These challenges might be overcome with the creation of clear language that stresses the patients goals of care. A new order, “comfort feeding only,” that states what steps are to be taken to ensure the patients comfort through an individualized feeding care plan, is proposed. Comfort feeding only through careful hand feeding, if possible, offers a clear goal‐oriented alternative to tube feeding and eliminates the apparent care–no care dichotomy imposed by current orders to forgo artificial hydration and nutrition.

Hospital Characteristics Associated With Feeding Tube Placement in Nursing Home Residents With Advanced Cognitive Impairment

CONTEXT Tube-feeding is of questionable benefit for nursing home residents with advanced dementia. Approximately two-thirds of US nursing home residents who are tube fed had their feeding tube inserted during an acute care hospitalization. OBJECTIVE To identify US hospital characteristics associated with higher rates of feeding tube insertion in nursing home residents with advanced cognitive impairment. DESIGN, SETTING, AND PATIENTS The sample included nursing home residents aged 66 years or older with advanced cognitive impairment admitted to acute care hospitals between 2000 and 2007. Rate of feeding tube placement was based on a 20% sample of all Medicare Claims files and was assessed in hospitals with at least 30 such admissions during the 8-year period. A multivariable model with the unit of the analysis being the hospital admission identified hospital-level factors independently associated with feeding tube insertion rates, including bed size, ownership, urban location, and medical school affiliation. Measures of each hospitals care practices for all patients with serious chronic illnesses were evaluated, including intensive care unit (ICU) use in the last 6 months of life, the use of hospice services, and the ratio of specialist to primary care physicians. Patient-level characteristics were also considered. MAIN OUTCOME MEASURE Endoscopic or surgical insertion of a gastrostomy tube during a hospitalization. RESULTS In 2797 acute care hospitals with 280,869 admissions among 163,022 nursing home residents with advanced cognitive impairment, the rate of feeding tube insertion varied from 0 to 38.9 per 100 hospitalizations (mean [SD], 6.5 [5.3]; median [interquartile range], 5.3 [2.6-9.3]). The mean rate of feeding tube insertions per 100 admissions was 7.9 in 2000, decreasing to 6.2 in 2007. Higher insertion rates were associated with the following hospital features: for-profit ownership vs government owned (8.5 vs 5.5 insertions per 100 hospitalizations; adjusted odds ratio [AOR], 1.33; 95% confidence interval [CI], 1.21-1.46), larger size (>310 beds vs <101 beds: 8.0 vs 4.3 insertions per 100 hospitalizations; AOR, 1.48; 95% CI, 1.35-1.63), and greater ICU use in the last 6 months of life (highest vs lowest decile: 10.1 vs 2.9 insertions per 100 hospitalizations; AOR, 2.60; 95% CI, 2.20-3.06). These differences persisted after controlling for patient characteristics. Specialist to primary care ratio and hospice use were weakly or not associated with feeding tube placement. CONCLUSION Among nursing home residents with advanced cognitive impairment admitted to acute care hospitals, for-profit ownership, larger hospital size, and greater ICU use was associated with increased rates of feeding tube insertion, even after adjusting for patient-level characteristics.

A cross-national survey of tube-feeding decisions in cognitively impaired older persons.

OBJECTIVES: Many factors affect the decision to institute long‐term tube‐feeding in older persons. The objectives of this cross‐national survey are to examine the tube‐feeding decision‐making process for cognitively impaired older persons from the perspective of the substitute decision‐makers (SDM) and to contrast this process in US and Canadian healthcare settings.