Burden and well-being among a diverse sample of cancer, congestive heart failure, and chronic obstructive pulmonary disease caregivers.

CONTEXT: Three important causes of death in the U.S. (cancer, congestive heart failure, and chronic obstructive pulmonary disease) are preceded by long periods of declining health; often, family members provide most care for individuals who are living with serious illnesses and are at risk for impaired well-being. OBJECTIVES: To expand understanding of caregiver burden and psychosocial-spiritual outcomes among understudied groups of caregivers-cancer, congestive heart failure, and chronic obstructive pulmonary disease caregivers-by including differences by disease in a diverse population. METHODS: The present study included 139 caregiver/patient dyads. Independent variables included patient diagnosis and function; and caregiver demographics, and social and coping resources. Cross-sectional analyses examined distributions of these independent variables between diagnoses, and logistic regression examined correlates of caregiver burden, anxiety, depressive symptoms, and spiritual well-being. RESULTS: There were significant differences in patient functioning and caregiver demographics and socioeconomic status between diagnosis groups but few differences in caregiver burden or psychosocial-spiritual outcomes by diagnosis. The most robust social resources indicator of caregiver burden was desire for more help from friends and family. Anxious preoccupation coping style was robustly associated with caregiver psychosocial-spiritual outcomes. CONCLUSION: Caregiver resources, not patient diagnosis or illness severity, are the primary correlates associated with caregiver burden. Additionally, caregiver burden is not disease specific to those examined here, but it is rather a relatively universal experience that may be buffered by social resources and successful coping styles.

Discussion as a factor in racial disparity in advance directive completion at nursing home admission.

Studies have consistently shown racial disparities in advance directive completion for nursing home residents but have not examined whether this disparity is due to differences in interactions with healthcare providers. This study had two aims: to determine whether the racial disparity in advance directive completion by nursing home residents is related to differences in discussion of treatment restrictions with healthcare providers and to examine whether there is a racial disparity in perceptions of residents' significant others that additional discussions would be helpful. Participants were 2,171 white or black (16% of sample) residents newly admitted to 59 nursing homes. Data were collected from structured interviews with residents' significant others and review of nursing home charts. Questions included whether advance directives were completed, whether treatment restrictions were discussed with the resident or family, and whether more discussion would have been helpful. Frequencies according to race were determined for each question; P-values and logistic regression models were obtained. Black residents were less likely to have completed any advance directives (P<.001), and they (P<.001) and their family members (P<.001) were less likely than whites to have discussed treatment restrictions with healthcare providers. Logistic regression models indicated that disparity in treatment restrictions narrowed when these discussions occurred. Significant others of black residents were more likely than those of white residents to consider further discussion helpful (P<.001), especially with physicians. Racial disparity in treatment restrictions may be due in part to a difference in discussion with healthcare providers; increasing discussion may narrow this disparity.

Predictors of bone loss after hip fracture.

Although accelerated bone mineral density (BMD) loss follows hip fracture, little is known about factors associated with this loss. We examined potential predictors of BMD loss in a cohort of community-dwelling women who had sustained hip fracture and who were followed for 1 year after fracture. BMD was measured at the femoral neck, intertrochanteric region, and total body, during hospitalization and 2, 6, and 12 months later. Demographic, health, lifestyle, clinical, surgical, and functional characteristics at baseline, and postfracture activity were evaluated for associations with baseline BMD and BMD 1 year later. To examine possible BMD-dependent effects, high and low baseline BMD groups were defined. None of the studied factors consistently predicted either baseline BMD or BMD at 1 year after fracture, among women with either high or low baseline BMD. Baseline BMD was the only factor that substantially and consistently predicted change, explaining 70% to 90% of variation. These results suggest that BMD will not be preserved by general rehabilitative measures and that prompt, specific intervention to minimize bone loss after hip fracture is an essential element of clinical management of the hip fracture patient.

Gender differences in mortality after hip fracture: the role of infection.

UNLABELLED: Possible explanations for the observed gender difference in mortality after hip fracture were examined in a cohort of 804 men and women. Mortality during 2 years after fracture was identified from death certificates. Men were twice as likely as women to die, and deaths caused by pneumonia/influenza and septicemia showed the greatest increase. INTRODUCTION: Men are more likely to die after hip fracture than women. Gender differences in predisposing factors and causes of death have not been systematically studied. MATERIALS AND METHODS: Participants (173 men and 631 women) in the Baltimore Hip Studies cohort enrolled in 1990 and 1991, at the time of hospitalization for hip fracture, were followed longitudinally for 2 years. Cause-specific mortality 1 and 2 years after hip fracture, identified from death certificates, was compared by gender and to population rates. RESULTS AND CONCLUSIONS: Men were twice as likely as women to die during the first and second years after hip fracture (odds ratio [OR], 2.28; 95% CI, 1.47, 3.54 and OR, 2.21; 95% CI, 1.48, 3.31). Prefracture medical comorbidity, type of fracture, type of surgical procedure, and postoperative complications did not explain the observed difference. Greatest increases in mortality, relative to the general population, were seen for septicemia (relative risk [RR], 87.9; 95% CI, 16.5, 175 at 1 year and RR, 32.0; 95% CI, 7.99, 127 at 2 years) and pneumonia (RR, 23.8; 95% CI, 12.8, 44.2 at 1 year and RR, 10.4; 95% CI, 3.35, 32.2 at 2 years). The magnitude of increase in deaths caused by infection was greater for men than for women in both years. Mortality rates for men and women were similar if deaths caused by infection were excluded (3.46 [1.79, 6.67] and 2.47 [1.63, 3.72] at 1 year and 0.96 [0.48, 1.91] and 1.26 [0.80, 1.98] at 2 years). Deaths related to infections (pneumonia, influenza, and septicemia) seem to be largely responsible for the observed gender difference. In conclusion, an increased rate of death from infection and a gender difference in rates persists for at least 2 years after the fracture.

Prediction of fracture in nursing home residents.

OBJECTIVES: To investigate cross-validated methods of identifying patients at increased risk of fracture in nursing homes using readily available data. DESIGN: Prospective cohort study with 18 months of follow-up. SETTING: Forty-seven randomly selected nursing homes in Maryland. PARTICIPANTS: One thousand four hundred twenty-seven white female nursing home residents aged 65 and older were followed for fracture for 18 months after baseline assessment. MEASUREMENTS: Fracture ascertained by physician note or x-ray from chart abstraction; demographic and baseline data extracted from the Minimum Data Set (MDS). RESULTS: Exploratory analyses on a random subset (67%) of the data (development sample) identified variables that might be important in predicting subsequent fracture and included variables for how the resident moved between locations in her room or adjacent corridor (mobility), age, weight, height, independence in eating and dressing, urinary incontinence, resistance to care, falls in the previous 6 months, a dementia score, and other activities of daily living. A simple scoring algorithm derived from a subset of these MDS variables showed good sensitivity (.70) but low specificity (.39) in the random validation sample. CONCLUSION: A scoring algorithm developed in more than 1,400 white females from 47 nursing homes in the state of Maryland shows high sensitivity for identifying women at increased risk for fracture and may be useful in targeting fracture prevention programs.