Barriers to follow-up of hypertensive patients.

Lack of follow-up care for hypertension adversely affects health in urban communities. The authors designed this study to (1) evaluate the effectiveness of a specialized intervention program for hypertension follow-up and (2) evaluate the associations with loss to follow-up. They evaluated factors related to loss to follow-up to either a routine care medical clinic or a special primary care intervention program (the Competitive Initiative Program [CIP]). They also conducted interviews to provide in-depth information on the barriers to this program. They found that patients referred through the CIP were significantly more likely to receive follow-up care through a primary care provider. Cost of care, long waiting times, lack of physician continuity, and more pressing priorities explained the lack of follow-up care. Despite a program to provide health care at no cost to patients, lack of insurance and worries about cost are described as barriers to adequate follow-up for hypertension treatment.

Common infections in older adults.

Infectious diseases account for one third of all deaths in people 65 years and older. Early detection is more difficult in the elderly because the typical signs and symptoms, such as fever and leukocytosis, are frequently absent. A change in mental status or decline in function may be the only presenting problem in an older patient with an infection. An estimated 90 percent of deaths resulting from pneumonia occur in people 65 years and older. Mortality resulting from influenza also occurs primarily in the elderly. Urinary tract infections are the most common cause of bacteremia in older adults. Asymptomatic bacteriuria occurs frequently in the elderly; however, antibiotic treatment does not appear to be efficacious. The recent rise of antibiotic-resistant bacteria (e.g., methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococcus) is a particular problem in the elderly because they are exposed to infections at higher rates in hospital and institutional settings. Treatment of colonization and active infection is problematic; strict adherence to hygiene practices is necessary to prevent the spread of resistant organisms.

New-onset incontinence and markers of frailty: data from the Hispanic Established Populations for Epidemiologic Studies of the Elderly.

BACKGROUND: Urinary incontinence in older adults has many distinct etiologies and is associated with lower self-reported health. However, it is unclear whether the new onset of urinary incontinence marks newly emergent frailty. METHODS: Using a longitudinal population-based survey of older Mexican Americans (N = 2660) across five south-western states, this study compared the strength of association between markers of physical frailty such as activities of daily living (ADLs), instrumental activities of daily living (IADLs), and performance (timed walk, timed chair rise, and tandem balance) with baseline incontinence (prevalent disease) and new-onset incontinence (incident disease). RESULTS: We found that 14.1% of the participants (n = 329) were incontinent at baseline (prevalent cases) and 11.6% (n = 208) were newly incontinent 2 years later (incident cases). Controlling for other covariates, prevalent incontinence was only associated with a 60% increased risk of having difficulty walking 8 ft. Incident incontinence was associated with a twofold increased risk of impairment in ADLs and IADLs, and poor performance on all three physical measures. CONCLUSIONS: Incident incontinence is associated with an increased risk of more global functional impairment. Thus, incident disease may be an important early marker for signaling the onset of frailty among persons who become incontinent after the age of 65 years.

Prevalence, incidence, and risk factors associated with hip fractures in community-dwelling older Mexican Americans: results of the Hispanic EPESE study. Establish Population for the Epidemiologic Study for the Elderly.

OBJECTIVES: To determine the rates and risk factors associated with hip fractures in the community-dwelling older Mexican-American population. DESIGN: A prospective survey of a regional probability sample of older Mexican Americans aged 65 and over. SETTING: The 1993-1996 Hispanic Established Population for the Epidemiologic Study of the Elderly (H-EPESE), a probability sample of noninstitutionalized Mexican Americans, aged 65 and over, living in the Southwestern states of Texas, New Mexico, Colorado, Arizona, and California. PARTICIPANTS: In 1993-1994 and in 1995-1996, 2895 persons, aged 65 and over, considered Mexican American, were selected at baseline as a weighted probability sample. Sample weights were used to extrapolate to the estimated 498,176 older Mexican Americans residing in the Southwest US. MEASUREMENTS: Self-reported hip fracture and functional measures by in home interviews. RESULTS: Hip fracture prevalence was 4.0% at baseline. The overall incidence of hip fractures for women was 9.1 fractures/1000 person-years. The incidence rate for men was 4.8 fractures/1000 person-years. Extrapolation from these data to the entire older Mexican American population indicated that approximately 5162 new fractures occurred in the population during the 2 year study period. In women, hip fractures were associated independently with advanced age, not being married/living alone, having had a stroke, limitations with activities of daily living and instrumental activities of daily living. In men, only the latter limitations were associated independently with hip fracture. CONCLUSIONS: This study indicates that older Mexican American people may have hip fracture incidence rates that place them at highest risk among the Hispanic subgroups. In light of a sparse literature on this population, the fracture estimates derived from this work contributes to our understanding of the true fracture estimates in this population. Based on the extrapolated population rates, hip fracture in this population is a significant public health problem. Adequate preventive measures need to be implemented in this growing US population.

Barriers and benefits to leisure-time physical activity among older Mexican Americans.

OBJECTIVE: To identify the perceived barriers to and benefits of leisure-time physical activity among older Mexican Americans (MA) and European Americans (EA). DESIGN: Cross-sectional survey using in-home interviews of subjects. SETTING: Subjects recruited from 10 family practice offices in South Texas that are part of a practice-based research network. PARTICIPANTS: Two hundred ten MA and EA adults, aged 60 years and older, interviewed between April 1994 and April 1996. MEASUREMENTS: The perceived benefits and barriers summary score from the San Diego Health and Exercise Questionnaire, the Minnesota Leisure Time Physical Activity Questionnaire, body mass index, chronic diseases, depressive symptoms, and demographics. MAIN RESULTS: Older MA reported greater perceived benefits to physical activity and fewer perceived barriers than older MA while having lower levels of habitual physical activity. Lower levels of education, male sex, higher body mass index, and older age were also associated with lower levels of habitual physical activity. CONCLUSIONS: Although MA reported lower levels of physical activity, they perceived greater benefits and fewer barriers to physical activity. These attitudes about physical activity held by older MA may present an opportunity to encourage greater levels of physical activity throughout this population.

Patterns of prescription drug utilization in elder Mexican Americans: results from the Hispanic EPESE Study. Established Population for the Epidemiologic Study of the Elderly.

The objective of this study was to determine the patterns of prescription medication usage among community-dwelling Mexican-American elders. This was a cross-sectional survey of a regional probability sample of 2,895 community-dwelling Mexican Americans, aged 65 and over. Of the sample, 58.1% used at least one prescribed medication within the two weeks prior to their participation in the study. Women were significantly more likely than men to use analgesics, non-steroidal anti-inflammatory agents, prescription nutritional supplements, and other central nervous system and endocrine medications. Subjects aged 75 and over were more likely to use cardiovascular medications, nutritional supplements, ophthalmic preparations and antihistamines, while those in the age groups 65-69 and 70-74 were more likely to use hypoglycemic and endocrine medications. Interestingly, there was a significantly decreased usage of hypoglycemic medications in the older age group (aged 75 and over) as compared with the younger age groups (65-69 and 69-74). This may indicate that Mexican American elders are dying at younger ages from complications related to diabetes mellitus and are not alive to use hypoglycemic medications at ages 75 and over. Also, men used more hypoglycemic medication than women (77% vs 70%). There was no relationship between use of medication and severity of diabetic illness.

The associations between health and domestic violence in older women: results of a pilot study.

This study examined the association of domestic violence (DV) with the general physical and mental health of older women. This pilot cross-sectional survey studied 257 women, aged 50-79, who came for screening visits to the Observational Study arm of the Women's Health Initiative's (WHI) Newark, NJ, site between June 1995 and August 1996. A 27-item, interviewer-administered questionnaire was used to detect DV. To measure overall health status, we used questions from the Medical Outcomes Study Short Form 36. Of the 257 women interviewed, 82 (31.9%) had experienced DV at some point in their life; 51 (22.6%) had been threatened, and 31 (15%) had experienced physical assault. Women who were either physically assaulted or threatened had lower mental component summary (MCS) scores (50.0 versus 53.7). Women who had only been threatened had a mean MCS score of 49.7 compared with 53.8 for nonthreatened women. Both of these MCS scores indicate poorer mental health. DV, which about 1 in 4 women experience over their lifetime, has a negative relationship to health status. Women who have experienced DV have lower MCS scores than those who have not. They also tend to have lower physical component summary scores. These findings suggest the importance that detection and prevention of DV have for women's health.

Domestic violence education in family practice residencies.

BACKGROUND AND OBJECTIVES: This study evaluated the extent of domestic violence (DV) education in US family practice residency programs and compared the results to those of a prior study of the same topic. METHODS: We mailed a four-page survey to the directors of all US family practice residency programs. The survey asked the extent to which the topic of DV in particular and other areas of violence in general are included in the curriculum. RESULTS: Surveys were returned from 298 (65.9%) programs, of which 69.4% of respondents indicated that the extent to which violence education is a formal part of their curriculum is either somewhat or a great deal, and 79.9% responded similarly about DV education specifically. On average, programs provide 4-5 hours of training each year, mostly through didactic lectures. Compared to a previous study, our findings demonstrate an increase in violence education in these programs. CONCLUSION: Our findings demonstrate that family medicine educators have increased the amount of residency curricular time devoted to training on DV.

Health screening in older women.

Health screening is an important aspect of health promotion and disease prevention in women over 65 years of age. Screening efforts should address conditions that cause significant morbidity and mortality in this age group. In addition to screening for cardiovascular disease, cerebrovascular disease and cancer, primary care physicians should identify risk factors unique to an aging population. These factors include hearing and vision loss, dysmobility or functional impairment, osteoporosis, cognitive and affective disorders, urinary incontinence and domestic violence. Although screening for many conditions cannot be proved to merit an "A" recommendation (indicating conclusive proof of benefit), special attention to these factors can decrease morbidity and improve quality of life in aging women.

Diagnostic approach to the confused elderly patient.

Confusion in the elderly patient is usually a symptom of delirium or dementia, but it may also occur in major depression and psychoses. Until another cause is identified, the confused patient should be assumed to have delirium, which is often reversible with treatment of the underlying disorder. Causes of delirium include metabolic disorders, infections and medications. Thyroid dysfunction, vitamin deficiencies and normal-pressure hydrocephalus are some potentially reversible causes of dementia. Major irreversible causes include Alzheimer's disease, central nervous system damage and human immunodeficiency virus infection. All but the rarest causes of confusion can usually be identified based on the complete history, medication review, physical examination, mental status evaluation and laboratory evaluation with longitudinal reevaluation.

Special health considerations in African-American elders.

Older African Americans constitute an expanding part of the elderly population in the United States. Although socioeconomic factors affect longevity and functional status more than race, African-American elders, as a whole, show poorer health status, as well as greater levels of financial strain and care-giver burden. Incidence rates of hypertension, heart disease, stroke, end-stage renal disease, dementia and prostate cancer are higher among African Americans than among the white population. The incidence of depression, however, is lower. Cancer survival rates are also lower, in part because of lower rates of cancer screening in this group. Physicians should carefully choose instruments to assess cognitive and physical status in African-American elders. The Activities of Daily Living scale and the Short Portable Mental Status Questionnaire are two tools that have been specially tested and shown to be reliable and valid in this population group. The Geriatric Depression Scale is a useful diagnostic tool that is quick to use in a busy office practice. Taking the time during an initial visit to understand the patient's values and perceptions of health and illness builds a sense of comfort and trust that will set a positive tone for the entire doctor-patient relationship and may empower the patient to take positive steps to improve health habits.

Barriers to black women's participation in cancer clinical trials.

This study examines attitudes that may deter black women from participating in cancer research. Subjects were recruited from women who did not respond to the initial recruitment mailing for the Women's Health Initiative. Each subject was administered a 7- to 10-minute telephone survey. One third (29) of the 80 subjects were black. Fifty-six percent of black women and 71% of white women had positive attitudes toward cancer clinical trials. More than 80% of the women surveyed agreed that clinical research benefits society and increases medical knowledge. However, almost one third of the black women agreed that scientists cannot be trusted while only 4% of whites responded similarly. Additionally, 29% of black women agreed that researchers did not care about them compared with 14% of white women. Only 28% of black women felt that clinical research in the United States was ethical, and 37% had a preference to be treated by a black scientist compared with 2% of whites. Controlling for other covariates, black women had more negative altitudes overall to clinical trials than white women. These findings support the likelihood that barriers exist for the participation of blacks and other minorities in clinical research. These barriers may impact the involvement of black women in cancer clinical trials. Improving trust and creating a perception of a caring attitude from investigators are important to overcoming these barriers. The inclusion of more black scientists as leaders of cancer clinical trials also may help improve these participation rates.

Ethical considerations with African-American elders.

African American elders are a diverse group whose values and beliefs are part of the ethics of United States society. The interplay between these beliefs and the health care system offers many challenges for the geriatrician. Addressing issues of autonomy, beneficence, nonmaleficence, truth-telling, confidentiality, and justice are important in caring for African American elders.

Outcomes of skilled cardiopulmonary resuscitation in a long-term-care facility: futile therapy?

OBJECTIVE: To assess whether cardiopulmonary resuscitation performed by in-house physicians is effective for long-term-care residents. DESIGN: Retrospective chart review. SETTING: Long-term-care facility with an intermediate care unit, skilled care unit, and a convalescent and assessment unit at a retirement community for veterans. PARTICIPANTS: All residents resuscitated from April 1987 to August 1990. All participants were male. The mean age was 75 years +/- 7.3 (range 42-93 years). MAIN OUTCOME MEASUREMENTS: Charts were abstracted for demographics, advanced directives information, information about the arrest, and post-resuscitation course. RESULTS: Forty-five elderly residents underwent resuscitation during this period. Nine residents (20%) were successfully resuscitated, with seven dying within 24 hours of hospitalization. No residents survived to return to long-term care (95% CI, 0-7%). The diagnoses were consistent with age-related chronic disease. Seventeen (38%) arrests were witnessed. The predominant rhythm at onset of resuscitation was asystole. CONCLUSION: We conclude that cardiopulmonary resuscitation, even when performed by a trained and experienced physician and team, has limited benefit for elderly long-term-care populations.