Oral healthcare issues in rural residential aged care services in Victoria, Australia.

OBJECTIVES: To identify major issues in providing and accessing oral health care in Victorian rural residential aged care services from the perspectives of dentists, aged care staff and residents. METHODS: Structured interviews were conducted with five dentists, nine aged care staff and six residents. Three focus groups were conducted with aged care staff. These data were thematically analysed independently by two researchers. RESULTS: The challenges reported by dentists included complexity of care, infrastructure needs and need for skill development. Aged care staff reported lack of skills and confidence in providing oral hygiene care, especially in residents with natural teeth, and an increasing burden on their daily workload. Residents reported concern and shame regarding their declining oral health status and increased challenges accessing appropriate oral health care. CONCLUSION: These findings indicate the need to build and sustain aged care 'oral health teams' who are able to provide daily oral hygiene care for residents and mentor other staff. Rural dentists need access to gerodontic training, portable equipment and appropriate workspaces in aged care services. Aged care and oral health services need to establish clear referral and communication pathways.

Early hospital readmission is a predictor of one-year mortality in community-dwelling older Medicare beneficiaries.

BACKGROUND: Hospital readmission within thirty days is common among Medicare beneficiaries, but the relationship between rehospitalization and subsequent mortality in older adults is not known. OBJECTIVE: To compare one-year mortality rates among community-dwelling elderly hospitalized Medicare beneficiaries who did and did not experience early hospital readmission (within 30 days), and to estimate the odds of one-year mortality associated with early hospital readmission and with other patient characteristics. DESIGN AND PARTICIPANTS: A cohort study of 2133 hospitalized community-dwelling Medicare beneficiaries older than 64 years, who participated in the nationally representative Cost and Use Medicare Current Beneficiary Survey between 2001 and 2004, with follow-up through 2006. MAIN MEASURE: One-year mortality after index hospitalization discharge. KEY RESULTS: Three hundred and four (13.7 %) hospitalized beneficiaries had an early hospital readmission. Those with early readmission had higher one-year mortality (38.7 %) than patients who were not readmitted (12.1 %; p<0.001). Early readmission remained independently associated with mortality after adjustment for sociodemographic factors, health and functional status, medical comorbidity, and index hospitalization-related characteristics [HR (95 % CI) 2.97 (2.24-3.92)]. Other patient characteristics independently associated with mortality included age [1.03 (1.02-1.05) per year], low income [1.39 (1.04-1.86)], limited self-rated health [1.60 (1.20-2.14)], two or more recent hospitalizations [1.47 (1.01-2.15)], mobility difficulty [1.51 (1.03-2.20)], being underweight [1.62 (1.14-2.31)], and several comorbid conditions, including chronic lung disease, cancer, renal failure, and weight loss. Hospitalization-related factors independently associated with mortality included longer length of stay, discharge to a skilled nursing facility for post-acute care, and primary diagnoses of infections, cancer, acute myocardial infarction, and heart failure. CONCLUSIONS: Among community-dwelling older adults, early hospital readmission is a marker for notably increased risk of one-year mortality. Providers, patients, and families all might respond profitably to an early readmission by reviewing treatment plans and goals of care.

Arterial stiffness and cognitive decline in well-functioning older adults.

BACKGROUND: Stiffness of the central arteries in aging may contribute to cerebral microvascular disease independent of hypertension and other vascular risk factors. Few studies of older adults have evaluated the association of central arterial stiffness with longitudinal cognitive decline. METHODS: We evaluated associations of aortic pulse wave velocity (centimeters per second), a measure of central arterial stiffness, with cognitive function and decline in 552 participants in the Health, Aging, and Body Composition (Health ABC) study Cognitive Vitality Substudy (mean age ± SD = 73.1 ± 2.7 years, 48% men and 42% black). Aortic pulse wave velocity was assessed at baseline via Doppler-recorded carotid and femoral pulse waveforms. Global cognitive function, verbal memory, psychomotor, and perceptual speed were evaluated over 6 years. RESULTS: After adjustment for demographics, vascular risk factors, and chronic conditions, each 1 SD higher aortic pulse wave velocity (389 cm/s) was associated with poorer cognitive function: -0.11 SD for global function (SE = 0.04, p < .01), -0.09 SD for psychomotor speed (SE = 0.04, p = .03), and -0.12 SD for perceptual speed (SE = 0.04, p < .01). Higher aortic pulse wave velocity was also associated with greater decline in psychomotor speed, defined as greater than 1 SD more than the mean change (odds ratio = 1.42 [95% confidence interval = 1.06, 1.90]) but not with verbal memory or longitudinal decline in global function, verbal memory, or perceptual speed. Results were consistent with mixed models of decline in each cognitive test. CONCLUSIONS: In well-functioning older adults, central arterial stiffness may contribute to cognitive decline independent of hypertension and other vascular risk factors.

Arterial stiffness and gait speed in older adults with and without peripheral arterial disease.

BACKGROUND: Central arterial stiffness is increasingly recognized as an important predictor of cardiovascular events and mortality in older adults; however, few studies have evaluated the association of arterial stiffness with mobility decline, a common consequence of vascular disease. METHODS: We analyzed the association of pulse wave velocity (PWV), a measure of aortic stiffness, with longitudinal gait speed over 7 years in 2,172 participants in the Health, Aging and Body Composition (ABC) Study (mean age ± s.d. 73.6 ± 2.9 years, 48% men, 39% black). RESULTS: In mixed-effects models adjusted for demographics, each s.d. (396 cm/s) higher PWV was associated with 0.015 (s.e. 0.004) m/s slower gait at baseline and throughout the study period in the full cohort (P < 0.001); this relationship was largely explained by hypertension and other vascular risk factors. Among participants with peripheral arterial disease (PAD) (n = 261; 12.7%), each s.d. higher PWV was independently associated with 0.028 (s.e. 0.010) m/s slower gait speed at baseline and throughout the study period (P < 0.01). CONCLUSIONS: These findings suggest that aortic stiffness may be especially detrimental to mobility in older adults with already compromised arterial function.

Ability to walk 1/4 mile predicts subsequent disability, mortality, and health care costs.

BACKGROUND: Mobility, such as walking 1/4 mile, is a valuable but underutilized health indicator among older adults. For mobility to be successfully integrated into clinical practice and health policy, an easily assessed marker that predicts subsequent health outcomes is required. OBJECTIVE: To determine the association between mobility, defined as self-reported ability to walk 1/4 mile, and mortality, functional decline, and health care utilization and costs during the subsequent year. DESIGN: Analysis of longitudinal data from the 2003-2004 Medicare Current Beneficiary Survey, a nationally representative sample of Medicare beneficiaries. PARTICIPANTS: Participants comprised 5895 community-dwelling adults aged 65 years or older enrolled in Medicare. MAIN MEASURES: Mobility (self-reported ability to walk 1/4 mile), mortality, incident difficulty with activities of daily living (ADLs), total annual health care costs, and hospitalization rates. KEY RESULTS: Among older adults, 28% reported difficulty and 17% inability to walk 1/4 mile at baseline. Compared to those without difficulty and adjusting for demographics, socioeconomic status, chronic conditions, and health behaviors, mortality was greater in those with difficulty [AOR (95% CI): 1.57 (1.10-2.24)] and inability [AOR (CI): 2.73 (1.79-4.15)]. New functional disability also occurred more frequently as self-reported ability to walk 1/4 mile declined (subsequent incident disability among those with no difficulty, difficulty, or inability to walk 1/4 mile at baseline was 11%, 29%, and 47% for instrumental ADLs, and 4%, 14%, and 23% for basic ADLs). Total annual health care costs were $2773 higher (95% CI $1443-4102) in persons with difficulty and $3919 higher (CI $1948-5890) in those who were unable. For each 100 persons, older adults reporting difficulty walking 1/4 mile at baseline experienced an additional 14 hospitalizations (95% CI 8-20), and those who were unable experienced an additional 22 hospitalizations (CI 14-30) during the follow-up period, compared to persons without walking difficulty. CONCLUSIONS: Mobility disability, a simple self-report measure, is a powerful predictor of future health, function, and utilization independent of usual health and demographic indicators. Mobility disability may be used to target high-risk patients for care management and preventive interventions.

Contested surveillance: risk, safety, and cervical screening in Australia.

The expectation of participation in cervical screening programs has become a ubiquitous feature of women's lives; but despite the obvious importance of trying to prevent cervical cancer, both the expression and fulfilment of that expectation are far from straightforward. This is because the actors involved are not always consistent in their interpretation of the risks involved and safety sought. The history of cervical screening in Australia illustrates how the implementation of medical surveillance can be shaped by such interpretations. We argue in particular that conflict in Australia over screening frequency requires an explanation of this kind, and more broadly that we have entered an era of preventive medicine that can be described as one of 'contested surveillance'.

Hospitalization and change in body composition and strength in a population-based cohort of older persons.

OBJECTIVES: To examine the association between hospitalization and annual changes in body composition and strength in older adults. DESIGN: Cohort study. SETTING: Clinic examinations in Pittsburgh, Pennsylvania, or Memphis, Tennessee. PARTICIPANTS: Well-functioning adults aged 70 to 79 who participated in the Health, Aging and Body Composition Study. MEASUREMENTS: Hospitalizations were reported at annual clinic visits and in semiannual phone interviews. In the event of death or reported hospitalization, hospitalizations were adjudicated according to medical record review. Dual X-ray absorptiometry (DXA) assessments of total, lean, and fat mass were conducted in six annual examinations, and measures of knee extensor strength were conducted in two annual examinations. RESULTS: DXA assessments followed 2,309 hospitalizations. In men and women, hospitalization in the previous year was associated with greater declines in total mass (-0.76 and -0.81 kg, respectively), fat mass (-0.41 and -0.54 kg), and lean mass (-0.33 and -0.25 kg) (P < .001 for all) than in nonhospitalized participants, after adjustment for demographics and baseline values. Hospitalization was associated with strength declines in men (-4.02 Nm, P = .046) but not in women. Relationships were similar after adjusting for health behaviors and chronic conditions, although the association between hospitalization and strength was attenuated. Associations increased with number of days hospitalized; hospitalizations totaling 8 days or more in the previous year were associated with significantly greater loss of total, lean, and fat mass and loss of strength in both sexes than in nonhospitalized participants. CONCLUSION: Hospitalization is associated with significant changes in body composition and strength in older persons. These effects appear particularly important in persons hospitalized for 8 or more days per year.

Qualities of fatigue and associated chronic conditions among older adults.

CONTEXT: Although fatigue is a common and distressing symptom, a well-specified definition of fatigue is lacking. One of the least well-defined aspects of fatigue is its quality, which might reflect the underlying pathophysiology. OBJECTIVE: To identify the qualities of fatigue and assess whether they are associated with distinct chronic conditions. METHODS: We identified five fatigue qualities in the literature, two mental and three physical, and selected representative items from those available in our data from a prospective cohort of 495 community-dwelling primary care patients aged 65 years or older. We then examined the prevalence of each quality, the correlations among qualities, and the association of fatigue qualities with health and functional status, including chronic conditions. RESULTS: Fatigue was very common among older primary care patients, with 70% reporting one or more fatigue qualities and 43% reporting feeling tired most of the time, and was associated with worse health and functional status. Physical fatigue qualities were more common than mental qualities. Correlations among fatigue qualities were 0.09-0.27 and did not support the mental vs. physical classification. Different fatigue qualities were not well explained by older adults' underlying chronic conditions. Rather, the cumulative number of fatigue qualities was associated with worse health and function. CONCLUSION: These first steps in exploring fatigue qualities suggest that different fatigue qualities could represent disparate manifestations of a common underlying etiology, while not ruling out distinct underlying pathophysiologies.

Biopsychosocial characteristics of community-dwelling older adults with limited ability to walk one-quarter of a mile.

OBJECTIVES: To establish nationally representative estimates of the prevalence of self-reported difficulty and inability of older adults to walk one-quarter of a mile and to identify the characteristics independently associated with difficulty or inability to walk one-quarter of a mile. DESIGN: Cross-sectional analysis of data from the 2003 Cost and Use Medicare Current Beneficiary Survey. SETTING: Community. PARTICIPANTS: Nine thousand five hundred sixty-three community-dwelling Medicare beneficiaries aged 65 and older, representing an estimated total population of 34.2 million older adults. MEASUREMENTS: Self-reported ability to walk one-quarter of a mile, sociodemographics, chronic conditions, body mass index, smoking, functional status. RESULTS: In 2003, an estimated 9.5 million older Medicare beneficiaries had difficulty walking one-quarter of a mile, and 5.9 million were unable to do so. Of the 20.2 million older adults with no difficulty in activities of daily living (ADLs) or instrumental activities of daily living (IADLs), an estimated 4.3 million (21%) had limited ability to walk one-quarter of a mile. Having difficulty or being unable to walk one-quarter of a mile was independently associated with older age, female sex, non-Hispanic ethnicity, lower educational level, Medicaid entitlement, most chronic medical conditions, current smoking, and being overweight or obese. CONCLUSION: Almost half of older adults and 20% of those reporting no ADL or IADL limitations report limited ability to walk one-quarter of a mile. For functionally independent older adults, reported ability to walk one-quarter of a mile can identify vulnerable older adults with greater medical problems and fewer resources and may be a valuable clinical marker in planning their care. Future work is needed to determine the association between ability to walk one-quarter of a mile walk and subsequent functional decline and healthcare use.

Antitumor activity of a selectively replication competent herpes simplex virus (HSV) with enzyme prodrug therapy.

BACKGROUND: HSV1790 is an oncolytic virus generated by inserting the enzyme nitroreductase (NTR) into the virus HSV1716. NTR converts the prodrug CB1954 into an active alkylating agent. MATERIALS AND METHODS: In vitro, 3T6 cells (non permissive to HSV) were used in order to distinguish between virus-induced cytopathic effect and cell death due to activated prodrug. In vivo, xenograft models were injected with HSV1790 (10(5)-10(9) PFU) with or without CB1954 (max 80mg/kg) and tumor volume recorded regularly. Biodistribution of HSV1790 was determined immunohistochemically and by PCR. RESULTS: HSV1790 + CB1954 in vitro was more effective at killing tumor cells than the virus or the prodrug alone. In vivo, the combination reduced tumor volume and increased survival compared to treatment with HSV1790 or CB1954 alone. Following systemic administration of HSV1790, viral replication was detected in tumors, but not organs. CONCLUSION: HSV1790 + prodrug enhances tumor cell killing in vitro and reduces tumor volume and increases survival in vivo.

Methylphenidate for the treatment of depressive symptoms, including fatigue and apathy, in medically ill older adults and terminally ill adults.

BACKGROUND: Depressive symptoms, fatigue, and apathy are common symptoms among medically ill older adults and patients with advanced disease, and have been associated with morbidity and mortality. Methylphenidate has been used to treat these symptoms because of its rapid effect. Despite the long history of methylphenidate use for the treatment of depressive symptoms, fatigue, and apathy, there is little definitive evidence to support its use. OBJECTIVE: The aim of this paper was to review the efficacy and tolerability of methylphenidate in the treatment of depressive symptoms, fatigue, and apathy in medically ill older adults and adults receiving palliative care. METHODS: English-language articles presenting systematic reviews, clinical trials, or case series describing the use of methylphenidate for the treatment of depressive symptoms, fatigue, or apathy in medically ill older adults or adults receiving palliative care were identified. The key words methylphenidate and either depressive, depression, fatigue, or apathy were used to search the Cochrane Database, MEDLINE, PsycINFO, and International Pharmaceutical Abstracts. Included articles addressed depressive symptoms, fatigue, or apathy in (1) older adults (generally, age > or =65 years), particularly those with comorbid medical illness; (2) adults receiving palliative care; and (3) adults with other chronic illnesses. I excluded articles regarding treatment of depression in healthy young adults; bipolar disorder and attention-deficit/hyperactivity disorder; and narcolepsy, chronic fatigue syndrome, and related disorders. RESULTS: A total of 19 controlled trials of methylphenidate in medically ill older adults or patients in palliative care were identified. Unfortunately, their conflicting results, small sample sizes, and poor methodologic quality limited the ability to draw inferences regarding the efficacy of methylphenidate, although evidence of tolerability was stronger. The available evidence suggests possible effectiveness of methylphenidate for depressive symptoms, fatigue, and apathy in various medically ill populations. CONCLUSION: In the absence of definitive evidence of effectiveness, trials of low-dose methylphenidate in medically ill adults with depression, fatigue, or apathy, with monitoring for response and adverse effects, are appropriate.

Missing data: a special challenge in aging research.

Scientific evidence should guide clinical care, but special methodological challenges influence interpretation of the medical literature pertaining to older adults. Missing data, ranging from lack of individual items in questionnaires to complete loss to follow-up, affect the quality of the evidence and are more likely to occur in studies of older adults because older adults have more health and functional problems that interfere with all aspects of data collection than do younger people. The purpose of this article is to promote knowledge about the risks and consequences of missing data in clinical aging research and to provide an organized approach to prevention and management. Although it is almost never possible to achieve complete data capture, efforts to prevent missing data are more effective than analytical "cure." Strategies to prevent missing data include selecting a primary outcome that is easy to determine and devising valid alternate definitions, adapting data collection to the special needs of the target population, pilot testing data collection plans, and monitoring missing data rates during the study and adapting data collection procedures as needed. Key steps in the analysis of missing data include assessing the extent and types of missing data before analysis, exploring potential mechanisms that contributed to the missing data, and using multiple analytical approaches to assess the effect of missing data on the results. Manuscripts should disclose rates of missing data and losses to follow-up, compare dropouts with participants who completed the study, describe how missing data were managed in the analysis phase, and discuss the potential effect of missing data on the conclusions of the study.

Fatigue predicts mortality in older adults.

OBJECTIVES: To determine the association between fatigue and survival over 10 years in a population of older community-dwelling primary care patients. DESIGN: Prospective cohort study. SETTING: Medicare health maintenance organization and Veterans Affairs primary care programs. PARTICIPANTS: Older primary care patients (N=492). MEASUREMENTS: Fatigue, operationalized as feeling tired most of the time, was assessed at baseline. Mortality was ascertained from the National Death Index. Covariates included demographics, comorbidity, cognitive function, depressive symptoms, body mass index, self-rated health, functional status, and gait speed. RESULTS: Mortality rates at 10 years were 59% (123/210) for older adults with fatigue, versus 38% (106/282) for those without fatigue (P<.001). After adjustment for multiple potential confounders, participants who were tired at baseline had a greater risk of death than those who were not (hazard ratio=1.44, 95% confidence interval=1.08-1.93). CONCLUSION: A single simple question "Do you feel tired most of the time?" identifies older adults with a higher risk of mortality. Further research is needed to identify and characterize the underlying mechanisms of fatigue, to develop and test specific treatments, and to determine whether improvement leads to decreased morbidity and mortality.

Explaining the effect of gender on functional transitions in older persons.

BACKGROUND: Women live longer but experience greater disability than men. The reasons for this gender difference in disability are not well understood. OBJECTIVE: Our objectives were to determine if the higher prevalence of disability in women is due to greater incidence of disability, longer duration of disability, or both, and to identify factors that potentially explain these gender differences. METHODS: 754 community-living persons aged 70 and older who were non-disabled (required no personal assistance) in four essential activities of daily living (ADLs) were assessed monthly for disability for up to 6 years. A multi-state extension of the proportional hazards model was used to determine the effects of gender on transitions between states of no disability, mild disability, severe disability, and death, and to evaluate potential mediators of these effects. RESULTS: Women were more likely to make the transition from no disability to mild disability and less likely to make the transitions from mild to no disability and from both mild and severe disability to death. The gender difference in the transitions between no disability and mild disability was largely explained by differences in gait speed and physical activity, but gender difference in transitions to death persisted despite adjustment for multiple potential mediators. CONCLUSION: The higher prevalence of disability in women versus men is due to a combination of higher incidence and longer duration, resulting from lower rates of recovery and mortality among disabled women.

Fatigue and function over 3 years among older adults.

BACKGROUND: Fatigue is a common complaint among older adults, but the association of fatigue with subsequent function is not well known. METHODS: This 3-year longitudinal study of older primary care patients evaluates the association of fatigue, operationalized as feeling tired most of the time, with functional status at baseline and over time. RESULTS: After adjustment for multiple potential confounders, participants who were tired at baseline had worse Short Form-36 Physical Performance Index scores, activity of daily living scores, and gait speeds. These functional deficits persisted throughout the follow-up period. CONCLUSIONS: Fatigue in older adults is associated with functional deficits that persist for years. Further research is needed to understand the causes of fatigue and to develop specific treatments for this serious symptom.

Depressive symptoms in late life: associations with apathy, resilience and disability vary between young-old and old-old.

OBJECTIVE: Prior research has found that disability and apathy are associated with late-life depression. However, the effect of age on these associations in "late-life," an ambiguous term encompassing all individuals typically older than 60 years, has not been examined. We investigated the association of depression with disability, apathy and resilience across the age range of late-life. METHODS: One hundred and five community-dwelling elderly with moderate levels of disability were assessed using the Geriatric Depression Scale (GDS), Hardy-Gill Resilience Scale, Starkstein Apathy Scale and IADL/ADL questionnaire. Multiple regression analysis was used to assess relationships between depression, disability, apathy and resilience, stratified by age (<80 vs. >80). RESULTS: In the <80 year old subject group, resilience, apathy and disability scores (partial type III R(2) = 11.1%, 10.4% and 12.8%, respectively) equally contributed to the variability of GDS score. In contrast, in the >80 year old subject group, apathy (partial type III R(2) = 18.7%) had the greatest contribution to GDS score. CONCLUSIONS: In elderly persons under age 80, resilience, apathy and disability all have relatively equal contributions to depression scores, whereas in those over age 80, depression is most highly correlated with apathy. These data suggest that depressive symptoms in elderly persons have different clinical features along the age spectrum from young-old to old-old.

Improvement in usual gait speed predicts better survival in older adults.

OBJECTIVES: To estimate the relationship between 1-year improvement in measures of health and physical function and 8-year survival. DESIGN: Prospective cohort study. SETTING: Medicare health maintenance organization and Veterans Affairs primary care programs. PARTICIPANTS: Persons aged 65 and older (N=439). MEASUREMENTS: Six measures of health and function assessed at baseline and quarterly over 1 year. Participants were classified as improved at 1 year, transiently improved, or never improved for each measure using a priori definitions of meaningful change: gait speed (usual walking pace over 4 m), 0.1 m/s; Short Physical Performance Battery, 1 point; Medical Outcomes Study 36-item Short Form Health Survey physical function, 10 points; EuroQol, 0.1 point; National Health Interview activity of daily living scale, 2 points; and global health change, two levels or reaching the ceiling. Mortality was ascertained from the National Death Index. Covariates included demographics, comorbidity, cognitive function, and hospitalization. RESULTS: Of the six measures, only improved gait speed was associated with survival. Mortality after 8 years was 31.6%, 41.2%, and 49.3% for those with improved, transiently improved, and never improved gait speed, respectively. The survival benefit for improvement at 1 year persisted after adjustment for covariates (hazard ratio=0.42, 95% confidence interval=0.29-0.61, P<.001) and was consistent across subgroups based on age, sex, ethnicity, initial gait speed, healthcare system, and hospitalization. CONCLUSION: Improvement in usual gait speed predicts a substantial reduction in mortality. Because gait speed is easily measured, clinically interpretable, and potentially modifiable, it may be a useful "vital sign" for older adults. Further research is needed to determine whether interventions to improve gait speed affect survival.