Here - American Geriatrics Society

Dear Annual Meeting Attendee:
The American Geriatrics Society Annual Scientific Meeting is the premier educational event in geriatrics, providing the latest
information on clinical geriatrics, research on aging, and innovative models of care delivery. The 2012 Annual Meeting
will address the professional and educational needs of geriatrics professionals from all disciplines through state-of-the-art
educational sessions and research presentations.
This supplement of the Journal of the American Geriatrics Society is devoted to abstracts of the scientific presentations
that are scheduled for the 2012 AGS Annual Scientific Meeting. We are hopeful that this supplement will be helpful to
those of you who are planning to attend the meeting so as to maximize your attendance at educational, research, and clinical
presentations of interest to you.
We are also pleased to provide these abstracts to subscribers of the Journal. We believe that they are an important way of
keeping JAGS readers up-to-date on the latest advances in the field.
Sincerely,
Belinda Vicioso, MD
Barbara Resnick, PhD, CRNP
2012 AGS Annual Meeting Program Chair AGS President

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Paper Session
Clinical Decision-Making
Thursday, May 3
7:30 am – 9:00 am
P1
Lagtime to Benefit for Colorectal Cancer Screening: A Survival
Meta-Analysis.
S. J. Lee, 1 W. J. Boscardin, 1,2 I. Stijacic-Cenzer, 1,2 J. Conell-Price, 1
S. O’Brien, 1 L. C. Walter. 1,2 1. Division of Geriatrics, SFVAMC, UCSF,
San Francisco, CA; 2. Department of Epidemiology and Biostatistics,
University of California, San Francisco, San Francisco, CA.
Supported By: Dr. Sei Lee was supported by Hartford Geriatrics
Health Outcomes Research Scholars Award, the Hellman Family
Award for Early Career Faculty at UCSF and the KL2RR024130
from the National Center for Research Resources, a component of
the NIH.
Dr. Louise Walter was supported by R01CA134425 from the
National Cancer Institute, which was administered by the Northern
California Institute for Research and Education.
This work was supported with resources of the Veterans Affairs
Medical Center, San Francisco, California.
Background: Guidelines recommend targeting colorectal cancer
(CRC) screening to healthy patients whose life expectancy exceeds
the cancer screening’s lagtime to benefit (i.e. time between screening
and when the benefits of screening are seen). However, the lagtime of
CRC screening is uncertain. Our goal was to determine a pooled,
quantitative estimate of the lagtime to benefit for CRC screening
from randomized controlled trial (RCT) data.
Methods: We conducted a survival meta-analysis of CRC
screening RCTs focusing on older patients (age greater than 50) identified
by Cochrane and USPSTF reviews as high quality. Four population-based
RCTs of fecal occult blood testing from Denmark, England,
Sweden, and the United States (n=327,043) were included in
our meta-analysis.
Results: 4.9 years (95%CI: 2.1 to 9.5) passed before one CRC
death was prevented for 5000 persons screened (absolute risk reduction
or ARR=0.0002). It took 10.4 years (95%CI: 6.1 to 16.6) before
one CRC death was prevented for 1000 persons screened
(ARR=0.001) and 14.6 years (95%CI: 9.7 to 21.2) for 2 CRC deaths
to be prevented for 1000 persons screened (ARR=0.002).
Conclusions:The lagtime to prevent one CRC death per 1000 persons
screened is 10.4 years suggesting that CRC screening should be
targeted toward patients with a life expectancy greater than ten years.
P2
Preferences for Deactivation of Implantable Cardioverter
Defibrillators in the Setting of Advanced Illness.
J. A. Dodson, 1 T. Fried, 1 P. H. Van Ness, 1 N. Goldstein, 2 R. Lampert. 1
1. Yale University School of Medicine, New Haven, CT; 2. Mount Sinai
School of Medicine, New York, NY.
Background: Some implantable cardioverter defibrillator (ICD)
recipients with advanced illness receive painful shocks at the end of
life. The purpose of our study was to explore preferences for ICD deactivation
in the setting of hypothetical advanced illness.
Methods: We conducted a cross-sectional telephone survey of
patients age ≥50 with ICDs followed in a single electrophysiology
practice in New Haven, CT. Sociodemographic and clinical characteristics,
as well as self-reported functional status, were obtained. Patients
were then asked whether they would opt for ICD deactivation
in five distinct scenarios: (1) permanently unable to get out of bed, (2)
permanent memory problems, (3) burden to family members, (4) on
breathing machine >1 month, (5) advanced incurable disease. Patients
who answered “possibly yes” or “definitely yes” to any scenario
were categorized as considering deactivation.
Results: Surveys were completed in 100 patients. Mean age was 71
years, 28% were female, and 18% were nonwhite.Among respondents,
71 patients (71%) would consider ICD deactivation in one or more
scenarios. Responses varied considerably by scenario. Patients considered
deactivation most often in the setting of advanced incurable disease
(61%), and least often if permanently unable to get out of bed
(25%) (Figure). Patients were more likely to consider deactivation if
they were white, had not received a prior ICD shock, or were disabled.
Conclusions: The majority of patients with ICDs would consider
deactivation in at least one scenario reflecting advanced illness.This preference
was most common in the setting of incurable disease, but also not
uncommon in the setting of cognitive impairment or burden to family.
P3 Encore Presentation
Self-rated Health and Walking Ability Predict 10-year Mortality in
Older Women with Breast Cancer.
J. A. Eng, 1,2 K. M. Clough-Gorr, 3,4 R. A. Silliman. 1,2 1. Medicine-
Geriatrics, Boston University School of Medicine, Boston, MA; 2.
Boston University School of Public Health, Boston, MA; 3. Institute
of Social and Preventive Medicine, University of Bern, Bern,
Switzerland; 4. National Institute for Cancer Epidemiology and
Registration, Institute of Social and Preventive Medicine, University of
Zurich, Zurich, Switzerland.
Supported By: John A. Hartford Foundation, Health Resources and
Services Administration (D01HP08796-05-00), National Institutes of
Health (K05 CA92395), National Cancer Institute (R01 CA106979,
R01 CA/AG 70818, R01 CA84506)
Background: Self-rated health (SRH) and mobility predict mortality
in general populations but have not been well-studied in older
women with breast cancer. Methods: Women aged ≥65 years with primary
stage I-IIIA breast cancer were enrolled at 4 sites. Data were
collected over 10 years from medical records, annual interviews, and
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the National Death Index. We created a 4-level variable combining
baseline SRH and ability to walk several blocks (SRHWALK). Cox
proportional hazards models were used to examine the impact of
SRHWALK on 10-year all-cause mortality. Analyses were adjusted
for age, socio-demographic and tumor characteristics, initial therapies,
BMI, comorbidity, emotional health, social support, and upper
body function. Results: 660 women with breast cancer were studied
(18% age 80+, 48% stage II-III, 59% with ≥1 comorbidity). At 10
years, 80% of women with low SRH and walking limitations had died
vs. 50% of those with high SRH and no walking limitations (Figure 1,
p0.85 (p=0.02). OS
was associated with ECOG PS (HR 1.8, p=0.05), Activities of Daily
Living (ADL) impairment (HR 5.6, p=0.005), and Vulnerable Elders
Survey (VES-13, HR 5.3, p=0.002), but only VES-13 (HR 15.61,
p=0.016) was significant in a backward stepwise multivariate regression
model. Age was not associated with either RDI or OS.
Conclusions: ECOG PS was associated with completing
RDI>85%, a commonly used and validated cut-off for chemotherapy
efficacy. SPPB may help further risk-stratify. VES-13, a validated 13-
item questionnaire which is easily administered in clinic, was the
strongest correlate of OS, stronger than age or ECOG PS. Age was
not correlated with completion of full dose chemotherapy or OS in
this older cohort. Geriatric screening measures including SPPB and
VES-13 should be used in addition to ECOG PS to risk-stratify older
patients with CRC.
P5 Encore Presentation
Preparing for Decision Making Beyond Advance Directives:
Perspectives from Patients and Surrogates.
R. McMahan, 1,2 S. J. Knight, 2,1 M. Fuez, 2 R. L. Sudore. 2,1 1. Geriatrics,
UCSF, San Francisco, CA; 2. San Francisco VA, San Francisco, CA.
Supported By: Veterans Affairs
Background: Traditional advance care planning (ACP) has focused
on documenting life-sustaining treatment preferences in advance
directives (ADs). This focus fails to provide direction for or decrease
the stress of making many, complex decisions over the course
of serious illness. To identify steps beyond ADs to better prepare patients
and their families, we sought to understand diverse, older patients’
and surrogates’ experiences with decision making for serious
illness.
Methods: We conducted 13 English and Spanish-speaking focus
groups with participants from San Francisco VA and county hospitals.
Seven groups included patients (n=38), aged ≥65 years, who reported
making serious medical decisions. Six groups included surrogate
decision makers (n=31), aged ≥18 years. Semi-structured
interviews asked about decision making experiences and what best
prepared participants. Two reviewers performed qualitative, thematic
content analysis.
Results: Mean patient age was 78±8 years and 61% were nonwhite.
Mean surrogate age was 57±10 years and 91% were nonwhite.
Analysis revealed 5 themes to best prepare for decision making.
(1) Identify and ask a surrogate to make decisions – “My wife
wouldn’t be objective. My daughter would make good judgments,
but she didn’t know I wanted her to. You have to ask.” (2) Discuss
leeway in surrogate decision making – “As a child, I would feel better
knowing he would want me to evaluate and change decisions
based upon things which have occurred since he put that in writing.”
(3) Reflect on past experiences to define values for care – “My father
had cancer of the bile duct – he died a miserable death. I don’t
want to put myself or my family through it. I know this.” (4) Tell
others about one’s wishes – “We have three boys and a girl, and we
selected the daughter. When the brothers got the directives they
said, ‘Hey, dad, what’s going on?’ and so we had to talk about it.” (5)
Ask clinicians about the outcomes of treatment – “I would ask
about the side effects. You have to know how your life is going to
be. Will it be good?”
Conclusions: 5 additional ACP steps, beyond ADs, may better
prepare patients and surrogates for complex medical decisions. To be
effective, ACP needs to expand beyond asking patients to make decisions
about life-sustaining treatment and must also focus on preparation
for medical decision making.
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P6
CRASH: A Brief Screening Tool to Identify High-Risk Older
Drivers.
M. E. Betz, 1 R. Schwartz, 2 J. Haukoos, 1,3 C. DiGuiseppi, 4 M. Valley, 1
R. Johnson, 1 S. Lowenstein. 1 1. Emergency Medicine, University of
Colorado School of Medicine, Aurora, CO; 2. Division of Geriatrics,
University of Colorado School of Medicine, Aurora, CO; 3.
Emergency Medicine, Denver Health Medical Center, Denver, CO; 4.
Epidemiology, Colorado School of Public Health, Aurora, CO.
Supported By: Funding: Emergency Medicine Foundation and John
A Hartford University of Colorado Denver Center of Excellence.
This study was also supported in part by Grant Number
R49/CCR811509 from the Centers for Disease Control and
Prevention. Its contents are solely the responsibility of the authors
and do not necessarily represent the official views of the CDC.
Background: Current older driver screening tools are impractical
for use in busy clinical settings. We sought to develop and internally
validate a brief questionnaire to identify drivers needing further
evaluation.
Methods: Cross-sectional study of patients aged 65+ years at a
geriatric clinic or emergency department (ED) who drove at least occasionally,
spoke English and had no significant cognitive impairment.
Study staff administered a confidential survey to 246 participants,
enrolled equally from the clinic and ED (participation rate:
43%). Logistic regression was used to identify characteristics associated
with an adverse driving event (ADE), defined as 1+ reported
crash or police stop while driving within the preceding 12 months.
Results: Median participant age was 76 years; half were women.
Most participants (82%, 95%CI 77-86%) reported daily or near-daily
driving; 15% (95%CI 11-19%) reported an ADE. Age and gender
were not associated with ADEs. The final model included five variables
associated with an ADE, to which the CRASH tool assigns one
point each (table): “C” ever feels confused or disoriented while driving;
“R” regular (daily or near-daily) driver; “A” avoids driving alone;
“S” has difficulty seeing the license plate in front while stopped; and
“H” reports that someone has recommended handing over the keys
in the past year. In internal validation, the CRASH tool maintained
its goodness-of-fit (average p=0.70) and had an averaged area under
the ROC curve of 0.72. A score of two or higher was 64% (95%CI 46-
79) sensitive and 70% (95%CI 64-77) specific for an ADE.
Conclusions: The simple, history-based CRASH screening tool
may be useful to identify older drivers who need additional evaluation.
Prospective testing is needed to validate the tool and determine
optimal cut-points for clinical use.
Paper Session
Plenary
Thursday, May 3
11:00 am – 12:00 pm
P7
Out of Pocket Spending in the Last 5 Years of Life.
A. S. Kelley, 1 K. McGarry, 2 J. S. Skinner. 3 1. Geriatrics and Palliative
Medicine, Mount Sinai School of Medicine, New York, NY; 2.
Department of Economics, University of California, Los Angeles, Los
Angeles, CA; 3. Department of Economics, Dartmouth College,
Hanover, NH.
Background: A key objective of the Medicare program was to
reduce the risk of financial catastrophe arising from out-of-pocket
(OOP) health-related expenditures among older adults. Yet little is
known about the financial risks faced by Medicare beneficiaries related
to the death of a household head or spouse. We aimed to measure
risks to financial security arising from OOP health-related expenditures
among a nationally representative cohort of adults over
age 65.
Methods: We included participants from the Health and Retirement
Study (HRS) aged 65 years or older, who died between 2003 -
2008 (N = 3,809). We used detailed HRS survey data for each subject
and spouse, when applicable, to examine total OOP health-related
expenditures in the 5 years preceding the subject’s death. We also
measured OOP spending by category of spending (e.g. nursing home,
insurance, and others) and examined OOP spending stratified by
cause of death and quartile of household wealth.
Results: Average OOP expenditures in the five years prior to
death were $34,497.99 (median, $20,876; 90th percentile, $77,910) for
individuals and $46,767 (median $36,874; 90th percentile, $87,081) for
married couples in which one spouse dies. Median expenditures were
84% of median net financial wealth. By cause of death, individuals’
average total spending ranged from $33,699 for those with infectious
disease to $59,314 for those with Alzheimer’s disease. Spending on
long-term care needs was substantial. For the entire sample, 24% of
spending was for nursing home care and 9% for helpers and other expenses
to retain independence at home. Spending differed sharply by
wealth; ranging from $20,241 in the lowest wealth quartile to $49,477
in the highest.
Conclusion: Despite nearly universal insurance coverage under
the Medicare program, older adults face considerable financial risk
from out-of-pocket medical expenses in the last 5 years of life. Longterm
care expenses appear large yet insurance coverage for these expenses
is limited.Wealth-related differences in the components of care
could exacerbate existing inequalities in well-being at the end of life.
P8 Encore Presentation
Geriatric versus General Medical Conditions have Opposite Effects
on Overall Quality of Ambulatory Care.
L. Min, 1,2 E. Kerr, 1,2 C. Blaum, 1,2 C. Cigolle, 1,2 D. Reuben, 4
N. Wenger. 4,3 1. Medicine, University of Michigan, Ann Arbor, MI; 2.
GRECC and Center for Clinical Management Research, VA
Healthcare Systems, Ann Arbor, MI; 3. RAND, Santa Monica, CA; 4.
UCLA, Los Angeles, CA.
Supported By: Agency for Healthcare Quality and Research (Min
and Blaum), VA Healthcare System Health Services Research
(Kerr) and the Geriatric Research Clinical Care Center (GRECC,
Min, Cigolle, and Blaum), Hartford Foundation (Min), RAND
(Wenger, Min), NIA-Pepper Center (Min), NIH-LRP (Min), NIH-
K08 (Cigolle).
Background: Contrary to expectations, patients with greater comorbidity
receive better - rather than worse - quality of care. We evaluated
whether time-consuming geriatric conditions differ from general
medical conditions in their effect on quality.
Sample: 644 older (age >=75) ambulatory care patients in the
Assessing the Care of Vulnerable Elders-2 (ACOVE-2) study.
Methods: Predictors: Condition counts, defined as general medical
(atrial fibrillation, coronary artery disease, heart failure, cerebrovascular
disease, diabetes, hypertension) vs geriatric (falls, dementia,
hearing impairment, incontinence, malnutrition, and
osteoporosis). Outcome: Overall quality of care (QOC) using 65
process-of-care quality indicators, calculated as a mean score across
preventive and eligible general medical, and geriatric-specific care
over 13 months. We used multivariable regression to test for relationships
between overall quality and both geriatric and general medical
condition counts, controlling for age, gender, functional status, and
number of primary care visits.
Results: General medical condition counts (mean 1.9, range 0-6)
were comparable to geriatric conditions (mean 1.6, range 0-4) but the
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two counts were uncorrelated (r=.04, p=.3). Nearly all had at least
one condition in each category, and more than half (52%) had at least
2 conditions in each category. Each additional general medical condition
was associated with a 5% point increment in QOC, while each
additional geriatric condition was associated with a 3.2% point decrement,
independent of each other and the multivariable controls
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growth in NP care of Medicare patients from 1997-2008 and its relationship
with state regulations and also with the availability of primary
care physicians.
Methods: Medicare beneficiaries aged 65 or above with Parts A
and B coverage who were not enrolled in a health maintenance organization
for the entire 12 months of each year during 1996-2008
were selected. We assessed the percentage of community-dwelling
and long term nursing home residents billed by an NP or who received
the majority of their primary care from NPs.
Results: The percentage of community-dwelling Medicare beneficiaries
billed for outpatient NP services rose from 0.3% in 1997 to
7.9% in 2008, while for nursing home patients the increase was from
3.0% to 24.7%. By 2008, 2.2% of community-dwelling and 15.5% of
nursing home residents received the majority of their primary care
from NPs. The percent of community dwelling residents receiving the
majority of their primary care from NPs in 2008 ranged from 0.7% in
Hawaii to 10.8% in Alaska, while for nursing home patients it ranged
from 0% in Wyoming to 44.3% in Tennessee. Compared with states
with the most restrictive regulations, the odds of receiving the majority
of primary care from NPs was 2.5 fold higher for communitydwelling
patients in states with the most liberal regulations. Similar
associations with state laws were found when we measured the number
of NPs practicing per 100,000 adults in the state, using data from
state licensing boards. The availability of primary care physicians
modestly affected NP activity in community-dwelling patients. Neither
availability of primary care physicians nor state regulations were
associated with odds of receiving care from NPs for long term nursing
home residents. In five states that modified their regulations during
1997-2007, the percentage of patients with an NP as PCP increased
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management in collaboration with primary care (PCP) improved care
quality and reduced acute care utilization for seniors at high risk of
hospitalization.
Objective: To assess the impact of GRACE Team Care on hospital
readmissions in older veterans at a Veterans Affairs Medical Center
(VAMC).
Methods: Veterans 65 or older with PCPs from 4 of 5 VAMC
clinics were enrolled following discharge home from an acute hospitalization
on the medicine service from April 2010 to June 2011. After
an initial home-based transition visit, a nurse practitioner and social
worker (GRACE Team) returned to conduct a geriatric assessment
visit. Guided by 12 geriatric protocols and input from the GRACE
geriatrician, pharmacist, and psychologist, the GRACE Team developed
a veteran-centric care plan and collaborated with the PCP to
implement that plan. Hospitalized veterans with PCPs from the fifth
VAMC clinic that did not get GRACE but who otherwise met enrollment
criteria served as a comparison group. Data on demographics,
comorbidity, hospital utilization, and mortality were drawn from VA
databases.
Results: 174 veterans (mean age 78 years, range 65-97; 97%
male) were enrolled in GRACE and followed for an average of 8.5
months (range 0.4-15.5), and 77 veterans (mean age 77 years, range
65-93; 94% male) in the comparison group were followed for an average
of 8.6 months (range 0.4-16.0). Charlson Comorbidity Index
scores were similar between groups: GRACE mean 2.40 (range 0-13)
vs. comparison mean 2.17 (range 0-10). GRACE veterans vs. comparison
had lower readmission rates at 7 days (2/174 [1.1%] vs. 5/77
[6.5%], p=0.03); 14 days (8/174 [4.6%] vs. 7/77 [9.1%], p=0.25); 30
days (17/174 [9.8%] vs. 13/77 [16.9%], p=0.11); and 60 days (26/164
[15.9%] vs. 17/73 [23.3%], p=0.17). Over the follow-up period,
GRACE veterans had a lower mortality rate than the comparison
group (17/174 [10%] vs. 13/77 [17%], p=0.11).
Conclusion: GRACE Team Care, which provided in-home, veteran-centric,
geriatric care management while supporting VA primary
care, had a positive impact on reducing hospital readmissions.
GRACE may offer an opportunity for better care at lower costs in
high risk older veterans.
P15
The Falls and Fractures Clinic: Testing an Integrated Model of
Secondary Prevention in a High-Risk Older Population.
G. Duque, 1,2 P. Suriyaarachchi, 1,2 D. Boersma, 1,2 O. Demontiero, 1,2
G. Loza-Diaz, 1 A. Sharma. 2 1. Ageing Bone Research Program, The
University of Sydney, Penrith, NSW, Australia; 2. Geriatric Medicine,
Nepean Hospital, Penrith, NSW, Australia.
Supported By: Nepean Medical Research Foundation
INTRODUCTION: Although falls and fractures are highly
prevalent in older persons, there is still a fragmentation in terms of
falls being assessed by geriatricians and fractures remaining within
the scope of other specialties. Therefore, an integrated model of secondary
prevention for falls and fractures run by geriatricians is highly
needed.
OBJECTIVE: To evaluate the effectiveness of a multidisciplinary
Falls and Fractures Clinic as an optimal integrated model to assess
risk and to prevent new events in a high-risk older population.
METHODS: Four hundred and thirty subjects (mean age=82,
65% female) were assessed between January 2009-June 2011 at the
Falls and Fractures Clinic, Nepean Hospital (Penrith, NSW, Australia).
Assessment included fear of falling (SAFFE), risk factors for
falls and fractures, physical examination, nutrition, depression, grip
strength (dynamometer), densitometry, posturography (Medicaa,
Uruguay), gait parameters (GaitRITE®), and blood tests for secondary
causes of osteoporosis including vitamin D and parathyroid hormone
(PTH). An integrated plan was then designed according to the
subject’s risk factors. Subjects were surveyed by phone (month 3) and
fully re-assessed at the clinic nine months later.
RESULTS: 77% had suffered a fall and 38% had suffered a fracture
before the assessment. An average of 6.5+/-2.8 falls and 3.5+/-1.8
fracture risk factors were identified per subject. At the time of the
second assessment, the incidence of falls was reduced in -
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ent. We hypothesize that resveratrol may be acting through SIRT-1,
which in turn inhibits p53-regulated senescence. Because colon cancer
is a disease whose incidence rises with age, the ability of resveratrol
to inhibit senescence and the aging process in colonic mucosa will
potentially have profound applicability to colon cancer prevention.
P17
The Role of SIRT3-dependent Autophagy in Age-Related
Hearing Loss.
I. Pena , F. A. Pereira. Huffington Center on Aging, Departments of
Otolaryngology-HNS and Molecular & Cellular Biology, Baylor
College of Medicine, Houston, TX.
Supported By: American Federation for Aging Research / Medical
Student Training in Aging Research Program, The Oticon
Foundation / The American Academy of Otolaryngology–Head &
Neck Surgery Foundation, Huffington Center on Aging–Baylor
College of Medicine.
Background: In 2005, the WHO estimated that 278 million people
suffered moderate-to-profound hearing impairments. This number is
expected to reach 900 million people by 2050, creating immense socioeconomic
burdens worldwide. Age-related hearing loss (AHL), a
disorder associated with accumulated cellular oxidative damage, affects
more than 40% of Americans over age 65. The mitochondrial
deacetylase SIRT3 improves antioxidant defenses by activating isocitrate
dehydrogenase 2, thereby increasing the reduced-to-oxidized glutathione
ratio. Oxidative stress induces autophagy, a process by which
cells degrade and recycle their contents to preserve cellular health.The
precise molecular mechanisms by which cells respond to oxidative
stress and induce autophagy via SIRT3 have not yet been elucidated.
Methods: We investigated the role of SIRT3 in regulating autophagy
in model systems. We used inner ears, brain, heart, and fibroblasts
from wild type (WT), SIRT3-overexpressing, and Little
mice (have 40% longer lifespan and reduced oxidative stress). Experiments
included activation and inhibition of autophagy and expression
of SIRT3 to determine its potential role in SIRT3-dependent
protective mechanisms against cellular damage and AHL.
Results: The average SIRT3 levels were increased 18% in 24-
month-old WT mice and increased 628% in 24—month-old Little mice,
compared to their 4-month-old littermate controls.When SIRT3 levels
were depleted in WT fibroblasts using siRNA, autophagy was activated
as measured by LC3-II/LC3-I ratio. After an 18- or 24-hour treatment
with 100nM rapamycin, autophagy levels also increased 1.8-fold while
SIRT3 levels decreased 1.37-fold.Activating autophagy by 2 or 4 hours
of starvation increased activation 8.35-fold and SIRT3 levels decreased
3.9-fold. Inhibiting autophagy with 50uM Wortmannin for 2 or 4 hours
decreased autophagy 2.78-fold and increased SIRT3 levels 1.35-fold.
Conclusion: These preliminary results suggest autophagy is
linked to SIRT3: increased SIRT3 is associated with improved oxidative
protection and decreased autophagy and vice versa. These findings
may provide therapeutic insight into rational drug design of new
medications that activate SIRT3 or autophagy for the prevention of
age-related hearing loss and to improve health span.
P18 Encore Presentation
Lipid-depleted apolipoproteins and amyloid peptides are influenced
by APOE genotype and cognitive diagnosis.
A. J. Hanson, 1,2 J. L. Bayer-Carter, 1,2 P. S. Green, 1,2 T. J. Montine, 1,2
L. D. Baker, 1,2 G. S. Watson, 1,2 L. M. Bonner, 2 M. Callaghan, 2
J. B. Leverenz, 1,2 B. K. Walter, 2 E. C. Tsai, 1,2 C. W. Wilkinson, 1,2
J. Zhang, 1 S. Craft. 1,2 1. University of Washington Medical Center,
Seattle, WA; 2. GRECC, VA Puget Sound Health Care System,
Seattle, WA.
Supported By: T32 AG-000258-13 to Dr. Hanson, R37 AG-10880
from NIA to Dr Craft, P50 AG-05136 to Dr. Montine.
BACKGROUND: Sporadic Alzheimer’s disease (AD) is caused
in part by decreased clearance of the Aβ amyloid breakdown products.
Apolipoproteins play an important yet unclear role in Aβ peptide
clearance, particularly ApoE since its E4 variant is a risk factor
for AD. Work in cell culture and animal models have shown that
lipid-depleted apolipoproteins are less effective at binding Aβ, and
that lipoprotein-depleted (LD) fractions of Aβ peptides are more
toxic to neurons. However, not much is known about the lipid states
of these proteins in human CSF.
METHODS: Cerebrospinal fluid (CSF) was obtained from 20
participants with normal cognition (mean age 69 ± 7) and 27 with
amnestic mild cognitive impairment (MCI) (mean age 67 ± 6). We determined
the APOE genotype status of each participant. Lipid-depleted
ApoE and ApoJ and lipoprotein-depleted Aβ peptides were
separated by density gradient ultracentrifugation and levels were
then measured by ELISA. Groups were compared using analysis of
covariance.
RESULTS: Subjects with an APOE ε4 allele (E4+) had higher
lipid-depleted ApoE levels, for both normal and MCI groups
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control collagen had greater expression of alpha 2 integrin, which mediates
cell-extracellular matrix interactions (Hynes, 1987). In conclusion,
collagen from aged mice that have received short-term caloricrestriction
or rapamycin display impaired capacity to polymerize into
a 3D matrix. Fibroblasts placed in these gels display lower cell count
and increased expression of SPARC, but decreased alpha 2 integrin.
These data show that short-term caloric-restriction and rapamycin interventions
alter collagen’s structural properties and influence fibroblast
behavior in ways that might impair wound healing.
P20
Platelet and Monocyte Responses are Impaired in Elderly Septic
Patients.
M. Rondina, 1 C. K. Grissom, 2 E. S. Harris, 1 S. Kalva, 1 S. Men, 1
G. A. Zimmerman, 1 A. S. Weyrich. 1 1. Internal Medicine, Univ. of
Utah, SLC, UT; 2. Critical Care, IMC, SLC, UT.
Supported By: Supported by grants from the NIH (HL091754,
HL066277, K23HL092161, ULI-RRO25764).
The ligand P-selectin (P-SEL) on the platelet surface allows for
heterotypic formation of platelet-monocyte aggregates (PMAs) that
augment innate immune responses. Impaired PMA formation in elderly
patients may contribute to their higher risk of sepsis and subsequent
adverse events but remains unexplored. We prospectively compared
P-SEL expression and PMA levels in elderly (age≥65, n=29)
and young (age

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A BSTRACTS
centration ≤ 37.5 ng/ml. Sixty-four patients received either weekly vitamin
D3(n=31) or placebo (n=33) for 6 months; both groups received
800 mg calcium citrate daily. Baseline and 6 month measures
included peak VO2, 6 minute walk distance (6MW) and Get Up and
Go. Isokinetic muscle strength was measured at 60 and 120 degrees
using knee extensors and flexors. Health status was measured with
the Kansas City Cardiomyopathy Questionnaire (KCCQ). Between
group comparisons were made using ANCOVA models that adjust
for baseline measures.
Results: Subjects in the vitamin D group were 65.8 ± 10.6 years
old, 52% women, and 61% African American. Subjects in the placebo
group were 66.0 ± 10.4 years old, 46% women and 67% African
American. At baseline the vitamin D group mean serum 25OHD was
19.1 ± 9.3ng/ml and increased by 42.3 ± 16.4 ng/ml at 6 months. Baseline
mean serum vitamin D in the placebo group was 17.8 ± 9.0 ng/ml,
and decreased by 0.2 ± 6.6 ng/ml at 6 months (between groups
p0.15). Adjustment for baseline characteristics sex,
race, and ejection fraction did not change results.
Conclusions: There is no evidence to suggest that high dose vitamin
D3 improves physical performance or health status for older
adults with HF. Vitamin D repletion in patients with HF should conform
to standard vitamin D guidelines for older adults.
P23
Improving 25-hydroxyvitamin D Status in Home-bound Elders and
its Effect on Falls.
D. K. Houston, 1 J. A. Tooze, 1 J. L. Demons, 1 B. Davis, 1 R. Shertzer-
Skinner, 1 L. Kearsley, 2 R. Gottlieb, 2 J. D. Williamson. 1 1. Sticht Center
on Aging, Wake Forest School of Medicine, Winston Salem, NC; 2.
Senior Services, Inc., Winston Salem, NC.
Supported By: Supported by the Wake Forest Translational
Science Institute, Center for Integrative Medicine and Pepper
Center (P30-AG21332).
Background: Home-bound older adults are a particularly vulnerable
subgroup of older adults for poor dietary intake and nutritional
health, nutrition-related health conditions, and functional decline.
Although vitamin D supplementation has been shown to be
effective in preventing falls in controlled clinical trials, whether these
findings can be successfully translated to community-based programs
has not yet been determined. We conducted a 5-month randomized,
placebo-controlled pilot study to assess the feasibility of delivering vitamin
D supplements to home-bound older adults receiving Meals on
Wheels (MOW) and the effectiveness of the vitamin D supplements
to improve 25-hydroxyvitamin D (25(OH)D) levels and reduce falls.
Methods: Sixty-eight MOW clients in Forsyth Co, NC, who were
not currently taking prescription vitamin D 2
or >1000 IU/day of vitamin
D 3
were enrolled from December 2010 through March 2011
(mean age, 77.8 yrs; 72% women; 75% black). Serum 25(OH)D was
measured at baseline and 5-month follow-up and falls assessed by
monthly fall calendars and phone calls. Participants were randomized
by MOW route to receive 100,000 IU vitamin D 3
(n=38) or an active
placebo control (n=30) once a month along with their MOW meal.
Results: Serum 25(OH)D levels (mean±SD) at baseline were
22.5±12.2 and 18.9±10.6 ng/mL in the intervention and control group,
respectively (p=0.22). Ninety percent of participants received 4 or
more of the 5 vitamin D/placebo monthly doses. Serum 25(OH)D
levels improved significantly in the intervention group compared to
the control group (LS means±SE: +20.4±1.8 vs. -2.2±2.1 ng/mL adjusted
for age, gender, race, randomization group and baseline
25(OH)D, p1.0 m/s and impaired
motor skill (by Figure of 8 walk time, F8WT > 8 secs).
Methods: Forty older adults were randomized to MS or SE
treatment arms. Both arms were 1 hour, twice weekly, PT-supervised
interventions for 12 weeks. Pre and post intervention assessments
performed by masked assessors included gait efficiency or energy
cost of walking (mean rate of O2 consumption for 3 minutes of preferred
speed treadmill walking divided by speed, ml/kg-m), gait
speed, obstacle walk, F8WT and the Late Life Function and Disability
Index disability subscale (LLFDI). Outcomes between arms were
compared with ANCOVA, adjusted for the pre-intervention value.
Results: Of 40 randomized subjects; 38 completed the trial (MS,
n=18; SE, n=20; mean age 77.1±6.0 years). Gait efficiency improved
(energy cost decreased) marginally more in MS than SE (- 0.04 vs. -
0.02 ml/kg-m, adjusted difference, AD=0.03, p=0.13). MS improved
more than SE in gait speed (0.13 vs. 0.05 m/s; AD=0.11, p=0.008); obstacle
walk time (-0.89 vs. -0 .42 secs; AD=0.60, p=0.01), and F8WT (-
0. 22 vs. -0.89 seconds; AD=1.39, p

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creating a barrier to treatment. A simple 3-item measure (the 3IQ)
was developed to facilitate diagnosis, but the efficacy and safety of
using the 3IQ to initiate treatment are unknown.
Methods: In this double-blinded trial, 645 ambulatory women
diagnosed with urgency incontinence using the 3IQ rather than an extended
evaluation were randomized to 12 weeks of pharmacologic
therapy with fesoterodine (4-8 mg daily) (N=322) or placebo
(N=323). Change in urgency incontinence over 12 weeks was assessed
by voiding diaries. Safety was assessed through adverse event monitoring
and measurement of post-treatment postvoid residual volume
(PVR), with specialist referral for PVR ≥ 250 mL or safety concern.
Results: Mean (SD) baseline urgency incontinence frequency
was 3.9(3.0) episodes/day. After 12 weeks, women in the fesoterodine
group reported an average of 0.9 fewer urgency incontinence, 1.0
fewer total incontinence, and 0.9 fewer urgency-associated voids per
day, compared to placebo (P 65 should receive 1-1.5
mg/kg. We determined whether older patients were less likely than
younger patients to be given propofol for induction; whether propofol
dose decreased with increasing age, per published guidelines; and
whether, for patients > 65 years, increasing doses of propofol were associated
with post-induction hypotension.
Methods: We conducted a retrospective multivariate analysis of
data from the Anesthesia Information Management System at Mount
Sinai Hospital with IRB approval. We obtained data for 41,156 cases
age 18-90, undergoing GA between 2006 and 2010, after excluding
cardiac and obstetric cases. Post-induction hypotension was defined
by meeting either of 2 criteria: (1) mean arterial pressure (MAP) decrease
> 40% and MAP < 70 mmHg, or (2) MAP < 60 mmHg.
Results: In the population studied, 31,827 patients (77%) received
propofol. The cohort receiving propofol was younger (53 years
vs. 60 years), non-emergent (88% vs. 75%), and had lower ASA physical
status (51% ASA I-II vs. 23%) (p < 0.001 for each). Propofol dose
decreased with increasing age (Pearson correlation = -0.35). The median
dose for patients 65 population,
47% received > 1.5 mg/kg. A larger dose of propofol was associated
with an increased likelihood of hypotension in the post-induction period,
and this effect was age-dependent. For the same increase in
propofol dose (0.5 mg/kg), a 65 year old was less likely to experience
hypotension than an 80 year old (OR=1.09 vs. 1.15, respectively).
Conclusions: A large cohort of patients > 65 were given higherthan-recommended
doses of propofol for induction of GA. Higher
doses were associated with increased incidence of significant hypotension
in the post-induction period. This is clinically important because
significant post-induction hypotension has been associated
with increased incidence of post-operative adverse events.
Paper Session
Epidemiology
Saturday, May 5
10:45 am – 12:15 pm
P28
Risk Factors for Restricting Back Pain in Community-Living Older
Persons.
U. E. Makris, 1,2 L. Han, 3 L. Leo-Summers, 3 L. Fraenkel, 3,4 T. M. Gill. 3
1. Internal Medicine, UT Southwestern Medical Center, Dallas, TX; 2.
Medicine, Veterans Affairs, Dallas, TX; 3. Internal Medicine, Yale
School of Medicine, New Haven, CT; 4. Medicine, Veterans Affairs,
West Haven, CT.
Supported By: T32 AG019134 Yale Geriatrics Training Program in
Aging Related Research and Clinical Epidemiology; ACR
REF/ASP Junior Career Development Award in Geriatric
Medicine; RO3 AG040653 NIA GEMSSTAR.
Background: Back pain is a common and costly condition
among older persons. Few prospective studies have evaluated the risk
factors for back pain in older persons.
Methods: We evaluated the 731 participants (mean age 78.8
years, 65% women) of the Precipitating Events Project, a prospective
study of community-living persons, aged 70+ years, who completed
monthly interviews of restricting back pain, defined as staying in bed
for at least 1/2 day and/or cutting down on one’s usual activities due
to back pain, for up to 126 months. Candidate risk factors were measured
from five domains (demographic, cognitive-psychosocial, health
related, habitual, physical capacity) during comprehensive homebased
assessments that were completed every 18 months for up to 108
months. Among participants without restricting back pain, two distinct
outcomes were determined during each 18-month interval: (1)
short-term (1 episode lasting 1 month) and (2) persistent (1 episode
lasting >= 2 months) or recurrent (>= 2 episodes of any duration) restricting
back pain. The cumulative incidence of the outcomes were
estimated during the total follow-up period using a GEE binomial
model. A multivariable Cox model was used to evaluate the adjusted
associations between each candidate risk factor and the two outcomes
of interest.
Results: The cumulative incidence was 17.8% (95% CI: 16.5,
19.3) for the short-term outcome and 17.9% (16.1, 19.9) for the persistent/recurrent
outcome. Factors independently associated with a
higher risk of developing short-term restricting back pain included female
sex (HR 1.30, P=0.01), hip weakness (HR 1.19, P=.001) and poor
grip strength (HR 1.24, P=.04); and for the persistent/ recurrent outcome
included female sex (HR 1.48, P=0.01), depressive symptoms
(HR 1.57, P=

P APER
A BSTRACTS
be amenable to interventions designed to prevent the occurrence,
persistence, or recurrence of this common disorder in older persons.
P29
Falls and Orthostatic Hypotension: Re-examining Limits.
A. Cleinman, 1 M. E. Griswold, 2 E. Simonsick, 3 W. M. Meeks, 1
K. Gregg, 1 L. Ferrucci, 3 B. G. Windham. 1 1. Department of Medicine,
Division of Geriatrics, University of Mississippi Medical Center,
Jackson, MS; 2. Center of Biostatistics and Bioinformatics, University
of Mississippi Medical Center, Jackson, MS; 3. Clinical Research
Branch, NIH - National Institute on Aging, Baltimore, MD.
Supported By: National Institutes of Health, National Institute
on Aging
Background: Guidelines recommend treating orthostatic hypotension
(OH) to reduce risk of falls in older adults. We hypothesized
that low systolic blood pressure (SBP) upon standing and/or decreases
from usual SBP, even without meeting OH criteria, would also
be related to falls risk.
Methods: Baltimore Longitudinal Study of Aging participants (
>65y) with a first visit that evaluated OH and self-report of falls in the
previous 12 months were examined. Participants with >10 visits were
excluded to minimize extended cohort participation bias. OH was defined
using the classical definition of SBP decrease >20mmHg or diastolic
BP decrease > 10mmHg, 3 minutes after standing from a
supine, resting position. Logistic regression was used to examine associations
between falls and BP measures, adjusting for age, sex, race,
education, stroke, diabetes, hypertension, and vision.
Results: Among 412 participants, (aged 65-97, 45% female, 64%
white), 115 (28%) reported falling: 77 had one fall and 38 reported >2
falls. Only 19 participants (4.6%) had formally defined OH. Falls
were more common in those with OH (53% vs 27%, p=0.033). In adjusted
models, falls were significantly associated with OH, OR=3.05
(95% CI: 1.06, 8.78) p=0.038, but not with final standing SBP,
OR=1.01 (0.99, 1.02) p=0.358. Furthermore, each 1mmHg decrease in
SBP upon standing was associated with an additional 6% increase in
risk, OR=1.06 (1.01, 1.10) p=0.008. This is equivalent to 31%, 73%,
and 198% increases in risk for 5, 10, and 20mmHg drops in SBP. The
risk associated with decreases in SBP upon standing did not depend
on the final standing SBP (p=0.74 for interaction).
Conclusions: The risk of falls in this sample depended on decreases
in SBP upon standing rather than the final standing SBP. Although
classically defined OH was associated with falls, increased
risks were seen for any decrease in SBP upon standing, even those
not meeting OH criteria. This suggests that a continuous spectrum of
SBP drops upon standing conveys important information about risk.
Any SBP drop may warrant consideration in falls risk assessments.
P30
Sensory and motor nerve function differentially relate to gait
parameters: the Health ABC Study.
E. S. Hile, 1 J. S. Brach, 1 M. Yang, 1 S. A. Studenski, 1 R. M. Boudreau, 1
P. Caserotti, 2,3 S. Satterfield, 5 A. V. Schwartz, 4 E. Simonsick, 2
L. Ferrucci, 2 T. B. Harris, 2 A. B. Newman, 1 E. S. Strotmeyer. 1 1.
University of Pittsburgh, Pittsburgh, PA; 2. National Institute on
Aging, Baltimore, Bethesda, MD; 3. University of Southern Denmark,
Odense, Denmark; 4. University of California, San Francisco, CA; 5.
University of Tennessee, Memphis, TN.
Supported By: National Institute on Aging (NIA) Contracts N01-
AG-6-2101; N01-AG-6-2103; N01-AG-6-2106; NIA grant R01-
AG028050, and NINR grant R01-NR012459.
Pittsburgh Claude D. Pepper Older Americans Independence
Center (P30 AG024827)
BACKGROUND: Many older adults have subclinical or undiagnosed
peripheral nerve decline. Sensory decline is associated with
gait deviations [reduced speed; increased double support time (DST)
and base of support (BOS)] in diabetic or neuropathic cohorts, but
less is known about age-related decline. Poor sensory and motor
nerve function associate with slower speed in the Health ABC cohort,
but how biomechanical gait parameters explain this is unknown.
We investigated relationships between nerve function and spatial or
temporal gait parameters. METHODS: Of 3075 baseline Health
ABC participants, we included 544 (83.4±2.7 yrs, 52.9% women,
35.5% black) with Year 11 gait parameters [4-m usual walk speed,
BOS, step length, step time, DST, stance and swing time] and nerve
function [sensory:1.4 and 10g monofilament (MF) detection, vibration
threshold (VT); motor: peroneal nerve conduction velocity
(NCV) and amplitude (CMAP)]. Gait parameters were outcomes
modeled with each nerve predictor by multivariate regression adjusted
for age, sex, race, BMI, diabetes, PVD, stroke, physical activity,
smoking and vision. Most gait parameters vary with speed, so final
models were adjusted for speed to assess independence. RESULTS:
Worse sensory and motor nerve function by VT or CMAP (but not
MF or NCV) related to slower speed. Worse VT associated with
longer stance and step times (p

P APER
A BSTRACTS
Conclusion: This study provides evidence that use of medications
with strong or moderate AC effects in older women is associated
with increased risk of falls, clinical vertebral fracture, and total
fractures, but is not associated with hip fracture or lower arm/wrist
fracture.
P32
Falls among Adult Patients Hospitalized in the United States:
Prevalence and Trends.
E. L. Bouldin, 1,2 E. M.Andresen, 2,3 N. E. Dunton, 4 M. Simon, 5
T. M.Waters, 8 M. Liu, 2 M. J. Daniels, 2 L. C. Mion, 6 R. I. Shorr. 7,2 1.VA
Puget Sound HSR&D, Seattle,WA; 2. University of Florida,
Gainesville, FL; 3. Instistute on Disability and Development, Oregon
Health & Science University, Portland, OR; 4. Health Policy and
Management, University of Kansas Medical Center, Kansas City, KS; 5.
Health Sciences, University of Southampton, Southampton, United
Kingdom; 6. School of Nursing,Vanderbilt University, Nashville,TN; 7.
Geriatric Research Education & Clinical Center, Malcolm Randall VA
Medical Center, Gainesville, FL; 8. Department of Preventive Medicine,
University of Tennessee Health Science Center, Memphis,TN.
Supported By: NIH/NIA R01-AG025285, NIH/NIA R01-AG033005
Background:The purpose of this study was to provide normative
data on fall prevalence in US hospitals and to determine 27-month
secular trend in falls prior to the implementation of the Centers for
Medicare and Medicaid Service (CMS) rule which does not reimburse
hospitals for care related to injury resulting from hospital falls.
Methods: We used data from the National Database of Nursing
Quality Indicators (NDNQI) collected between July 1, 2006 and September
30, 2008 to estimate prevalence and secular trends of falls occurring
in adult medical, medical-surgical and surgical nursing units.
More than 88 million patient days (pd) of observation were contributed
from 6,100 medical, surgical, and medical-surgical nursing
units in 1,263 hospitals across the United States.
Results: A total of 315,817 falls occurred (rate=3.56 falls/1,000
pd) during the study period, of which 82,332 (26.1%) resulted in an
injury (rate=0.93/1,000 pd). Both total fall and injurious fall rates
were highest in medical units (fall rate=4.03/1,000 pd; injurious fall
rate=1.08/1,000 pd) and lowest in surgery units (fall rate=2.76/1,000
pd; injurious fall rate=0.67/1,000 pd). Falls (0.4% decrease/quarter,
p

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A BSTRACTS
age increased, the overall rate of catheterization for all older inpatients
declined from 19.9% to 11.9%, a 40% reduction. The greatest
improvement was seen on the ACE Unit, where the rate of catheterization
declined from 20.4% to 9.7%, a 53% reduction. The catheter
utilization ratio decreased from 68% to 20%, while the average
catheter days per patient declined from 11.7 to 2.8 days per patient
across all inpatient units. Conclusions: This study demonstrates the
dramatic and sustained improvements in catheter utilization that can
be achieved with the support of a multi-modal educational intervention
in improving patient safety and quality care efforts around the
appropriate use of urinary catheters in a variety of inpatient settings.
P35
A Geriatrics rotation as a Medicine elective: A smart option for
medical students?
A. Nguyen , 1 E. Duthie, 1 E. Duthie, 2 K. Denson, 2 J. Franco. 2 1.
Institute for Health and Society, Medical College of Wisconsin,
Milwaukee, WI; 2. Internal Medicine, Medical College of Wisconsin,
Milwaukee, WI.
Background: Medical schools must look at innovative ways to
ensure that graduates achieve basic competencies in geriatrics and
encourage new physicians to consider the subspecialty. Our objectives
are to: 1) assess the impact of a month-long geriatrics rotation,
as part of the internal medicine clerkship, on M3 students’ knowledge,
skills, and attitudes toward geriatric practice and career choice;
and 2) assess knowledge outcomes by comparing mean NBME internal
medicine shelf exam scores between students who completed the
geriatrics rotation and students who completed the internal medicine
ward rotations.
Methods: This study was conducted at a medical school where a
month-long geriatrics evaluation and management (GEM) rotation
fulfills a graduation requirement in internal medicine. One-hour
focus groups were conducted with two cohorts: 1) students who rotated
through GEM and 2) students who did not. Thematic analyses
using the principles of grounded theory were performed to compare
group responses between the two cohorts. One focus group of 4-6
participants was conducted for each cohort. Independent t-test was
performed to compare mean NBME internal medicine shelf exam
scores between all GEM (n=124) and non-GEM (n=1318) students
who matriculated between 2005 and 2011. ANOVA was used to compare
the means after controlling for Step 1 exam scores.
Results: Focus groups revealed differences in reported comfort
and attitudes toward geriatric care with the GEM cohort reporting
higher levels of confidence with geriatric assessment skills. Mean
NBME internal medicine shelf exam scores between GEM students
[mean (SD)=73.66 (±7.2)] and non-GEM students [mean (SD)=73.60
(±7.4)] were not statistically significant (p=0.938). Controlling for
Step 1 scores did not produce statistically significant differences
(p=0.371).
Conclusion: Completing an internal medicine ward rotation requirement
using a geriatrics rotation is an innovation that medical
schools should consider. Comparisons of NBME scores show that
GEM students perform just as well on the internal medicine board
exam as their non-GEM colleagues but were more comfortable
with elder care. Evaluating geriatrics curricula will add to understanding
of student perspectives about geriatrics as a career field
and allow curriculum developers to identify areas of strength and
areas for improvement.
P36
Case Presentation as a Direct Observation Method to Evaluate
Internal Medicine Residents’ Systems-Based Practice Competency.
K. Ouchida, S. Ramsaroop, S. Mehta, L. Logio, R. Adelman,
E. Siegler. Medicine, Weill Cornell Medical Center New York
Presbyterian Hospital, New York, NY.
PURPOSE: Of the 6 core competencies the Accreditation
Council of Graduate Medical Education requires, systems-based
practice (SBP) often poses the greatest challenge for curriculum development
and evaluation. A redesigned geriatrics rotation for internal
medicine (IM) residents incorporates a SBP module with direct
exposure to health care sites and services utilized by older adults. This
study describes the use of a case presentation to evaluate IM residents’
knowledge of the health care system and ability to navigate it.
METHODS: Starting June 2011, all PGY-2 IM residents (N=48)
complete a 1-week SBP module as part of the required 4-week geriatrics
rotation. The module combines structured exposures to community-based
programs, supervised patient care on house calls and in
a transitional care clinic, and self-directed learning. Residents present
an older continuity patient to the geriatrics interdisciplinary team,
which then models a collaborative problem-solving approach. One
faculty member takes notes and emails residents a summary of the
identified problems and the team’s “action plan.” The problems and
recommendations were analyzed to generate a list of themes for coding.
Discrepancies in coding were resolved by discussion until consensus
was reached.
RESULTS: To date 21 (44%) IM residents have presented cases.
Presentations generated 19 types of biopsychosocial issues (mean 3.8
per patient) and 12 types of recommendations (mean 5.4). Lack of social
support (15.1%), care coordination challenges (13.9%), and negative
illness behaviors such as refusal of care (10.1%) represent the
most frequently identified problems. The interdisciplinary team’s recommendations
most often focused on care coordination strategies
(15%), community resources (14.2%), medical treatment or workup
(14.2%) and goals of care (13.3%). The case presentation received
one of the highest ratings from residents on the module evaluation
(4.75 out of 5).
CONCLUSIONS: A case presentation represents an effective
strategy for directly observing and evaluating IM residents’ systemsbased
practice competency. Presentations reveal residents’ struggles
with the health care system and comprehension of their older patients’
needs, and offer exposure to geriatric approaches through
practical advice. This evaluation method is feasibly implemented and
well-received by residents.
P37
Replicating a Chief Resident Immersion Training in Geriatrics
(CRIT).
S. Levine, 1 L. Caruso, 1 B. Brett, 2 H. Auerbach, 1 A. Jackson, 1
A. Burrows, 1 S. Chao. 1 1. Boston Univerisity Medical Center
(BUMC), Boston, MA; 2. Brett Consulting Group, Boston, MA.
Supported By: John A. Hartford Foundation, Association of
Directors of Geriatric Academic Programs (ADGAP)
Background: Chief residents (CRs) play crucial roles in resident
and student training and in quality patient care. They typically receive
minimal formal education in geriatrics, teaching skills and leadership.
With support from the John A. Hartford Foundation and ADGAP,
BUMC disseminated its successful 2-day offsite CRIT program, addressing
these deficiencies, to demonstrate national replicability.
Methods: Through a competitive RFP, 12 institutions in 3 cohorts
were selected to implement CRIT across specialties for 2 years
each. The modular curriculum included an unfolding case discussed in
small groups, evidence-based mini-lectures on geriatrics topics, and
interactive seminars on teaching and leadership skills. 1-to-1 consults
helped CRs develop an action project. Social opportunities were provided
to develop relationships. Faculty mentors were invited to increase
institutional “buy-in.” BUMC’s support to each institution included
attending BUMC’s CRIT. National evaluation of CRIT
included a self-report pre-survey, a 12-item pre- and immediate post-
CRIT knowledge test, and a 6-month follow-up survey, administered
by each institution. Results across institutions and cohorts were
merged for analysis.
Results: Over 3 years in 12 institutions, 301 CRs and 86 faculty
mentors participated in CRIT, representing 29 specialties. Response
AGS 2012 ANNUAL MEETING
S13

P APER
A BSTRACTS
rates for CRs were 99% (n=299) for the pre-survey, 97% (n=293) for
the pre-post test, and 78% (n=234) for matching pre to 6-month followup.
CRs showed significant gains in knowledge (p

P APER
A BSTRACTS
Methods: Data for acute hospital admissions were obtained
from 61 PACE programs across the US(over 25,000 enrollees), for the
time period 6/1/2008-5/31/2010. Program enrollment data for this
time period were also used together with diagnostic data on program
participants. For each program, exposure-adjusted hospitalization, 30-
day all-cause readmission, and PAH rates were calculated. Multivariate
analyses, with program fixed-effects, were used to assess the impact
of individual-level risk factors on hospitalization rates.
Results: The average hospitalization rate in PACE (547/1000
participants) was 43% lower than for non-PACE dually eligible recipients
of home and community-based services (HCBS) (962/1000).
PACE 30-day average readmission rate (19.1%) was 17% lower compared
to non-PACE dually eligible beneficiaries, age 65+ (22.9%).
The average PAH rate in PACE (175/1000) was 30% lower than
among duals in HCBS programs (250/1000). There were significant
variations across PACE sites in all hospital measures, which remained
after risk-adjustment.
Conclusions: Although PACE participants are among the
frailest of Medicare and Medicaid beneficiaries, their risk of hospital
use is significantly reduced in an integrated clinical care model that is
reinforced by integrated financing. Variations in hospital rates across
PACE indicate continued opportunities for further improvement
with regard to hospital use.
P41
Evaluation of a National Care Transition Program.
S. Wee, 1 P. Wang, 1 E. Koh, 1,2 A. Gan, 2 G. Ganesan. 2 1. Research,
Health Information Management and Evaluation, Agency for
Integrated Care, Singapore, Singapore; 2. Health Services Research
and Evaluation, Ministry of Health, Singapore, Singapore.
Background: Transitional care interventions for carefully selected
patients from hospital to other settings had shown promise in
reducing rates of subsequent hospitalizations. We evaluated the effectiveness
of a state funded national care transition care program involving
our five largest public hospitals to reduce acute care utilization.
The program was adapted from Coleman’s Care Transition
Program®.
Objectives: To compare the risk of hospital re-admission and
emergency department (ED) attendance of acutely ill patients on the
program to other patients admitted during a similar time frame,
matched for age, gender and hospital subsidy status.
Methods: Retrospective cohort study of 4132 patients discharged
from the five acute hospitals from Feb 2009 to Jul 2010 on
care transition program and 4132 control patients chosen from the
State Hospital Claim System. Propensity (conditional probability of
enrolment into program) scores were derived by multiple logistic regression
with the covariates age, gender, length of initial hospital stay,
Charlson index, past 180 days hospital admission, past 180 days ED
attendance. A logistic regression model was fitted to the data. Re-admission
and ED attendance were compared after covariate adjustment
and weighting by propensity scores.
Results: The baseline characteristics of patients in the two
groups were similar after weighting by propensity. Baseline characteristics
for the program patients were: age (SD) 79.2 (7.7) y, 44%
male, mean length of hospital stay (SD) 11.6 (13.1) days, mean Charlson
index (SD) 1.6 (1.8), mean no. of hospitalization and ED attendance
180 days prior to index admission were 0.79 and 1.9 respectively.
Subjects enrolled on the program were less likely to be readmitted
and visit the ED. The adjusted odds ratio (95% CI) comparing rehospitalisation
and ED re-attendance of program subjects with that
of controls at 30 days, were 0.68 (0.61, 0.76) and 0.79 ( 0.71, 0.89) respectively;
and at 180 days, were 0.79 (0.72, 0.87) and 0.88 (0.80, 0.97)
respectively.
Conclusion: Supporting patients and caregivers to take a more
active role during care transition through a care transition program is
effective in reducing subsequent re-hospitalization and ED attendance
in acutely ill patients at risk for transitions.
P42
The Epidemiology of Physically and Verbally Aggressive Behaviors
of Nursing Home Residents Directed at Staff.
M. Lachs, 1 A. Rosen, 2 K. Pillemer, 3 J. Teresi. 4 1. Medicine, Geriatrics,
Weill Cornell Medical College, New York, NY; 2. Emergency Medicine
Residency, New York Presbyterian Hospital, New York, NY; 3. Human
Development, Cornell University, Ithaca, NY; 4. Research Division,
Hebrew Home at Riverdale, Riverdale, NY.
Supported By: National Institute on Aging
National Institute of Justice
New York State Department of Health
Background: While considerable media attention has focused on
abuse of nursing home residents by staff, little research focus has
been directed towards examining the opposite phenomenon: physical
and verbal aggression directed at staff by nursing home residents. We
hypothesized that resident-to-staff aggression (RSA) is a potentially
common phenomenon, as dementia-related behavioral problems are
frequent in nursing home residents and often an impetus for nursing
home placement.
Objective: To perform the first methodologically rigorous study
on the prevalence of RSA in nursing homes.
Methods: We conducted this study as part of a large, multisite
NIA-funded study attempting to estimate the prevalence of residentto-resident
elder mistreatment in long term care facilities. For this
project, the behavior of 1,550 residents of 5 nursing homes was evaluated.
Certified nursing assistants primarily responsible for the care of
residents under study in the parent project were asked whether any
physical, verbal, or sexual behaviors were directed at them by the resident
in the previous two weeks using an instrument validated for this
purpose.
Results: Staff reported that 15.7% of residents directed abuse
towards them within the past two weeks. The most commonly reported
types of verbally abusive behavior reported were screaming
(9.0% of residents) and using bad words (7.2%). The most commonly
reported types of physically abusive behavior reported were hitting
(3.9% of residents) and kicking (2.6%). Aggressive behaviors reportedly
occurred most commonly in the patient room (84.8%) and in the
morning (84.3%).
Conclusion: RSA in nursing homes is highly prevalent. This phenomenon
may negatively affect quality of care, resident and staff
safety, and job satisfaction and staff turnover. Further studies are
needed to understand how and why it occurs, and to develop interventions
to mitigate its potential impact.
P43
Defining medically complex patients using chronic conditions,
healthcare utilization and functional status.
W. W. Hung, 1,2 A. S. Kelley, 1 E. Livote, 2 J. Penrod, 1,2 A. Federman, 1
A. L. Siu. 1,2 1. Mt Sinai School of Medicine, NY, NY; 2. JJP VAMC,
Bronx, NY.
Supported By: VA HSRD
Background:
The majority of healthcare costs are concentrated among a
small proportion of medically complex older adults. While complexity
is often defined by multiple chronic conditions, not all patients with
chronic conditions are complex and patients with a single serious illness
can have complex and costly medical needs. Our objective is to
evaluate 3 different definitions of complexity based on chronic conditions,
healthcare utilization, and functional measures by examining
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each definition’s predictive value for healthcare costs and survival.
We hypothesized that complexity should be predictive of healthcare
costs and survival.
Methods:
We used Medicare Current Beneficiary Survey data from 2000
(year 1) & 2001 (year 2). We excluded those under age 65, managed
care participants, & decedents in 2000. Using year 1 data, we developed
3 definitions of complexity from candidate variables including:
chronic conditions from claims; healthcare utilization patterns associated
with high costs in year 1; and self-reported functional status (i.e.
performance of activities of daily living). For each definition, we
measured prevalence, year 1 & 2 costs, and mortality in year 2 compared
to the full sample.
Results:
Older adults with 4 or more chronic conditions accounted for
24% of the population but accounted for 36% of health care costs in
year 2. Those who had a major chronic condition (i.e. high cost conditions
such as diabetes, dementia) and either 2 or more acute hospitalizations
or 3 or more other conditions accounted for 14% of the sample
but accounted for 29% of year 2 costs and had a year 2 mortality
rate of 20% vs. 5%. Adding the functional limitation in bathing identified
23% of the sample which accounted for 48% of costs in year 2
and had a year 2 mortality rate of 20% vs. 3%.
Conclusion:
Using chronic conditions alone identifies a population that has a
moderate concentration in future costs. Identification of medically
complex adults is improved when prior hospitalizations and functional
status are also considered. These measures can be used to identify
patients as appropriate targets for interventions to improve care
and reduce the costs of serious illness.
P44
Risk Factors for Early Hospital Readmission among Low Income
Seniors.
T. C. Iloabuchi, 1 W. Tu, 1,2 D. Mi, 2 S. R. Counsell. 1,2 1. Indiana
University School of Medicine, Indianapolis, IN; 2. Indiana University
Center for Aging Research, Indianapolis, IN.
Background: Early hospital readmission among older persons
often represents suboptimal care transitions and may result in adverse
health outcomes and avoidable costs.
Purpose: To identify risk factors available on admission that
could be used in identifying hospitalized low-income seniors at increased
likelihood for experiencing early readmission.
Methods: Prospective cohort study using data from the Geriatric
Resources for Assessment and Care of Elders (GRACE) randomized
controlled trial (RCT), which enrolled and followed over two years
951 adults ≥ 65 years with annual income

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Poster Session A
Thursday, May 3
12:00 pm – 1:30 pm
A1
FROZEN WITH PAIN.
A. Bhagavan, 1 A. Talsania, 1 S. Bellantonio. 2 1. Internal medicine,
Baystate Medical Center, Springfield, MA; 2. Geriatric medicine,
Baystate Medical Center, Springfield, MA.
Introduction:
Sternoclavicular joint (SCJ) septic arthritis, first described in
1896, constitutes

P OSTER
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been ruled out. It is then recommended that in patients who present
with delirium, ammonia level should be considered as part of the
workup especially if they have accompanying constipation.
A4 Encore Presentation
Delirious Because of Treatment: An Adverse Effect of Imipenem.
B. L. Africa, 1,2 D. Carthen, 1,2 H. Arabelo. 1,2 1. Geriatrics, St. Luke’s
Roosevelt Hospital Center, New York, NY; 2. Columbia University
College of Physicians and Surgeons, New York, NY.
The mainstay treatment of delirium is the reversal of the underlying
cause. In the elderly population, this is often caused by an infection,
for which antibiotics are initiated. However in this case, it was
the antibiotic that led to the delirium.
This is a case of a 91 year old woman with a history of chronic osteomyelitis
from an infected hip implant, who was admitted due to
weakness and lethargy. She was found to have a sinus tract in the left
hip with draining fluid and a urinary tract infection. She was started
on cefepime and vancomycin. On the subsequent day, her mental status
and leukocytosis has improved. Fluid cultures taken from her hip
grew Pseudomonas resistant to cefepime and thus imipenem was
started. Two days later she was found to be lethargic. She was diagnosed
that time with hypoactive delirium from the
osteomyelitis/hardware infection. Orthopedic surgery was consulted
for removal of her hip hardware; however she was deemed not a candidate
for surgery. Her symptoms progressed and she became comatose.
The family was informed regarding her poor prognosis. Subsequently,
her antibiotics were stopped due to futility. Two days after
stopping imipenem, she was awake and asking for food. Her condition
continued to improve and she was then eventually discharged home.
This case shows the clinical implication of an adverse effect of a
medication. Hypoactive delirium although not a known side effect of
imipenem, was observed in this particular case. This indicates the investigation
of other underlying causes of delirium, in which antibiotics
maybe one of them. There have been no known published articles
relating hypoactive delirium due to imipenem. It may be
worthwhile to investigate on this matter.
A5
Title: Multiple myeloma with spontaneous tumor lysis syndrome in
an elderly patient; a rare entity.
H. Chataut, M. Bednarczyk, M. Gorbien, M. Leiding, J. Olson.
Division of Geriatrics Medicine and Palliative Medicine, RUSH
University Medical Center, Chicago, IL.
Purpose: To recognize complications especially tumor lysis
which can be associated with multiple myeloma ( MM) in an elderly
patient.
Case Report: An 83 year old woman with history of coronary artery
disease presented with fatigue, weakness and unintentional 15
lbs weight loss over 3 months. She denied fever/chills, night sweats,
bladder/bowel complaints, bleeding from any site. Physical exam revealed
normal vital signs and unremarkable systemic exam. Laboratory
analysis revealed Hb 6 g/dL with normal MCV, Platelet count
48,000/dL creatinine 3.7 mg/dL, total protein 12.1g/dL with albumin
2.4 g/dL, Calcium 10.6 mg/dL, LDH 346 U/dL. Serum protein electrophoresis
showed monoclonal band. She was hydrated and transfused
packed RBCs and a bone marrow biopsy showed sheets of
plasma cells consisting of 70% of marrow cellularity. Bone survey revealed
multiple lytic lesions in skull, humerus, mandible. Chemotherapy
was being planned but in the interim the symptoms worsened and
laboratory analysis showed worsening creatinine 4.8 mg/dL, uric acid
13.9 meq/dL, phosphorus 6 meq/dL and potassium 5.3 meq/dL. She
was started on aggressive hydration and rasburicase for presumed
tumor lysis syndrome, which resulted in improvement in symptoms
and laboratory parameters. Dexamethasone was added for MM. Further
therapy is being planned as outpatient with bortezomib with
very close follow-up.
Discussion: The incidence of MM increases considerably with
age. The number of geriatric patients with MM is expected to increase
over time as a consequence of the increased life expectancy of the
normal population, and management of these patients is likely to become
particularly pertinent in coming years. MM in the elderly can be
a therapeutic challenge. Acute tumor lysis syndrome is rarely observed
in MM. The incidence is probably less than 1% of patients who
are treated with intermediate or high-dose chemotherapy. It is only
occasionally observed with dexamethasone or prednisone treatment.
Few case reports exist of the same. Spontaneous tumor lysis syndrome,
on the other hand, has not been reported in untreated
myeloma. Our case is unique with spontaneous tumor lysis in a very
elderly patient with new diagnosis of MM, rapidly declining performance
status with co-morbidities, presenting a therapeutic challenge.
A6
A case of atypical Gastro-intestinal bleeding (GIB) in an elderly; not
just diverticulosis.
H. Chataut, 1 M. Bednarczyk, 1 M. Gorbien, 1 M. Leiding, 1 J. Olson, 1
C. Teodoro, 1 R. Arora. 2 1. Department of Geriatric Medicine, RUSH
university medical center, Chicago, IL; 2. Gastroenterology, Rush
University Medical Center, Chicago, IL.
Purpose: GIB may present with vague symptoms and can be fatal.
Background: GIB that required multiple procedures along with
octreotide.
Method: Case report
Case report: A 85 year old man with receiving aspirin and
coumadin presented with confusion, hypotension, tachycardia, guaiac
positive and Hgb 5 gm/dl, INR 2.2. After resuscitation emergent
colonoscopy revealed diverticulosis, non bleeding angiodysplasia
(AVMs) and colon full of blood up to cecum with no blood in the terminal
ileum, suggesting colonic source for bleeding. EGD up to duodenum
showed no evidence of recent or active bleeding. Patient’s
Hgb continues to drop requiring 17 units of Packed RBC transfusion
in 2 days. Technetium labeled RBC scan localized the bleeding to
duodenum and jejunum. Enterescopy showed bleeding site in the
duodenum at junction of bulb and second portion of duodenum along
with non bleeding AVMs in small bowel. Bleeding site was treated
with epinephrine and cauterization. This temporarily stopped the
bleeding; however bleeding recurred in the following day. Then patient
underwent visceral arteriogram and empiric embolization of
gastroduodenal artery (GDA), superior rectal artery of inferior
mesenteric artery (IMA). In the setting worsening GIB, patient had a
trial of octreotide infusion along with pantoprazole intravenously.
Octreotide inhibits gastric acid secretion and decreases splanchnic
blood flow due to its vasoconstrictive effect. Thereafter, hemoglobin
stabilized and patient recovered.
Discussion: This is a complex case of GIB from multiple angiodysplasia
concurrent with diverticulosis. Patient presented with
hypovolemic shock from GI bleed, requiring multiple blood transfusions.
Thus we can initially assume that GIB from a large and readily
visible source. However, this was not the case. This presented a diagnostic
dilemma, which necessitated multiple procedures. To conclude,
a trial of octreotide was given in the context of worsening GIB. In this
case, looking and targeting a specific lesion may not be the best therapeutic
option. Thus we step back and treat the GI system with a
medication that affects it at all levels. This clinical scenario is not uncommon
since both occur in elderly patients. Octreotide has been
shown to halt bleeding in cases of angiodysplasia and was successful
in our patient.
A7
The four-year mystery diagnosis.
M. Walker, D. A. Pasquale. UPMC, Pittsburgh, PA.
Background:
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Achalasia is a rare, elusive, and progressive disease that is usually
diagnosed only once it has reached advance stages. Described is a
case of an older adult who after four years of extensive testing received
therapeutic treatment for symptoms of episodic hypersalivation,
vomiting, and weight loss.
Case description:
A 79 yo female with a history of Alzheimer’s Disease, atrial fibrillation,
and osteoporosis was first seen in the office in 2006 with the
complaint of episodic hypersalivation, vomiting, and weight loss. Initial
EGD was significant for H.pylori, pre-pyloric edema and ulcer,
gastric antrum thickening, and antral erosion. Laboratory tests, CT of
the abdomen, and ultrasound of the abdomen were negative. Her
symptoms persisted, however, after eradication of the H. pylori and
PPI therapy. Further investigations in 2009 involved obtaining a
colonoscopy and a non-air contrast barium enema; both revealed diverticulosis.
Transglutaminase and small bowel biopsy were subsequently
negative for celiac disease. In April 2010 she was diagnosed
with lymphoma and was started on Rituxan therapy; she completed 4
treatments. She then underwent psychiatric evaluation and was
treated for apparent paranoia.
In 2010 she again presented to the office with similar complaints.
She now stated that she regurgitated what she ate after approximately
15 minutes. She was given a trial of applesauce to verify
her statement and after 10 minutes she regurgitated the applesauce.
She was immediately admitted to the hospital for a barium swallow
study that resulted in retained barium confirming the diagnosis of
achalasia. The diagnosis of achalasia came with great relief to the patient.
Today, her symptoms have resolved with the use of botulinum
toxin injections.
diagnosis which often times diverts clinicians from less common and
treatable causes. This is a case of failure to thrive with chronic abdominal
pain suggestive of an underlying malignancy but found to
have a benign cause.
The patient is a 78 year old female, cognitively intact with no
past medical or surgical history, from Senegal, presented with a progressive
2- year history of intermittent, mild, lower abdominal pain
with normal soft bowel movements and 30-lb weight loss. Symptoms
worsened for the past 2 months. She reports bright red blood per rectum
but denies diarrhea, constipation, hematemesis,vaginal bleeding
or fever.
On physical examination, her abdomen was soft, non-distended
with mild bilateral lower quadrant tenderness, without guarding or
rebound. Rectal exam showed no hemorrhoids or masses with brown,
Guiac positive stools. CT scan of the abdomen revealed significant
circumferential thickening at the lower anus and rectum suspicious
for malignancy.
Colonoscopy failed to show any discrete mass but found irregularity
and bogginess of anal mucosa along with severe diverticulosis
of entire colonic mucosa. Biopsies were sent and were negative for
malignancy. Ova and parasite screen revealed Ascaris lumbricoides.
Patient was started on mebendazole. A three-week follow-up
was significant for improved appetite with relief of abdominal pain
and diarrhea.
Discussion:
Dealing with immigrants, parasitic causes of failure to thrive
should be considered. Most of the literature describes Ascariasis in
tropical and subtropical areas affecting mostly children without mentioning
any case in the Geriatric population. Adults with ascariasis
are more likely to present with biliary complications. However, significant
nutritional deficiencies can be seen due to malabsorption, as in
this case. Hence in an immigrant with failure to thrive, parasitic
causes should be entertained.
Barium Swallow
A8 Encore Presentation
Worming Through a Case of Failure to Thrive.
M. A. Rashad, 1 J. Angeles, 1 H. Arabelo, 1 B. Matti-Orozco. 1,2 1.
Geriatric medicine, St Lukes Roosevelt Hospital, New York, NY; 2.
Medicine, Columbia Univeristy College of Physicians and Surgeon,
New york, NY.
Failure to thrive is a common diagnosis in the elderly consisting
of physical frailty, cognitive impairment and functional disability.
Weight loss more than 5% within 1 year is considered as the key component
and usually attributed to poor oral intake, medications, depression,
stroke and dementia. Malignancy is also a major differential
A9
Arteriovenous malformations in End Stage Renal disease.
N. Maheshwari, 1 R. Varma, 1 S. Kulkarni, 1 D. Kumari, 2 E. Ong, 1
E. Roffe, 2 S. Chaudhari. 2 1. Internal Medicine, New York Medical
College Metropolitan Hospital Centre, Manhattan, New York, NY; 2.
Geriatrics, New York Medical College Metropolitan Hospital Center,
New York, NY.
Introduction: Angiodysplasias can cause upper and lower gastrointestinal
(GI) bleeding in small percentage of patients with an increased
prevalence in patients like ESRD. We present a case of a
ESRD patient with recurrent GI bleeding secondary to AVM that ultimately
required a life saving surgical intervention.
Case presentation: A 68 year old African American male patient
with ESRD on maintenance hemodialysis was referred from Dialysis
Center for evaluation of severe anemia with hemoglobin (Hb) of
5.1gm/dl. He was managed in the medical intensive care unit and stabilized
with multiple blood transfusions. EGD, colonoscopy and capsule
endoscopy were inconclusive except an AVM in the proximal jejunum
which was photocoagulated. Patient was discharged but
presented again after a repeat fall in Hb from 8.7 to 4.3 gm/dl and was
readmitted to MICU. A small bowel endoscopy did not demonstrate
any lesion this time, tagged RBC scan showed abnormal activity from
hepatic flexure till the sigmoid colon. Colonoscopy showed multiple
erythematous mucosal lesions in the cecum, ascending colon and a
solitary lesion in the left colon resembling AVM which was photocoagulated.
Patient continued to drop his Hb despite repeated blood
transfusion. A repeat colonoscopy showed fresh red blood throughout
the colon up till the cecum and no clear bleeding site identified.
Angiography of the celiac axis and superior mesenteric artery failed
to identify clear focus of bleeding. Finally patient underwent Right
hemicolectomy and distal ileal resection as a life saving procedure.
Patient remained stable postoperatively and made an uneventful recovery.
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Discussion: Angiodysplasia are cause of recurrent and chronic
GI bleeding with marked acute bleeding in a small minority of patients.
The reason for increased prevalence among patients with
ESRD is unknown. Angiodysplasia are usually diagnosed by endoscopy.Angiography
is gold standard for the diagnosis but it has low
sensitivity. Radionulide scanning is more sensitive than angiography
but lacks specificity. Bleeding angiodysplasia is commonly treated endoscopically.
Surgery and angiography are alternatives for patients in
whom endoscopic therapy has failed. Physician should aware of angiodysplaisa
as cause of GI bleeding in old age patient, especially
with ESRD.
A10
Old habits die hard.
Q. Syed. Geriatrics, Cleveland Clinic, Cleveland, OH.
Supported By: no financial disclosures
86 year old female is brought to the ER after being found by
daughter unresponsive in her house, with a needle in her arm. Patient
was not arousable by narcan IV 2mg administered by EMT. Past history
significant for hypertension, hepatitis B and hepatitis C. Social
history is significant for IV heroin abuse since age 25, along with inconsistent
use of marijuana and cocaine. She was enrolled in opioid
detoxification programs multiple times with no benefit. She received
detoxification therapy with methadone in 2002 and 2006, and with
buprenorphine and naloxone in 2009. She initially did well on
buprenorphine and naloxone but had a relapse during the time period
when close friends passed away. On arrival in ED, vital signs indicated
bp=186/102,p=81, T=98.6, =20, spo2=99% RA. On exam pt
was noted to be nonverbal, opening her eyes on painful stimulus only.
Pupils were reactive to light bilaterally, corneal reflex intact. Patient
was able to move all extremities in response to painful stimuli. CT
showed new acute subdural hematoma over the left cerebral hemisphere
measuring up to 1.4 cm at the level of the left frontal lobe with
1 cm midline shift. Patient underwent urgent craniectomy for evacuation
of left acute subdural hematoma. Urine toxicology screen was
positive for opiates. Patient was transferred to ICU and received mechanical
ventilation for supportive care. Neurological status improved
gradually within 1 week, patient became awake and alert, was
able to follow commands and verbally communicate. Muscular
strength was noted to be 3/5 bilat extremities. She was extubated day
10th. She was cleared by speech therapist for oral pureed diet. Rehab
team evaluated her and she was noted to require complete assistance
in moving from one side to another, and transfer. She was discharged
to skilled rehab 2 weeks after admission.
Heroin is the second most frequently cited primary substance of
abuse, after alcohol, for all admissions to substance abuse treatment
by adults over the age of 50. Analyses of the Treatment Episodes
Data Set (TEDS) identified that in 2005, 1 in 5.3 substance abuse admissions
of 50–54 year old were for heroin abuse. Review of literature
supports the need for practitioners within substance abuse settings to
be sensitive to the physical limitations of older adult clients. Reduced
mobility and stamina along with cognitive impairments associated
with aging and decades of substance abuse will require adaptations
within the treatment setting.
A11 Encore Presentation
Case Report: Immune Thrombocytopenic Purpura (ITP) Triggered
by Allopurinol Refractory to Steroids and Intravenous
Immunoglobulin (IVIG) Responded to Rituximab.
R. Kothari. Internal Medicine, Coney Island Hospital, Brooklyn, NY.
Background: ITP is an autoimmune disease that involves peripheral
and central opsonization of platelets by auto-antibodies directed
against different surface glycoproteins, leading to their premature
destruction by the reticulo-endothelial system. Allopurinol is a
xanthine oxidase inhibitor commonly used for the prevention of
gouty arthritis. Less than 1% of patients develop significant adverse
reaction including thrombocytopenia and vasculitis.
Case: An 89 year old lady with hypertension, chronic systolic
heart failure, stage 2 chronic kidney disease, gouty arthritis and peptic
ulcer disease was admitted with generalized petechial rash all over
her body after taking allopurinol for one week. On admission,
platelet counts were 127,000. She received intravenous steroids, Benadryl
and was discharged with a tapering dose of oral steroids. Her
platelet count was 73,000 upon discharge.
She was readmitted after 2 days due to development of oral ulcers
and odynophagia; platelet count was noted to be 52,000. Abdominal
sonogram did not show splenomegaly. She received high dose intravenous
steroids. Oral ulcers resolved, but there was no significant
improvement in rash and platelet counts. Platelet counts decreased to
14,000 after a total of 21 days of intravenous plus oral steroids, then
she received IVIG. She completed 5 days of IVIG but platelet count
decreased further to 7,000. Direct anticoagulation test was positive
and due to refractory thrombocytopenia she was given Rituximab.
After two doses of Rituximab, platelet counts increased to
25,000 and she was discharged home with oral steroids. On subsequent
clinic follow up visits, platelet counts improved to 100,000. She
completed tapered steroid treatment and after 7 days the platelet
count was within normal range. She was followed up in the clinic for
next 2 months and there was no thrombocytopenia noted.
Discussion: The principal therapeutic options for elderly patients
are similar to that of young adults. Age influences the response
and adverse effect of conventional ITP therapies. The duration of disease
before treatment with Rituximab did not affect responsiveness
to therapy.
A12
Case of nephrogenic diabetes inspidus due to chronic Lithium use.
R. Otsuka, S. Rahgoshay, T. V. Caprio. the University of Rochester
Medical Center, Rochester, NY.
Background: Lithium continues to be the mainstay for treatment
in many older adult patients with chronic psychiatric illness.
Lithium also has the potential for toxicity, drug-drug interactions and
life threatening side effects. Nephrogenic diabetes inspidus is one of
major concerns, causing hypernatremia and dehydration which may
be amplified in at-risk older adults. We present a case of acute lithium
induced nephrogenic diabetes.
Case Presentation: A 66 year old male with schizoaffective disorder
and intellectual disability was prescribed lithium for many
years and he presented to the hospital with lethargy for a few days.
He had been noted to be drinking several times from the faucet and
had increased nocturia prior to presentation. However due to his intellectual
disability, he was not able to communicate effectively to
make his needs known. Initial blood work revealed a serum sodium
of 154 meq/L. His renal function and other electrolytes were normal.
Lithium level was within a therapeutic range. He underwent desmopressin
stimulation test and was diagnosed with nephrogenic diabetes
inspidus. His Lithium was discontinued.
Discussion: This case highlights several challenges with the use
of lithium in older adults with chronic illness, impaired cognition, and
limitations in communicative abilities. Chronic lithium use is associated
with nephrogenic diabetic inspidus (resistance to ADH), resulting
in polyuria and polydipsia in up to 20 to 40 percent of patients receiving
therapy. Acute onset of nocturia is an important clue to
diagnose this condition, however nocturia can be a common symptom
in older adults which makes recognition challenging. Furthermore,
older adults are more susceptible to salt and water imbalance, including
dehydration and hypernatremia which can be life-threatening. In
addition, impaired sensation of thirst occurs with aging and may exacerbate
this condition. Another important consideration in this case is
that people with intellectual disabilities or chronic psychiatric illness
may have difficulty expressing their needs and obtaining access to hy-
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dration. Therefore, careful clinical monitoring by facility staff or families
and laboratory assessments are essential for patients receiving
lithium. Finally, there should be a consideration of changing therapy
to other medications if appropriate, especially for those at highest
risk for lithium-induced complications.
A13
Clinical Challenge of diagnosing Amyotrophic Lateral Sclerosis
(ALS) in Elderly Patients.
S. Rana, 1,2 N. Manov, 2 S. S. Rana. 3 1. Geriatrics, University of
Pittsburgh School of Medicine, Pittsburgh, PA; 2. Geriatrics, UPMC-
St Margaret Hospital, Pittsburgh, PA; 3. Neurology, Allegheny
General Hospital, Pittsburgh, PA.
Amyotrophic Lateral Sclerosis (ALS) occurs in 2 to 3 per 100
thousand population and predominantly affects elderly.Diagnosis is
made on clinical examination and ruling out other possible disorders.
Since the elderly patients commonly have other confounding comorbidities,
ALS is often misdiagnosed. We present two cases of ALS that
underwent spine surgery with misdiagnosis of weakness secondary to
degenerative spine disease.
Methods: Chart review of two patients
Case studies
Case 1: 78 year male with history of prostate and lung cancers
treated with chemotherapy in 2008, developed footdrop in fall of
2009. Initial EMG studies showed denervating process involving legs
which were felt to be secondary to peripheral neuropathy.Based on
imaging studies he underwent decompressive surgery at L4-5 level
with presumed diagnosis of radiculopathy. Patient continued to
worsen and developed diffuse weakness, progressive weight loss, and
respiratory failure for which he required tracheostomy and ventilator
support. Follow up EMG studies revealed widespread denervating
process, consistent with ALS.
Case 2: 71 year female with history of hypertension, coronary artery
disease, presented with weakness in legs, recurrent falls and “sciatic
pain”. She underwent imaging studies of spine and was diagnosed
with scoliosis. She underwent surgery at the thoracic level. She continued
to get weaker in her extremities and then developed
dysarthria. EMG studies showed widespread denervating process and
she was diagnosed with ALS.
Conclusion: Early ALS can be difficult to diagnose as there is no
diagnostic test available. In elderly patients, initial presentation of
ALS is commonly attributed to radiculopathies secondary to degenerative
spine disease. Better diagnostic tools are needed to help diagnose
patients with ALS. In the interim, patients with painless onset of
weakness, absence of sensory symptoms and presence of fasciculations,
should raise suspicion for ALS. In these patients, judicious approach
ie EMG studies by experienced electromyographers, and
carefully correlating the results to imaging studies are warranted. Increased
awareness, and multidisciplinary approach can prevent unnecessary
spine surgeries in these patients.
A14
A Stuttering Discovery of Lithium Toxicity.
S. Sabillo, 1 R. V. Samala, 2 J. O. Ciocon. 1 1. Geriatrics, Cleveland Clinic
Florida, Weston, OH; 2. The Harry R. Horvitz Center for Palliative
Medicine, Cleveland Clinic, Cleveland, OH.
Objectives
1. Describe a case of lithium toxicity presenting as stuttering
2. Enumerate the medications that may cause stuttering
3. Discuss the mechanisms and management of drug-induced
stuttering
Case
An 86-year-old female nursing home resident was typically described
by the care staff as alert, pleasant, and conversant, though disoriented
to time and place at times. She was frequently seen in the
hallways, interacting with personnel and patients, and often breaking
into song with her melodious voice. Her past medical history was significant
for dementia, epilepsy, and bipolar disorder. Chronic medications
included donepezil, risperidone, primidone, and lithium carbonate.
One day, she complained to her nurse that she had been
stuttering, finding it difficult to complete a sentence, as well as sing.
She grew increasingly bothered by her faltering speech as the days
wore on, and also pointed out that her grip on objects was becoming
weak. Her attending physician was subsequently informed of these
new symptoms. Physical and neurological examinations were unremarkable
aside from her obvious stutter. She was able to talk straight
for a few words, and then would begin to repeat syllables and words
until she became obviously frustrated and abruptly terminate her
sentence. A CT scan of her head was done which was similarly unremarkable.
Her stuttering persisted for 3 more months until a lithium
level was checked, and came back elevated at 2.0 mmol/L (0.6 to 1.2
mmol/L). Lithium carbonate was promptly stopped and after about 2
weeks, her level was back to normal, and her stuttering had completely
resolved.
Discussion
A broad array of drugs has been shown to cause stuttering. Included
in the list are phenothiazines, tricyclic antidepressants, benzodiazepines,
selective serotonin reuptake inhibitors, theophylline,
phenytoin, carbamazepine, and clozapine. Proposed mechanisms involve
different drug-receptor systems: cholinergic, dopaminergic, noradrenergic,
and serotonergic. In all previously reported cases, stuttering
stopped when the offending agent was discontinued. We find
great interest in this case since there has been a scarcity of literature
implicating lithium. Clinicians should, therefore, be aware of stuttering
as a potential sign of drug toxicity.
A15
Elderly Female with Hypercalcemia: Hodgkin Lymphoma
Masquerading as Relapsed Breast Cancer.
S. Lee, Y. Ang, S. Bellantonio. Internal Medicine, Baystate Medical
Center, Springfield, MA.
INTRO
Malignancy-associated hypercalcemia is common in metastatic
breast and prostate cancers as well as multiple myeloma. Hodgkin
Lymphoma(HL) infrequently causes hypercalcemia. In the elderly, it
can present as delirium and fatigue. We report a septuagenarian female
breast cancer survivor with hypercalcemia who was found to
have stage IVA HL.
CASE
A 76-year-old lady with history of right breast cancer status post
mastectomy and type 2 diabetes presented to her PCP with a 5 day
history of generalized malaise, intermittent confusion, nausea, vomiting,
diarrhea, and epigastric pain. An enlarged right supraclavicular
lymph node was found. Due to concern for cancer relapse, she was
sent to the hospital for evaluation. She was found to be hypercalcemic(iCa
1.6mmol/L) with normal phosphorous(3.4mg/dL),
PTH(52pg/ml), and PTHrP(0.74pmol/L) levels. Renal function was
good, and she had not been on vitamin D supplementation. CT scans
show multiple splenic masses, a liver lesion, and an enlarged right
subclavicular lymph node. Bone scan revealed no osseous involvement.
She was treated with IV fluids, zoledronic acid, and glucocorticoids
with normalization of serum calcium and resolved symptoms.
Eventually, a supraclavicular lymph node biopsy confirmed HL,
nodular sclerosing type. She was discharged with prednisone and
plans for outpatient chemotherapy.
DISCUSSION
Malignancy-associated hypercalcemia affects 20% of cancer patients.
This is most often PTHrP mediated. Also common is osteolytic
hypercalcemia due to cancer metastasis to bone. Overproduction of
calcitriol is a rare cause of hypercalcemia in malignancy(1% of cases).
Incidence of this complication in HL is about 5%[1]. HL can produce
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calcitriol via 1alpha-hydroxylase activity. This syndrome is characterized
by normal phosphate levels, normal or suppressed PTH and
PTHrP concentrations, and no osseous involvement. As with our patient,
glucocorticoids can reduce extrarenal calcitriol production and
inhibit osteoclastic bone resorption.
CONCLUSION
Advanced age is a cancer risk factor. The elderly account for
60% of newly diagnosed malignancies. Hypercalcemia is a common
cancer complication that can present in the frail elder with subtle
symptoms and oftentimes, delirium. This, in setting of a possible neoplasia,
should be entertained.
REFERENCE
1.Seymour JF, Gagel RF.Calcitriol:the major humoral mediator
of hypercalcemia in Hodgkin disease and nonHodgkin
lymphoma.Blood 1993;82:1383–94
A16
Describing an atypical variant of Guillain-Barré syndrome.
S. Gulati, S. Gupta, G. Gulati. Internal Medicine, The Reading
Hospital and Medical Center, West Reading, PA.
CASE:62-year-old Asian male, presented to the hospital with bilateral
extremity weakness after a trip to India 3 weeks ago, at which
time he had developed severe gastroenteritis. Weakness had started
in his upper extremities, followed by the lower. During hospitalization
he experienced wide fluctuations in his blood pressure and heart
rate (systolic blood pressure of 100-190 mm of Hg and heart rate
ranging from 60-130 bpm). On neurologic, he had 3/5 motor strength
of bilateral upper extremities, 4/5 of lower extremities, areflexia in
upper with normal reflexes in the lower extremities. Gait was normal,
so was the sensory and cranial nerve exam. Routine laboratory studies
including a CBC, basic metabolic panel, thyroid panel, vitamin
B12, folate levels and autoimmune markers were normal. ESR was
elevated at 48 mm/hour (normal: 0-15mm/hour). CSF analysis revealed
an elevated protein of 86 mg/dL (normal: 20-45mg/dL), with
normal glucose level and zero WBC’s. This suggested albuminocytologic
dissociation. Nerve conduction studies showed evidence of demyelination.
Despite his atypical presentation, he was diagnosed with
Guillain-Barré syndrome(GBS) and started on IVIGg for five days.
His respiratory status remained stable with an improved neurologic
exam. The patient was discharged on prednisone to an acute rehabilitation
facility.
DISCUSSION: GBS, a post infectious immune mediated disease,
manifests as an acute inflammatory ascending polyradiculoneuropathy
(with weakness and diminished reflexes). It has an annual incidence
in US of 1.2-3 per 100,000, making it the most common cause
of acute flaccid paralysis. The disease has a bimodal distribution, with
peaks in age 15-35 years and a second, higher peak in elderly patients
aged 50-75 years. There is a history of an antecedent illness (GI or
upper respiratory), 1-3 weeks prior to the onset.
Many clinical variants have been well documented. These include
acute inflammatory demyelinating polyneuropathy (AIDP),
acute motor axonal neuropathy (AMAN), acute motor-sensory axonal
neuropathy (AMSAN), Miller-Fisher syndrome, a pure sensory
variant of GBS.
CONCLUSION: A disease not fitting the typical definition of
GBS should not dissuade physicians from complete work up and
treatment. This becomes especially important in the elderly population,
because there is a 6-fold increase in the rate of death in patients
aged 60 years or older compared to persons aged 40-59 years.
A17
Recognize the likely association between herpes encephalitis and
cardiac arrhythmias.
S. Gulati, G. Gulati, R. Alweis. Internal Medicine, The Reading
Hospital and Medical Center, West Reading, PA.
CASE: A 73 year old male with past medical history of hypertension
and coronary artery disease on beta blocker therapy presented
to the hospital with an acute change in mental status following
an episode of witnessed tonic-clonic seizure-like activity. The patient
had recently flown and had developed low grade intermittent fever
since. Examination revealed obtundation with an otherwise non-focal
neurological exam. He was intubated for airway protection and transferred
to the ICU. Laboratory evaluation revealed only mild leukocytosis
with a normal differential. Blood chemistries were normal with
negative toxicology screening. Lumbar puncture revealed clear appearance
of the CSF, normal glucose of 76 mg/dl, elevated protein of
64 mg/dl (nl 20-45 mg/dl), elevated white cell count of 304 cmm (nl 0-
5 cmm), with 80% lymphocytes (nl 0-50%) and 1% neutrophils. Herpes
Simplex type 1 DNA was detected by PCR. A diagnosis of herpes
encephalitis was made and the patient was started on intravenous
acyclovir. After transfer out of the unit, he was noted to have sinus
bradycardia with heart rate ranging from 40-60 beats per minute. Review
of his rhythm revealed a first degree heart block. The patient
was evaluated and, for unclear reasons, restarted on his home dose of
metoprolol. This was followed by development of complete heart
block which necessitated implantation of a dual-chamber pacemaker.
DISCUSSION: Herpes simplex virus is the most common cause
of acute, sporadic viral encephalitis, accounts for 10% to 20% of all
cases. Of these more than 95% are caused by subtype I virus. The clinical
hallmark of HSV encephalitis is acute onset of fever accompanied
by focal neurologic signs (most commonly involving the temporal
lobes). There have been isolated case reports in literature
connecting cases of herpes encephalitis with development of cardiac
arrhythmias. Hence patients with encephalitis need close cardiac
monitoring. Literature search reveals that these patients spontaneously
recover with treatment of the underlying infection and have
not needed pacemakers.
Physicians taking care of patients need to recognize the association
of cardiac arrhythmias with non-cardiac causes like viral infection.
This can help avoid catastrophic sequelae.
A18
An unusual presentation of deep vein thrombosis due to May-
Thurner syndrome in an elderly man.
S. Nakagawa, 1 A. Fischman, 2 J. Farber, 1 F. Ko. 1 1. Department of
Geriatrics and Palliative Medicine, Mount Sinai School of Medicine,
New York, NY; 2. Departments of Radiology and Surgery, Mount
Sinai School of Medicine, New York, NY.
Case
A 79 year-old man presented with 2 weeks of progressive left
lower extremity (LLE) swelling with pain precluding ambulation. He
had significant unilateral non-pitting edema with skin discoloration
in the entire LLE and a positive Homans’ sign. A Doppler ultrasound
showed acute deep vein thrombosis (DVT). Despite starting anticoagulation,
swelling and pain worsened. A subsequent CT venogram
showed an extensive occlusive DVT from the left common iliac vein
to the popliteal vein. Endovascular Catheter Directed Thrombolysis
(CDT) and pharmacomechanical thrombectomy was performed with
successful clot removal. An intravascular ultrasound (IVUS) showed
focal narrowing of the left common iliac vein due to a crossing right
common iliac artery consistent with May-Thurner syndrome (MTS).
A self-expanding iliac stent restored iliofemoral venous system patency
and resolved LLE swelling. A small post-procedure hematoma
was seen which subsequently resolved. The patient remained stable
on enoxaparin with a patent stent 5 weeks after treatment.
Discussion
MTS typically occurs in women of childbearing age. The right
common iliac artery causes chronic external compression of the left
common iliac vein and predisposes patients to LLE proximal DVT.
Iliac vein compression needs aggressive management because it results
in recurrent thrombosis and post-thrombotic syndrome (PTS)
on anticoagulation therapy alone. Venography with IVUS is a superior
modality for diagnosis. CDT and stent placement followed by anticoagulation
is the most effective treatment. Due to its rarity in eld-
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erly men, index of suspicion for MTS was low in our patient. His striking
initial presentation and worsening symptoms after anticoagulation
prompted further evaluation, leading to the diagnosis of MTS.
Although CDT is associated with a higher risk of bleeding compared
to anticoagulation alone, its benefits outweigh risks in highly active
patients.
Conclusion
In acute proximal lower extremity DVT with severe symptoms,
diagnostic work-up with CT venogram and aggressive catheter-based
intervention should be pursued if indicated. Although DVT due to
MTS is very rare in older adults, failure to recognize can result in serious
vascular sequelae, particularly PTS, and thus appropriate clinical
suspicion should be maintained.
A19
The Importance of Goals of Care in Elders with Mild Dementia.
S. Arora, S. Khosla, M. J. Brennan. Internal Medicine, Baystate
Medical Center/Tufts Univ. School of Medicine, Springfield, MA.
Background:
Existing literature regarding goals of care for dementia patients
focuses on those with advanced disease facing end of life decisions
due to aspiration, infections and debility. Little attention has been
paid to those with early impairment. The authors present a case of an
elderly man with mild dementia for whom a lack of clarity around
goals prevented optimal care.
Case Report:
Mr. S. was an 88 year old with DM and CKD. A geriatrician diagnosed
a mild dementia while he was admitted for an RCA STEMI
with shock requiring vasopressors and intubation. Six weeks later he
was readmitted with syncope and bradycardia secondary to hypovolemia.
An echo documented an EF of 30-35%. AICD or pacer placement
for sinus node dysfunction was discussed; an EP consultant
opted for conservative treatment noting that Mr. S. had dementia.
There was no discussion with the patient or family about possible device
therapies. Within a week, Mr. S. returned to the ER unresponsive,
hyperkalemic and bradycardic with a heart rate in the 20s. He improved
with atropine but bradycardia recurred and attempts to place
a pacer failed. Mr. S. required prolonged CPR for PEA, asystole and
VT but was resuscitated and reintubated. At that point, his family
chose a DNR order. After a lengthy CCU stay and placement of a
dual chamber pacemaker, he was discharged for rehabilitation with
cognitive abilities near his baseline.
Discussion and Conclusions:
Would earlier pacemaker placement have saved Mr. S. suffering
and a long hospital stay? Was the decision not to place a pacemaker
influenced by his diagnosis of dementia? Potentially life-sustaining
therapies should not be foregone due to mild, cognitive deficits especially
if prognosis and goals of care have not been discussed. To avoid
unconscious paternalism, providers must not make judgments about
a patient’s quality of life without input from the patient and family. It
is best to clarify understanding and goals in the outpatient setting
when families are not overwhelmed and patients can participate. This
case was medically complex; elders like Mr. S. have largely been excluded
from the clinical trials of post MI devices. Improved communication
among primary care MDs, geriatricians, cardiologists and patients/families
is essential. Research on communication strategies to
enhance advanced care planning and to clarify clinical outcomes for
vulnerable geriatric cardiology patients are both sorely needed.
A20
Femoral Spontaneous fracture Associated with Bisphosphonate
Therapy.
S. Rahgoshay, S. M. Friedman, S. V. Bukata, T. V. Caprio. Division of
Geriatrics and Aging, University of Rochester, Rochester, NY.
BACKGROUND: Hip fractures are important because they are
associated with an increased rate of morbidity, substantial costs, and
overwhelming effects on quality of life. Bisphosphonates(BPPs) are
widely used for treatment of postmenopausal osteoporosis. BPPs
have proven efficacy in reducing the incidence of vertebral and nonvertebral
fractures. Although short term efficacy, safety and tolerability
of these drugs have been documented, an increasing number of recent
case reports suggest that some subtrochanteric hip fractures
might occur in patients who have been treated on a long-term with
BPPs due to suppressed bone turn over.
CASE SUMMARY: A 58 year old female with known osteoporosis
presented to the hospital after hearing an “audible creak”
while going up stairs, followed by a spontaneous right-sided subtrochanteric
hip fracture. Two weeks before the fracture she had prodromal
pain in the right thigh with walking difficulty and came to the
emergency department. Xrays of the right leg and hip did not show
any sign of fracture at that time and she was therefore treated with
analgesics. Five years previously, the patient had started taking alendronate
and after 2 years was switched to zoledronic acid with calcium
and vitamin D. At presentation again to the emergency department
she had severe pain, acute tenderness in the right thigh, and her
lower extremity was shortened with external rotation. The subthrochanteric
fracture was treated with an intramedullary gamma
nail and the patient recovered from surgery successfully. Routine
blood tests; including bone profile, viamin D, thyroid function tests
were normal. She was taken off her BPPs, and was discharged on calcium,
and vitamin D. Outpatient arrangements were made to repeat
her DEXA and to consider an alternative like teraparatide treatment
for osteoporosis.
CONCLUSION:
Bisphosphonates have proven efficacy in reducing the incidence
of vertebral and non-vertebral fractures. The literature suggests the
existence of BPP-related atypical fractures, with unique clinical and
radiographic features in patients on long-term BPP therapy as observed
in this case study. Continued use of BPPs beyond a treatment
period of 3 to 5 years should be reevaluated annually.
A21
A Doggone Cough-an unusual complication of pet ownership-a case
report. Nathan S, Gorbien M, Olson J, Leiding M, Bednarzcyk M.
S. N. Nathan. Department of Geriatric Medicine, Rush University
Medical Center, Chicago, IL.
Purpose: Discuss an unusual health consequence of pet ownership.
Background: Kennel Cough is an infectious tracheobronchitis. It
is a canine respiratory syndrome, often contagious in high density
areas-pet shops, kennels, etc. The most frequent bacterial isolate is
Bordetella bronchiseptica (B.b.)[i]. B.b. is a recognized respiratory
tract pathogen of mammals since 1910. Evidence suggests that it colonizes
human respiratory tract and causes infection in compromised
hosts[ii]. Old age is an immunocompromised state[iii]. Snakes are
also prone to pneumonia, which is contagious between species.This is
an 82 year old woman with Herpes Zoster, URI & systemic symptoms
after her dog was diagnosed with Kennel Cough, after exposure to
the neighbor’s dog. The neighbors illegally bred dogs, snakes & mice.
Method: Case report.
Case Report: Ms. C is an 82 year old woman with Herpes Zoster
seen in clinic for 2-3 days of URI & systemic complaints. The whole
family had been ill for weeks, they think from their dog. The dog was
diagnosed with Kennel Cough. The neighbor would sneak over & try
to get the family’s dog to impregnate his dog. The neighbor had 2 pitbulls
who died 4 weeks prior, whose bodies were dumped in the family’s
garbage. The neighbors also had an illegal snake farm, with 200 of
the snakes dying shortly before this visit.
Discussion: There is benefit to pet ownership in the elderly
[iv][v]. However, pets can transmit illness. This case shows an unusual
situation that put the patient, family & dog at risk for an unexpected
illness.
i J Vet Med Sci Vol 70: 563-569.(2008). “Etiologic Study of
Upper Respiratory Infections of Household Dogs”. Mochizuki M,
Yachi A, Ohshima T, Ohuchi A, Ishida T.
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ii J Clin Micrbiol. 1995 Aug; 33(8):2002-6. Human Bordetella
bronchiseptica infection related to contact with infected animals: persistence
of bacteria in host. Gueirard P, Weber C, Le Coustumier A,
Guiso N.
iii Trnspl Int. 2009 Nov;22(11):1041-50. Epub 2009 Jul 16. The
aging of the immune system. Weiskopf D, Weinberger B, Grubeck-
Loebenstein B.
iv J Am Geriatr Soc. 1999 Mar;47(3):323-9. Influence of companion
animals on the physical and psychological health of older people:
an analysis of a one-year longitudinal study. Raina P, Waltner-
Toews D, Bonnett B, Woodward C, Abernathy T.
v J Nutr Elder. 1996;15(3):15-31. Pet ownership may be a factor
in improved health of the elderly. Dembicki D, Anderson J.
A22
Aphasia vs. Dementia: A Case of Primary Progressive Aphasia.
S. S. Naqvi, C. D. Furman. Family & Geriatric Medicine, University of
Louisville, Louisville, KY.
Introduction: Primary Progressive Aphasia (PPA) presents with
dysnomia and impaired speech. Language dysfunction remains the
most salient feature and deteriorates most rapidly during the illness.
Impairments in other cognitive functions, including dementia, may
also emerge.
Case Report: A 70 y/o white male with h/o bipolar disorder, hallucinations,
hyperlipidemia, and PPA presented with his wife and son
to determine if he had dementia. Patient also had a h/o stuttering as a
child and alcoholism. Patient had memory problems the past 2 years
with a rapid decline over past 2-3 weeks. Patient did not recognize his
own home or wife and often wore wife’s clothes. He had difficulty
swallowing and eating. He developed poor coordination skills and
found it hard to place food into his mouth. In 2003, he retired as an attorney.
His symptoms began in 1999 with speech problems. He had
difficulty with expression of language, incomplete sentences, spelling
errors and word loss without compensation. In 2003, he was diagnosed
with PPA and was seen by multiple local and national neurologists
and neuropsychologists who unanimously agreed on a diagnosis
of PPA. Brain PET scans, done in 2006 and 2010, showed hypometabolism
in the left temporoparietal region, compatible with a neurodegenerative
disorder, most likely Alzheimer’s type. The patient was on
donepezil and memantine with no improvement and received speech
therapy with some improvement. At the current presentation, dementia
was diagnosed based on his memory loss and functional decline.
He was admitted to hospice because of dysphagia and his overall
decline.
Discussion:This case exemplifies affluent type PPA,a rare neurodegenerative
disorder in which symptoms start with language difficulty. Patients
with PPA can become mute and may eventually lose the ability to
understand written or spoken language. PPA is considered a form of dementia
because it causes a gradual cognitive decline to the point where
activities of daily living become compromised. Approximately 30% of
patients have shown the microscopic pathology of Alzheimer’s disease,
presumably with an atypical distribution of lesions. 70% of PPA is known
to be a type of frontotemporal lobar degeneration. Currently, there is no
effective pharmacologic treatment. However, evaluation by a speech
therapist is useful. When PPA is diagnosed, the patient and family should
be informed that PPA is a type of progressive dementia.
A23
Aspergilloma: association with chronic bronchiectasis and IgG2
deficiency.
T. T. Suh, 1,2 T. Efeovbokhan, 1,2 M. R. Hosler. 3 1. Family &
Community Medicine, UT Health Science Center in San Antonio, San
Antonio, TX; 2. ACE Unit, Christus Santa Rosa Hospital-City Centre,
San Antonio, TX; 3. Allergy, Asthma & Immunology Associates of
South Texas, San Antonio, TX.
BACKGROUND: Aspergilloma is fungal lung infection that
often causes cavitary lung lesions and the characteristic “fungus ball”
or mycetoma on CT scan. Up to 10% of patients with bronchiectasis
eventually become infected with aspergillus. It is thought that high
levels of complement found in patients with bronchiectasis prevent
the killing of aspergillus, allowing this fungal infection to occur. Up to
half of patients with idiopathic bronchiectasis have deficiency of either
IgA or IgG2 antibodies. Aspergilloma can also be a very rare
complication of etanercept for rheumatologic conditions like
rheumatoid arthritis, affecting about 0.01% of patients reporting side
effects with this drug.
CASE: A 75 year old Caucasian woman with multiple drug allergies,
BMI of 19.5, chronic bronchiectasis, rheumatoid arthritis
(being treated with etanercept and prednisone 5mg daily), an IgG2
subclass deficiency (being treated with monthly IVIg) and a functional
humoral immunodeficiency (with poor response to Pneumovax)
presented to her allergist with hemoptysis for one week. A
contrast-enhanced CT scan of the chest revealed a cavitary right
upper lobe lung lesion. The patient was hospitalized, and bronchoscopy
was performed. Tuberculosis and cancer were ruled out
from bronchial washings and biopsies, but results were suggestive for
aspergilloma. Because the patient was not thought to be a good surgical
candidate, she was placed on IV voriconazole for 4 weeks. After
completing this course of antifungal therapy, her hemoptysis resolved
and overall respiratory status improved.
DISCUSSION: Aspergilloma is a generally rare fungal infection
that can be seen in patients who are immunosuppressed. It is important
for geriatricians to be aware that aspergilloma is associated with
chronic bronchiectasis. In turn, chronic bronchiectasis is associated
with IgG2 deficiency that can be treated with IVIg. In particular,
geriatricians should also note that non-CF-related bronchiectasis is
more common and more severe in underweight Caucasian women
over the age of 60 years.
A24
CADASIL Disease: a case report of a rare, genetic early onset
dementia.
T. Leucker, 1 B. Setters. 2 1. Internal Medicine, University of Louisville,
Louisville, KY; 2. Family & Geriatric Medicine, University of
Louisville, Louisville, KY.
INTRODUCTION: Cerebral autosomal dominant arteriopathy
with subcortical infarcts and leukoencephalopathy (CADASIL), a
genetically determined arteriopathy involving the NOTCH 3 gene on
chromosome 19, is a rare cause of vascular dementia affecting only a
few hundred families worldwide. Clinical progression involves the sequential
development of migraine with aura at age 30, followed by ischemic
strokes, mood disorders then dementia at 50 yo and gait difficulty
at 60.
CASE REPORT: A 60 y/o AAF with a 40 year history of recurrent
headaches with nausea/vomiting, light sensitivity, worsening
memory loss and depression presented to the hospital 2 years ago
with a blurry vision, a lazy eye and left sided weakness. Exam on admission
did not reveal any neurological deficits, but given her extensive
family history of stroke and personal history of persistent symptoms
over the past few months, a full evaluation was completed. A
head CT demonstrated subtle areas of abnormal attenuation. Follow
up MRI identified diffuse hyper-intensities, heaviest in the temporal
lobes in a subcortical location involving white matter, which was very
concerning for a possible diagnosis of CADASIL disease given the
patient’s history. The remaining clinical workup, including lumbar
puncture was negative. The patient was offered genetic testing for
CADASIL disease, but due to lack of insurance no further testing was
done. Since this initial evaluation the patient had two more admission
for stroke like symptoms. She has shown progressive decline in cognitive
function including memory loss, aphasia, apraxia and a disturbance
in executive functioning resulting in a loss of her job and dependence
on her family for care with her daily activities.
CONCLUSION: CADASIL disease is a rare genetic cause of
dementia that can affect people of all ages and as such is not part of
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most physicians’ differential diagnosis when working up cognitive
disorders even in younger patients. Given that the presenting symptoms
may be vague and individually common with a routine evaluation
that is usually non-diagnostic, the clinical and family history can
be crucial in making the diagnosis. To establish the diagnosis a
NOTCH3 mutation by genetic analysis or a skin biopsy showing ultra
structural deposits within small blood vessels is needed.
A25
Space Occupying Lesions of the Brain Presenting with
Neuropsychiatric Symptoms.
T. Beben, M. F. Assal, D. D. Sewell, J. Reichstadt, J. W. Daly. UC San
Diego, San Diego, CA.
Supported By: No funders provided support for this research.
Introduction: Cognitive and behavioral problems are often attributable
to underlying degenerative or psychiatric processes. Here
we present two atypical cases.
Case 1: An 86-year-old man with a history of CAD and TIAs developed
memory and executive function deficits three years prior to
his presentation at our institution. Brain imaging and labs were normal
and he was eventually diagnosed with frontotemporal dementia.
Five months prior, his decline accelerated prompting placement in a
residential care facility. He was noted to have acutely worsening behavioral
symptoms, including wandering, disorganization, agitation,
and impulsivity leading to falls, which led to his admission to our behavioral
unit. Basic labs were normal. A head CT, ordered due to a recent
fall, unexpectedly demonstrated a large mass. Subsequent MRI
delineated a 7x4cm right temporal lobe mass with ring enhancement
and central necrosis, most consistent with glioblastoma multiforme,
which was felt to account for his accelerated decline. The patient was
treated symptomatically with divalproex, olanzapine, and dexamethasone.
After a family meeting, he was referred to hospice.
Case 2: A 60-year-old woman with a history of hypertension and
depression was brought to our geriatric assessment clinic by her
daughter to investigate the cause of her personality changes and decline
in executive function. She had worked as a lab technician until
six years prior, when she became unable to perform work on time or
learn new tasks. She had since been unemployed and could not manage
her finances. At times, she was withdrawn in her cluttered apartment
and neglected her personal hygiene. She also showed poor impulse
control and judgment through inappropriate actions with
strangers and debt accrual. Our initial evaluation revealed a score of
28/30 on the MoCA, but difficulty with attention. A routine brain
MRI was obtained, revealing a 7.2 cm extraaxial right frontal lobe
mass. She was admitted to neurosurgery. Upon successful resection of
the mass, a diagnosis of meningioma was confirmed. After a post-operative
course that was complicated by hydrocephalus requiring a VP
shut, her former personality began to re-emerge.
Conclusions: Brain masses should not be overlooked as a potential
cause of neuropsychiatric symptoms. An accurate diagnosis can
help define prognosis and may guide treatment options.
A26
Clinical significance of measuring Blood Pressures in bilateral arms
in patients with dizziness.
T. Gyurmey, P. Coll, K. Singh. Geriatrics, University of Connecticut
Health Center, Farmington, CT.
82 y/o lady with DM type 2, CAD, HTN, TIA, lumbar stenosis,
anemia of chronic disease, depression, GERD and PVD presents
with left arm easy fatigability and episodic dizziness for 1 year. She
was evaluated for dizziness and medications were reviewed with discontinuation
of betablockers and the left arm fatigue was presumed
by the patient to be as a result of the left shoulder replacement.She
was symptom free for a few months until they returned. Past surgical
history is significant for left shoulder joint replacement and left
carotid artery stenting. Medications include morphine, bupropion,
pravastatin, amlodipine, alendronate, epoetin alfa injections and lorazepam
prn.She is afebrile, BP Rt arm 142/48, BP Lt arm 102/40, PR
88 regular with diminished left radial artery pulsations, RR 12, orhtostatics
negative. EOMI, exams of the HEENT, lungs, heart, abdomen
and CNS were unremarkable. No peripheral edema. B/L Lower limb
pulses are equal and symmetric. Based on the difference in systolic
blood pressures and the symptoms, a presumptive diagnosis of Subclavian
artery stenosis with steal syndrome was made.
Management included prompt percutaneous transluminal angiography
followed by angioplasty involving tandem stents being
placed at two proximal left subclavian stenosed sites before the origin
of the vertebral artery without any complications. She was on clopidogrel
for a month and currently takes aspirin 325 mg daily and is
symptom free.
Discussion: Dizziness is a very common symptom in the elderly
and can lead to decreased quality of life and predispose to falls and
subsequent morbidity and mortality.Blood pressures, pulse rates and
orthostatics are routinely measured but not often in both arms which
could lead to missing the diagnosis of subclavian stenosis and steal
syndrome that this patient presented with. On the other hand a
falsely normal blood pressure reading in the arm affected by a stenosis
could delay a diagnosis of Hypertension and subsequently lead to
avoidable and sometimes devastating short term complications and
long term end organ damages. Measuring blood pressure and pulses
in both arms is a very simple but invaluable step that should be done
routinely.
A27
Closed head injury with multisensory loss in a 74 year old athlete
while playing senior league basketball.
U. Kakwan, 1 N. Miller, 3 U. Braun. 2,1 1. Geriatrics, Baylor College of
Medicine, Houston,TX; 2. Geriatrics, Michael E. DeBakey VAMC,
Houston,TX; 3. Brazos-Valley Community Agency Action, Bryan,TX.
Supported By: Nothing to disclose.
INTRODUCTION
Seniors are becoming more involved in competitive sports, and
injuries in this age group are not well described. We report a patient
who suffered traumatic brain injury with multisensory loss.
CASE PRESENTATION
A 74 year old Caucasian clinic nurse presented to the ER after
she was bumped into, fell backwards, and struck her head on the hard
court while playing basketball. She had brief LOC, bled from her
right ear canal, and reported hearing loss and severe dizziness.
Past medical history was significant for breast cancer in remission,
treated with an aromatase inhibitor, and severe osteoporosis,
treated with Calcium, Vitamin D, and alendronate. Head CT showed
bilateral temporal bone fractures, bleeding in both mastoids, contracoup
injury to the left frontal lobe, and subdural hematoma/subarachnoid
hemorrhage.
She was treated nonsurgically and discharged after 72 hours.
Dizziness was severe but responded to Eppley’s maneuver, followed
by vestibular home exercises. She had moderate symmetrical bilateral
sensorineural hearing loss of 40-50 dbl with minimal improvement
over 6 months.
She also suffers from complete anosmia and dysgeusia. The patient
returned to work after 8 weeks but struggled with patients’
names and short-term memory. Electronic records and her high preinjury
skills and medical knowledge acquired over many years compensated
for her losses.
This patient quit all her athletic activities except walking and expressed
that her losses are worse than when she faced cancer.
DISCUSSION
With the baby-boomers now turning 60, a more active generation
of elderly who may still actively participate in competitive sports
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is on the rise. Thus, more severe and complicated sports-related injuries
are likely to be encountered by emergency room physicians in
the near future.
These “fit” elderly are often still employed and despite being
high-performing, sports injuries sustained in this older group may be
more devastating and potentially disabling.
A28
Hands Tell All.
V. Nurpeisov, 1 A. Akintan, 1 N. Holland. 2 1. geriatric medicine, VA
Medical Center, Decatur, GA; 2. Geriatric medicine, Emory University
School of Medicine, Atlanta, GA.
An 85 year old gentleman with a history of hypertension, hyperlipidemia,
and tobacco use presented to the geriatric clinic with a history
of craving ice chips for several months and a twenty pound
weight loss over the previous six months. He denied any noticeable
change in stool habits, hematemesis, abdominal pain, or vomiting. He
did not use alcohol and had smoked cigarettes for the past 60 years.
His medications were: Lisinopril 5 mg daily, Aspirin 81mg daily, and
Hydrochlorothiazide 12.5 mg daily.
On exam he was a thin and cachectic. His vitals were stable.
There was no noticeable jaundice. His lungs were clear and heart
exam was unremarkable. His abdominal exam didn’t reveal any palpable
masses but revealed an enlarged liver.
His nails revealed spooning, evidence of nicotine staining and
changes consisitent with Terry’s nails. His labs showed normal
chemistries and urinalysis. TSH and vitamin B12 levels were normal.
He had a microcytic anemia, hemoglobin of 9 g/dl.
This patient was admitted and by CT colonoscopy, diagnosed
with colon cancer with metastasis to the liver. He and his family
elected for him to receive hospice care.
His Terry’s nail changes were consistent with hepatic disease.
These are usually seen with cirrhosis but in this case we felt these
changes were the result of hepatic metastasis. His nails also revealed
spooning consistent with an iron deficiency anemia as well as nicotine
staining on the second and third finger nails.
Based only on this gentelman’s history and nail changes as described,
colon cancer with liver metastasis was a leading diagnosis before
getting any diagnostic studies. Subsequent CT colonoscopy confirmed
this diagnosis. To our knowledge, this is the first case of
association of Terry’s nails with hepatic metastasis without hepatic
cirrhosis.
In this age of growing technology getting back to the bedside
and taking the time to listen, as well as look for subtle but important
physical exam findings still remains an important art and skill which
should not be overlooked.
Nail changes are easy to observe and often are associated with
important clues to underlying systemic illness in older patients.
This case report emphasizes Sir William Osler’s quote that “
every patient you see is a lesson in much more than the malady from
which he suffers.”
This poster will show pictures of this gentelman’s hands and nail
findings as well as other diagnostic nail changes in systemic disease.
A29 Encore Presentation
Metformin-associated severe hypomagnesemia; A Case report.
V. Kaushik. Geriatrics, UTMB, Galveston, Galveston, TX.
Supported By: UTMB
Introduction
Metformin is a oral hypoglycemic agent which decreases hepatic
glucose production, decreases intestinal absorption of glucose, and
improves insulin sensitivity by increasing peripheral glucose uptake
and utilization. The main use for metformin is in the treatment of diabetes
mellitus type 2, especially in overweight patients. Metformin reduces
diabetes complications and overall mortality. Hypomagnesemia
is not referred to as a side effect in the drug’s summary of product
characteristics information, but diarrhea is an important side effect
of metformin and various degree of hypomagnesemia and other
electrolyte imbalance from diarrhea have been reported in the literature.
One report describes a patient on metformin who developed diarrhea
and symptomatic hypomagnesemia (1).
Case presentation
Patient is an 78 year old Caucasian female with h/o diabetes
type II for more than 15 years, hypertension, hyperlipidemia and osteoarthritis.
Her diabetes was fairly controlled by glipizide and metformin.
Metformin was added to her medications three years ago for
better control of her diabetes. Her other medications include
enalapril, Felodipine, Clopidogrel (Plavix), Rosuvastatin (Crestor),
Hydrocodone-acetaminophen and Temazepam (Restoril). Patient
had normal serum magnesium levels prior to adding metformin. Two
months after adding metformin, her routine evaluation showed an
unexplained hypomagnesemia (1.0 mg/dl). Serum calcium, phosphorus,
potassium and renal function were normal. She did not report any
diarrhea. She continued to have chronic moderate to severe hypomagnesemia,
mostly in 0.9 -1.4 mg/dl range. Oral magnesium supplementation
was not very helpful . Her Metformin was discontinued six
months ago and since then her serum magnesium level is improving
slowly, now mostly in 1.5 -1.8 mg/dl range.
Conclusion
The lab findings in this case suggest severe hypomagnesemia,
without any evidence of diarrhea. Hypomagnesemia resolved with
discontinuation of metformin. Based on this association with metformin
and the lack of other clear precipitating causes, the most probable
cause of hypomagnesemia in this patient appears to be metformin.
Clinician should consider the possibility of
metformin-associated hypomagnesemia in patients with otherwise
unexplained hypomagnesemia.
References:
(1) A patient presenting with symptomatic hypomagnesemia
caused by metformin-induced diarrhea: a case report. Svare A. Cases
J. 2009 Oct 16;2:156.
A30
Birds Don’t Make the Best Companions: Hypersensitivity
Pneumonitis In The Elderly.
W. Ooi, S. Dahiya. Internal Medicine, Baystate Medical Center, West
Springfield, MA.
Hypersensitivity pneumonitis, also known as extrinsic allergic
alveolitis, represents a spectrum of immunologic-driven response to a
variety of inhaled allergens. The diagnosis requires a known exposure
to the offending agent along with compatible clinical, radiological
and laboratory studies.
A 67 year old lady with a history of bilateral pulmonary embolisms
presented with progressive dyspnea associated with productive
cough over one month. Patient denied fever, chills or night
sweats. No hemoptysis or lower extremity swelling. Past medical history
includes schizoaffective disorder, morbid obesity and osteoarthritis.
Physical exam was significant for hypoxia requiring 5L of
oxygen supplementation by nasal cannula. Lung and cardiac exam
were otherwise unrevealing. Laboratory studies were significant for
chronic anemia with hemoglobin of 9.8 gm/dL and elevated N-terminal
pro-brain natriuretic peptide of 826 pg/mL. Patient underwent a
computed tomography (CT) angiogram of the chest which revealed
mosaic pattern of lung attenuation bilaterally and mediastinal lymphadenopathy.
She was started on ceftriaxone and azithromycin for
treatment of atypical community-acquired pneumonia. Collateral history
from patient’s family later during her hospitalization revealed
that patient keeps 17 birds; parrots and macaws for the past 15 years.
Her house was revealed to be in an unhygienic condition with animal
excreta and clutter in her bedroom. Pulmonary recommended a
serum precipitin panel which revealed a positive qualitative titer of
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pigeon serum antibody. Inpatient pulmonary function test showed a
restrictive pattern with significant reduction in her lung diffusing capacity.
Patient was initiated on intravenous methylprednisolone for
five days. Repeat CT scan of her chest 6 days from admission showed
a significant improvement of her lung parenchymal disease and lymphadenopathy.
There are limitations to several proposed diagnostic criteria especially
in the setting of sub-acute or chronic disease. Misdiagnosis
and delays occur in the absence of a comprehensive review of environmental
exposure. This provides a diagnostic challenge in the elderly
and psychiatric population. Serum precipitins have poor sensitivity
and specificity. The risks of invasive diagnostic workup including
bronchoscopic lavage and lung biopsy may outweigh its benefits in
advanced disease. The treatment involves removal of the offending
agent and glucocorticoids.
A31
Lipedema, a frequently misdiagnosed problem in elderly patient.
Y. Ye, U. T. Efeovbokhan, R. W. Parker. UTHSCSA, San Antonio, TX.
Background: Lipedema was first described in 1940 as a bilateral,
gradual accumulation of fatty deposition in the lower extremities and
buttocks. The feet are usually spared which is difference from lymphedema.
This condition is found exclusively in females. It develops
insidiously after puberty and progresses gradually. This condition is
frequently misdiagnosed as lymphedema which is due to accumulation
of protein-rich interstitial fluid with the skin and subcutaneous
tissue caused by lymphatic dysfunction. We describe an elderly patient
with gradually enlargement of bilateral lower extremities for
five years complicated with recurrent skin infection and ulcers.
Methods: This case report describes the presentation of lipedema
in a 68 yr old female patient in which the lipedema is complicated
with lymphedema and skin infection.
Results: Case Presentation: A 68 yr old Caucasian female was
admitted for pain and smelling in bilateral lower extremities. The patient
noticed her both legs gradually becoming swelling for five years.
The swelling becomes worse when sitting for a long time and alleviated
when both legs are elevated. This condition made her confined
to wheelchair. One month ago, patient felt the swelling was getting
worse and she has severe pain in both calves. One course of clindamycin
did not improve the symptom. Physical examination revealed
massive bilateral lower extremity non-pitting edema. There
were firm subcutaneous, cobblestone like nodules and papules with
hyperpigmentation on both legs, especially in the lower one third of
the legs. There was noticeable bilateral erythema up to knees. The
skin was warm to touch. There is a 5x3cm open, foul smelling ulcer on
the left lower extremity. Bilateral ankles and feet were spared. Stemmer’s
sign was negative. Skin biopsy revealed benign polypoid skin
with dermal myxedematous-like change.
Conclusion: Although lipedema is not a rare condition, it is frequently
missed because clinicians lack familiarity with lipedema. Patient’s
history and physical examination are usually sufficient to differentiate
lipedema from lymphedema. However, patient with long
–standing lipedema may eventually develop mechanical insufficiency
of the lymphatic system, producing “lipolymphedema”. The discoloration
and epidermal change of the legs, as well as the skin infection
in this patient is probably due to the dysfunction of lymphatic system.
A32
“We need an interpreter!”
Y. Ang, S. Lee, M. Brennan. Internal Medicine, Baystate Medical
Center/ Tufts University School of Medicine, Springfield, MA.
Intro:
A growing number of immigrant elders in the US are at risk of
poorer health due to cultural and language barriers that limit access
to care.
Case:
A 65 year old Somali man (Mr. K) with dementia presented for
geriatric evaluation after years of cognitive decline. He was disoriented,
disinhibited, impulsive and had decreased speech and repetitive
vocalization. He responded “ I don’t know” to most queries. History
was difficult as the Somali interpreter did not arrive and family
members’ English was limited. Mr. K. was diagnosed with frontotemporal
dementia. Organizing medical care was complex. The language
barrier, poor health literacy and cultural beliefs (e.g. a reluctance to
allow “outsiders” into the home, views about the appropriate role of
women in the family and fears of “official paperwork”) presented
challenges. Medication adherence was frequently problematic as
even simple instructions were “lost in translation”. Appropriate documentation
for exemption from a citizenship interview exam required
significant time and a multidisciplinary effort.
Discussion:
37 million foreign-born immigrants lived in the US in 2006; 12-
15% were aged 65 or older. By 2050, elders will be 61% non-Hispanic
whites, 18% Hispanic, 12% black, 8% Asian, and 2.7%
“other”(1). Geriatric immigrants receive much less health care than
native-born seniors and are far more likely to be uninsured (33.2%
vs 12.7% in 2007)(2). Reasons include a dearth of culturally competent
services along with geographic and economic factors. However,
low English proficiency remains the major risk for poor access to
care. Communication is critical for effective and equitable health
care for ethnic elders.
Conclusion:
Care of older immigrants is challenging given current limitations
in culturally and linguistically sensitive services. Physicians must
consider potential obstacles to care for older immigrants and pay attention
to communication barriers and cultural values as well as clinical
symptoms. It is crucial for institutions to develop system wide
policies and practices that welcoming the diversity of our patient
populations.
References:
1. McBride M. (2010). Ethnogeriatrics and Cultural Competence
for Nursing Practice. Hartford Instutute for Geriatric Nursing
2010. Retrieved Nov 25, 2011, from http://consultgerirn.org.
2. Steven A. (2009, Aug). Facts on Immigration and Health Insurance.
Center for Immigration Studies. Retrieved Nov 25, 2011,
from http://www.cis.org/HealthCare-Immigration
A33
Heart failure in hospitalized elderly subjects in geriatric department:
poor and unusual clinical signs.
Y. Wolmark, 1 M. Gaubert-Dahan, 1 F. Tubach, 2,3 T. Zerah. 1 1. Hôpital
Bretonneau, Paris, France; 2. Hôpital Bichat, Paris, France; 3.
Université Paris Diderot, Paris, France.
Background: Heart failure is a frequent and serious disease in
the elderly. The purpose of the present study was to analyse the characteristics
of the patients with acute heart failure and to compare the
frequency of these characteristics between systolic heart failure (left
ventricular ejection fraction ≤ 50%) and diastolic heart failure. Methods:
The present study was an observational and prospective study
about the clinical features and the radiology, biology and echocardiography
results of 53 patients (mean age 87.8 years) hospitalized in
geriatric care units at Bretonneau hospital in Paris. The Fisher’s exact
test was used to compare 2 nominal variables and the Mann-Whitney
test to compare 2 ordinal variables. Results: The majority of the patients
had hypertension (83%), malnutrition (81%) and anaemia
(62%). Thirty eight percents experienced a first episode of heart failure.
Before the current episode of acute heart failure, 55% of patients
were treated with diuretic agents, 55 % with angiotensin-converting
enzyme inhibitors or angiotensin receptor blockers and 51% with
beta-blockers. The patients had 3 clinical signs or symptoms of heart
failure on average. The most frequent were: pulmonary rales (68%),
dyspnea (60%), crepitant rales (55%), weight gain (64%), peripheral
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edema (60%), and weakness (32%). Thirty six percents of the patients
reported a fall in the few days before the current episode of
heart failure. Fifteen percents of the patients had a delirium. The patients
with systolic heart failure had more cardiovascular diseases
(atrial fibrillation (28% versus 19%, p=0.028), angina (21% versus
4%, p=0.001), diabetes (9% versus 2%, p=0.074), and hypercholesterolemia
(15% versus 6%, p=0.041)) than the patients with diastolic
heart failure. Conclusions: Whether the heart failure is systolic or diastolic,
the clinical profile of old patients is poor and unusual, the
prevalence of malnutrition and anaemia is high and their treatment is
inadequate. Cardiovascular diseases are more frequent in patients
with systolic heart failure. Echocardiography enables the comprehensive
diagnosis of heart failure.
A34 Encore Presentation
Age Analysis of Long-Term Safety of Diclofenac Sodium 1% Gel
for Patients With Osteoarthritis of the Knee.
J. H. Peniston, 1 M. S. Gold, 2 M. S. Wieman, 3 L. K. Alwine. 4 1.
Feasterville Family Health Care Center, Feasterville, PA; 2. Novartis
Consumer Health, Inc., Parsippany, NJ; 3. Endo Pharmaceuticals
Inc., Chadds Ford, PA; 4. Downingtown Family Medicine,
Downingtown, PA.
Supported By: Novartis Consumer Health, Parsippany, NJ, and
Endo Pharmaceuticals, Inc., Chadds Ford, PA.
Background: Oral nonsteroidal anti-inflammatory drugs should
be used with caution in the elderly. This study evaluated the safety of
topical diclofenac sodium 1% gel (DSG) in an open-label extension
of 2 double-blind, randomized, 3-month trials of DSG in patients ≥35
years with a ≥6-month history of symptomatic Kellgren-Lawrence
grade 1–3 knee OA.
Methods: Patients applied 4 g DSG to 1 or both knees 4 times
daily for 9 (continuing patients) or 12 (new patients) months; use of
rescue acetaminophen (≤4 g/d) was allowed. AEs were monitored
throughout the study and the Western Ontario and McMaster Universities
Osteoarthritis Index (WOMAC) pain, stiffness, and physical
function subscales were assessed at baseline and 3, 6, 9, and 12
months.
Results: The safety population (947 patients; 575

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increased LOS. There were no gender differences, but American Indians
had shorter LOS than Whites or African Americans. History of
cigarette smoking, advanced age, and unclear diagnosis were also associated
with longer LOS.
Conclusion: The severity of the stroke, co-morbidities, and prestroke
status of a stroke survivor may contribute to the LOS of stroke
patients and affect their overall post-stroke outcome. Although biological
factors are most influential, social and psychological factors
also played a role.
A37
Correlation of health professional (KPS) and patient-rated (pKPS)
Karnofsky Performance Status and associations with measures of
geriatric assessment (GA) domains.
T. Jolly, 1 A. Deal, 1 G. Williams, 1 S. Alston, 1 B. Gordon, 1 J. Pan, 1
S. Moore, 2 W. Taylor, 3 H. Muss. 1 1. University of North Carolina,
Chapel Hill, NC; 2. Rex Hematology Oncology Associates, Raleigh,
NC; 3. New Bern Cancer Care, New Bern, NC.
Supported By: Supported in part by the University Cancer Research
Fund, Lineberger Comprehensive Cancer Center, Chapel Hill, NC
BACKGROUND: KPS is frequently used to assess function in
older patients; however, it is prone to observer bias and has limited
ability to detect abnormalities in other GA domains. This study explores
the relationship between KPS and pKPS and their association
with measures of GA domains.
METHODS: Data from the Carolina Senior registry which includes
the North Carolina Cancer Hospital and community affiliates
for patients ≥65 years were analyzed using Fisher’s Exact and
weighted kappa (κ) statistics. Patients completed a predominantly
self administered GA (Hurria et al, Cancer 2005) which included rating
scales for both KPS and pKPS.
RESULTS: The 386 evaluable enrollees had median age: 73
(range 65-97); and were 81% female; 89% white; 55% married; 83%
retired; 72% at least some college education; 97% a cancer diagnoses.
There was fair agreement [κ=0.26 (95% CI 0.18-0.33)] between
KPS and pKPS for patients with scores ≥ 40% (Fig. 1). There
were statistically significant associations between KPS and pKPS
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categories based on Mini-Mental State Examination (MMSE) scores:
>23 and those < 23.
Results: The following differences were found between dementia(D)
and non-dementia(ND) patients: Proportion with of twice
daily brushings or more: Annual dental visits: 36% (D) vs. 54% (ND);
flosses teeth: 11% (D) vs. 25% (ND); 51% (D) vs. 54% (ND); problems
with teeth:16%(D) vs. 26%(ND); complaining of dental pain:
20% (D) vs.21% (ND); wear dentures: 57% (D) vs. 58% (ND); problems
with dentures: 25% (D) vs. 30% (ND); Two of the comparisons
attained statistical significance(p< .05): annual dental visits(r=.18)
and flossing teeth (r=.18). There were no significant correlations between
the dichotomized MMSE score and the dental variables. In the
dementia group, having at least an annual visit to dentist was significantly
associated with stage of dementia; 71% and 22% had annual
visits among person with mild and moderate or severe stages, respectively
(χ2 = 6.62, df=1, p=.01). However, no other sociodemographic,
cognitive, or neuropsychiatric variables were associated with annual
dental visits.
Conclusion: Although both groups showed substandard levels of
care, persons with dementia had significantly lower levels of dental
care, and this worsened with the stage of the dementia. The study confirms
that need for education of caregivers and increased accessibility
to oral health care in older adults with dementia.
Key Words:
Dental care; Geriatrics; Dementia
A40
Counting Pop-Drops: Emergency Department Re-Visits by Persons
with Dementia.
C. Clevenger, 1,2 D. Khalili, 2 Z. Yang. 3 1. Birmingham/Atlanta
GRECC, Department of Veterans’ Affairs Medical Center, Grayson,
GA; 2. Nell Hodgson Woodruff School of Nursing, Emory University,
Atlanta, GA; 3. Rollins School of Public Health, Emory University,
Atlanta, GA.
BACKGROUND: Twenty-six to forty percent of older emergency
department (ED) patients are estimated to have dementia. We
conducted a pilot study in which persons with dementia (PwD) had
twice the number of ED visits over a one-year period compared to
those without dementia. The purpose of this study is to compare the
pattern of ED use, discharges, and hospital admissions between older
ED re-visitors with and without dementia.
METHODS: The study employed retrospective chart review of
persons over the age of 70 who accessed the ED of an urban academic
medical center ≥ 2 times in 2009 with chief complaints of moderate
severity. We reviewed clinical notes from the ED visit as well as
inpatient and outpatient records for documentation of dementia.
Dates and outcomes of ED visits (admission to hospital or discharge
from ED) were used to calculate interval between visits and variables
of events occurring within 7, 30, 60 and 90 days. We asked the following
research questions: What is the mean number of days between
ED visits for PwD? How likely are PwD to re-visit the ED within 30
days compared to those without dementia? Is there a delay in hospital
admission for PwD as shown by multiple ED discharges prior to
hospital admission?
RESULTS: The study sampled 540 ED visits made by 154 persons;
54 were PwD (35.1%). The mean number of days between ED
visits was 41.5 for those without dementia and 33.7 for PwD
(p=0.160). Persons with dementia made 207 of the 540 total ED visits
(38.3%); 154 of the 386 re-visits (39.9%); and 95 of the 219 30-day revisits
(43.4%). The likelihood ratio of an ED re-visit in = 65 years with at least 1 ED visit
between 1/1/00 and 9/30/07 (N = 4,964). Latent class analysis models
were estimated to identify groups (or classes) with similar numbers of
(1) primary care (PC) visits; (2) outpatient ED visits (i.e. treated and
released); and (3) hospital days within 12 months preceding the index
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ED visit. A multinomial logistic regression model was used to compare
health care utilization measures in each class to the overall sample
mean.
Results: 5 groups with distinct patterns of health service use in
the year preceding an index ED visit emerged. Two groups, dubbed
“Wellderly,” had fewer chronic conditions than the population mean.
The 1st group [“Wellderly with PC”, 39%] used less ED and hospital
care, but had higher PC visits compared to the overall mean (6.2 vs 4).
Members of this group were more likely to be female, live alone and
have higher income (P

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Methods: A longitudinal, retrospective database analysis included
outpatient data from the Veterans Health Administration
(VHA). The study sample included veterans age 65 years or older
with at least one outpatient primary care visit or one inpatient visit
between fiscal year 2003 to 2005. We identified veterans with an ICD-
9 diagnosis of insomnia, anxiety, PTSD, depression or chronic pain
and potentially inappropriate prescriptions of antihistamines, psychotropics,
musculoskeletal relaxants and opioids. We examined demographic
data, Selim index comorbidities, total number of medications
prescribed, and utilization of geriatric primary care. All analysis
was conducted using SPSS-14. We obtained IRB approval.
Results: Of the 41, 432 veterans identified, 21.8% (9,086) received
a HRME. Only 7.9% of veterans older than 85 years of age received
a HRME. More minorities received a HRME than whites
(10.7% vs. 74.8%).Veterans exempted from a medication co-payment
received more HRME than those not exempt (76% vs. 23.5%). Of
those veterans with a HRME, 44.6% received 12 or more medications.
Utilizing geriatric care in 2005 resulted in fewer HRME prescriptions
(3.5% vs. 4.8) whereas more than 33% of veterans with 5 or more primary
care visits received a HRME. Veterans with 0 to 1 physical conditions,
but >2 mental health conditions received fewer HRME.
Conclusion: HRME are common in the older adult veteran population.
Geriatric primary care and older veterans age are protective
characteristics, which are similar to other studies. Future studies
should focus on interventions to reduce the number of HRME older
adults receive.
References: 1. Zhan C, Sangl J, Bierman AS et al. Potentially inappropriate
medication use in the community-dwelling elderly: findings
from the 1996 Medical Expenditure Panel Survey. JAMA
2001;286:2823-2829.
A46
Differences in Vitamin D Deficiency by Ethnic/Racial Background
in a Geriatric Clinic, Houston, TX.
N. Rianon, 3 K. Murphy, 1 C. Dyer, 2 B. Selwyn. 4 1. Family and
Community Medicine, University of Texas Medical School at
Houston, Houston, TX; 2. Integrative Nursing Care, University of
Texas Houston Health Science Center- School of Nursing, Houston,
TX; 3. Internal Medicine, University of Texas Medical School at
Houston, Houston, TX; 4. Epidemiology, University of Texas Houston
Health Science Center- School of Public Health, Houston, TX.
Supported By: The project was supported by funding from the
Herzstein Foundation
Background: Vitamin D deficiency documented in a national
study (NHANES 2001-2004) in more than 70% of older patients at
risk of age related bone loss or osteoporosis occurred in a higher percentage
of African Americans (AA) (97%) and Hispanics (90%)
than in Caucasians (72%). Under- recognition of vitamin D deficiency
led to under-treatment in patients needing prevention of, and
treatment for osteoporosis. This cross sectional pilot study describes
variations in Vitamin D testing and deficiency by ethnic/racial background
among at risk patients in Houston, Texas.
Methods:
Electronic chart review recorded the ethnic/racial background
for 72 patients receiving treatment for menopausal symptoms, osteoporosis
and related fractures in a geriatric clinic in Houston, Texas
from January 2009 to December 2010. Orders for serum 25 hydroxy
vitamin D indicated vitamin D testing, and serum vitamin D levels
recorded as less than 30 ng/ml indicated deficiency in this study.
Results:
The patient group was mostly women (93%) and had a mean
age of 79±9 years (range 57 – 97 years). Most of the patients were
Caucasians (64%), while 25% were AA and 11% were of “Other”
ethnicities (7 Hispanics, 1 Asian). About half (49%) were not tested
for Vitamin D levels. Of those tested (N=37), 68% were Caucasians,
24% were AA and 8% were of “Other” ethnicities. About 46% of
those tested had Vitamin D deficiency. Vitamin D deficient patients
(N=17) were 65% Caucasians, 23% AA and 12% were of “Other”
ethnicities.
Conclusions:
We report a lower prevalence of vitamin D deficiency among
African American and Hispanic patients in Houston, Texas compared
to the NHANES data. Our results may be reflective of the dietary
and environmental differences in the population served in this region.
Further studies that outline vitamin D deficiency in diverse ethnic
and racial groups will help to improve osteoporosis management
in older patients.
A47
Impact of race on cognitive assessment among hospitalized elders.
B. Benizry, 1 N. Campbell, 2,3 S. L. Hui, 1,3 T. Perkins, 3 B. A. Khan, 1,3
M. O. Farber, 1 W. Ely, 4,5 M. A. Boustani. 1,3 1. School of Medicine,
Indiana University, Indianapolis, IN; 2. Pharmacy Practice, Purdue
University, Indianapolis, IN; 3. Regenstrief Institute, Inc., Indianapolis,
IN; 4. School of Medicine, Vanderbilt University, Nashville, TN; 5.
Geriatric Research Education Clinical Center (GRECC), VA
Tennessee Valley, Nashville, TN.
Supported By: This work was supported by grants K23AG26770-01
and R01AG034205-01A1 from the National Institute on Aging
(NIA); the Hartford Foundation; the Atlantic Philanthropy; and the
American Federation for Aging Research (AFAR). Additionally,
Braca Benizry was supported by a Medical Student Training in
Aging Research (MSTAR) award administered by the AFAR and
the NIA. The sponsor had no role in the study design, evaluation, or
manuscript development.
Background: Racial disparities in health care quality and outcomes
have been studied and well characterized for various medical
conditions. African Americans have been suggested to have a higher
likelihood of developing chronic forms of cognitive impairment such
as dementia, however little information exists regarding racial disparities
in acute cognitive impairment or delirium. Our objective was to
evaluate the association between Race and diagnosis and recognition
of cognitive impairment and delirium.
Methods: This study was an observational cohort study taking
place at Wishard Hospital, an urban public hospital in Indianapolis.
Participants included 991 patients aged 65 years and older admitted
to general inpatient medical services between July 2006 and March
2008. Cognitive impairment was identified using the Short Portable
Mental Status Questionnaire and delirium was identified using the
Confusion Assessment Method. Recognition of cognitive impairment
and delirium was determined by examining ICD-9 codes in the Regenstrief
Medical Record System (RMRS) within one year prior to
hospitalization through discharge or hospital admission through discharge,
respectively.
Results: 424 patients (43%) screened positive for cognitive
impairment and 173 patients (17%) screened positive for delirium.
Sixty-seven percent of those with recognized cognitive impairment
and 68% of those with recognized delirium were African
American. After adjusting for potential confounders, the odds
ratio for the relationship between race and recognition of cognitive
impairment was 1.61 (95% confidence interval = 0.98, 2.64)
and recognition of delirium was 1.51 (95% confidence interval =
0.64-3.57).
Conclusion: Among hospitalized older adults, neither the diagnosis
nor recognition of cognitive impairment and delirium differed
between races; however, a trend towards better recognition
of cognitive impairment and delirium among African Americans
may exist.
S32
AGS 2012 ANNUAL MEETING

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A48
Ninety-Day Mortality Among Older Adults Following Hospital
Admission for Pneumonia.
O. E. Abreu Lanfranco, 1,2 H. Rahbar, 1,2 C. Biedron, 1,2 A. Singh, 2
M. Tims, 2 B. Ramasamy, 2 T. Chopra, 1,2 K. S. Kaye. 2,1 1. Infectious
Disease, Wayne State University, Detroit, MI; 2. Infectious Disease,
Detriot Medical Center, Detroit, MI.
Background: Pneumonia is one of the leading causes for acute
hospitalization in the US. In older adults, pneumonia is associated
with increased morbidity, functional status deterioration, resources
and mortality. We aimed to identify factors associated with an increased
risk for 90-day mortality after hospitalization for pneumonia
in older adults and to define the impact of hospital readmission on
mortality.
Methods: Study conducted at the Detroit Medical Center. Retrospective
chart review in patients over 65 years of age who had a primary
diagnosis of pneumonia from January to March 2011. Data abstracted
from medical records. Cases were defined as patients who
died within 90 days following hospital discharge and controls were
patients who did not die during the 90-day period following hospital
discharge. Controls were matched by hospital and calendar time of
admission.
Results: A total of 160 patients were studied with a mean age of
77.7 years +/-8.2, 54% were men. Thirty-four patients (21%) died
within 90 days after the initial discharge (21%). Cases were more
likely to be readmitted within 30 days of the index hospitalization
(85.3% and 40.9%; OR 8.33, 95% CI 3.3-25), need assistance with 3 or
more ADLs (64.7% and 38.9%, OR 2.88(95% CI 1.3-6.3), have a
Braden score < 16 (55.9% and 29.4%; OR 3.1, 95% CI 1.4-6.6), have a
pleural effusion on radiography (50% and 25.3%; OR 2.9, 95% CI
1.3-6.4), be treated for healthcare-associated pneumonia(58.8% and
30.2%; OR 3.3, 95% CI 1.5-7.2), more likely to have a higher Charlson’s
Score (OR 3.05, 95% CI 1.28-7.25) and Pneumonia Severity
Index(OR 0.14, 95% CI 0.24-0.78). In multivariate analysis, independent
predictors of 90-day mortality included readmission within
30 days (OR 6.8, 95% CI 2.4-19.6), Pneumonia Severity Index > 4
(OR 3.29, 95% CI 1.32-8.19), and having been treated for HCAP (OR
2.32, 95% CI 1.01-5.35).
Conclusions: Among older adults discharged from the hospital
with pneumonia, mortality rates exceeded 20%. Readmission within 30
days was associated with a greater than 7-fold increase in 90-day mortality,
patients treated for HCAP during their initial pneumonia admission
had a greater than 2.5-fold increased risk for 90-day mortality.
A49
DRIVING CESSATION: NOT A ONE WAY DECISION.
R. A. Marottoli, 1,2 K. Araujo, 1 P. Peduzzi. 1 1. Yale University School
of Medicine, New Haven, CT; 2. VA CT, West Haven, CT.
Background: While it is often assumed that driving cessation is a
final decision, it is likely that many individuals return to driving after
temporarily stopping. The purpose of this study was to determine the
frequency of occurrence and factors associated with the resumption
of driving after initial cessation.
Methods: Participants were community-living active drivers age
70 years and older recruited from general medical clinics and community
sources. Participants were assessed in-person at baseline and
followed prospectively for two years with phone contacts every six
months that included questions on driving status.
Results: 615 drivers had a mean age of 78.8 (+/-4.9) years, 12%
were women, mean MMSE score was 27.4 (± 2.1) points, average
mileage was 129 (± 109) miles per week, and 72% drove daily. 68 drivers
(11%) stopped driving at some point during two years of followup.
Of these, 25 (37%) had resumed driving by the end of two years of
follow up. Compared to drivers who stopped permanently, those who
returned to driving had higher weekly mileage (153 v. 90, p=.01),
fewer chronic conditions (64 v. 84% w/≥3, p=.06), higher self-rated
health (80 v. 58% excellent/good, p=.07), higher MMSE scores (64%
v. 40% scored ≥ 28, p=.05), drove more often (92 v. 53% daily, p=.001),
and faster gait speed (75 v. 47% ≤ 7 sec, p=.02).
Conclusion: The decision to stop driving is not always final. In
this cohort a substantial proportion of older people returned to driving
after temporarily stopping. Identifying these individuals and the
factors contributing to their decisions to both stop and return to driving
may help clinicians counsel other drivers and families facing this
transition.
A50
Differential impact of hypertension and diabetes on cognitive tests
over 4 years.
R. M. Allman, 1,2 P. Sawyer, 2 M. Crowe, 3 R. E. Kennedy, 4 R. V. Sims. 1
1. Birmingham/Atlanta VA GRECC, Birmingham, AL; 2.
Gerontology, Geriatrics, and Palliative Care, University of Alabama at
Birmingham, Birmingham, AL; 3. Psychology, University of Alabama
at Birmingham, Birmingham, AL; 4. Biostatistics,
Birmingham/Atlanta VA GRECC, Birmingham, AL.
Supported By: National Institute on Aging
Purpose: To understand predictors of changes in cognitive
screening tests over four years in community-dwelling older adults.
Methods: This is a prospective, observational study of community-dwelling
Medicare beneficiaries aged 65 years and older that
completed a comprehensive baseline in-home assessment (1999-
2001) and a repeat in-home assessment in 2004. Data included sociodemographics,
medical conditions diagnosed by a physician and
health behaviors. Cognitive tests included drawing a clock (CLOXI),
copying a clock (CLOX2), and a 30-point multi-item cognitive assessment
(MICA). Multivariable linear regression models controlling for
age, race, sex, education, and income were used to test the independence
and significance of associations between baseline diabetes, hypertension,
arrhythmia, coronary artery disease, geriatric depression
score (GDS), smoking pack years, BMI>30, unintentional weight loss,
vision, leisure time physical activity, and incident stroke or dementia
diagnoses on changes in the three cognitive tests over 4 years.
Results: Mean age of the sample (N=580) at baseline was 73.6
(53% female; 46% African American). Mean (SD) baseline cognitive
scores were 10.9 (2.8) for CLOX1, 12.9 (1.9) for CLOX2, and 26.5
(3.5) for MICA. Mean declines (SD) in the cognitive test scores were
0.6 (3.4), 0.5 (2.3), and 0.9 (3.0), respectively (p

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Design. CaMos is an ongoing 10 year prospective cohort study.
Population. Age and sex matched Canadian population who are
non-institutionalized individuals and reside in nine CaMos study
centers.
Methods. Data from 2819 men and 6444 women were classified
as current GC users and non-users. New fractures based on self-reports
from an annually completed questionnaire included vertebral,
hip, other (excluding hip, vertebral, toes, fingers, skull fractures) and
any fracture (excluding toes, fingers, skull fractures). Multivariable
survival analyses were conducted to examine the association between
the time to new fracture and GC use. Hazard ratios and 95% confidence
intervals (CI) were calculated.
Results. The mean age, femoral neck T-score (standard deviation)
and GC use at baseline of the cohort was 62.0 (13.3), -1.07
(1.03) and 128 (1. 4%), respectively. During the 10 year period, 130
(1.4%), 157 (1.7%), 869 (9.7%) and 1102 (11.9%) individuals developed
a new osteoporotic vertebral, hip, other and any fracture. Ever
taking GC for a minimum of one month in both men and women had
a hazard ratio of 1.4 (95% CI: 1.0 -1.8), 1.9 (95% CI: 1.0-3.6), 0.97
(95% CI: 0.4-2.2),1.2 (95% CI: 0.9-1.6) for developing a new nonspine,
hip, spine and any fracture as compared to those who never
took GC, respectively.
Conclusions. CaMos is the first prospective long-term study with
data over 10 years showing that GC use is associated with higher incident
fragility fractures.
Key Words: glucocorticoids, fractures, bone mineral density
A52
Unsteadiness in Post-acute Care (PAC): Prevalence and Associated
Characteristics.
S. Bangalore, S. E. Hardy. Medicine/Geriatrics, University of
Pittsburgh, Pittsburgh, PA.
Supported By: NIA, Hartford Foundation
Background-Unsteadiness is a subjective sense of loss of equilibrium
or balance in regard to the environment. Patients in PAC frequently
complain of unsteadiness, requiring a detailed evaluation.
The purpose of this study is to describe the prevalence of unsteadiness
and the characteristics associated with it.
Methods-We performed cross-sectional analysis of baseline data
on previously community-dwelling older adults admitted to skilled
nursing facilities for PAC (age 81±8, 85% white, 71% female) obtained
by in-person assessment and review of hospital records. Of the
125 participants, 35 (28%) had no unsteadiness, 18 (14.4%) had mild,
50 (40%) had moderate, and 22 (17.6%) had severe unsteadiness. The
characteristics of participants with and without unsteadiness were
compared using Chi-Square, Fisher’s exact, and t-tests.
Results-Characteristics significantly associated with any unsteadiness
are presented in the table (values represent % or
mean±SD). Age, sex, race, pain, systolic BP

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351,874 visits to the ED, out of which 63,278 (18%) were of adults
aged 60 and over (A60), while 17,593 (5%) were aged 80 years or
older (A80). There was an increase in 83.2% of elderly visits throughout
the years. It was additionally verified that of the total number of
A60 and A80, respectively 46.1% and 51% were female; 24.5% and
31.9% were admitted to hospital wards (versus 5.4% among patients
aged from 18 to 59 years); and 1.4% and 2.8% died still at the ED or
subsequently during hospital stay (versus 0.4%). The median length
of stay for A60 was 3.1 days at the ED, and 5 days at the hospital
wards (versus 2.5 and 3 days). Injuries and their consequences
(17.8%), symptoms and signs involving the digestive system and abdomen
such as abdominal pain, nausea and vomiting (8.4%), general
symptoms and signs such as fever, syncope and collapse, malaise and
fatigue (5.5%), specific medical procedures and health care actions
(4.7%), acute upper respiratory infections (4.4%) and dorsopathies
(3.5%) were the most common diagnoses, as defined using the ICD-
10 blocks of codes. Conclusion: Older adults are increasingly seeking
care in the ED. They are more frequently hospitalized and have
higher mortality than younger patients who seek care in the same setting.
Injuries and digestive system complaints are the most frequent
motivations for their visits. The high frequency of non-specific symptoms
like malaise, fatigue and fever indicate the need of an expert
team to make the correct diagnoses in this setting.
A55
Nonagenarians: an increasing reality in the emergency room.
T. J. Avelino-Silva, L. A. Gil, A. L. Bierrenbach, C. Toscano, W. Jacob-
Filho, F. Ganem. Hospital Sirio-Libanes, Sao Paulo, SP, Brazil.
Supported By: None of the authors reported a potential, real, or
perceived conflict of interest or financial disclosure. No sponsors
participated in or funded this research.
Background: In Brazil, as in more developed countries, the
strongest growth of the older population shall be in the age bracket
above 80. How does one guarantee an efficient health system and
quality of life for this new mass of older citizens? It was our objective
to better understand the characteristics of the patients over 90 years
of age who seek care in the emergency room. Methods: We retrospectively
reviewed a database containing information of all the patients
who visited the emergency department (ED) of a 350-bed private tertiary
care general hospital in São Paulo, Brazil, from January 2003 to
December 2010. Data pertaining to the patients who were 90 years of
age or older were searched for the following: age; gender; principal
diagnosis (ICD-10 codes); hospital admission; length of stay; and outcome.
Results: Over the 8-year study period, there were 351,874 visits
to the ED, out of which 63,278 (18%) were of adults aged 60 and over
(A60), while 4,099 (1.1%) were aged 90 or older (A90). There was an
expressive growth of the number of older adult visits to the ED
throughout the years (83.2%), but it was the age group over 90 that
showed the most remarkable expansion (95.6%). Of the total number
of A90, 58.1% were female, while only 46.1% were so if one considered
A60. A90 were admitted to hospital wards in 35.1% of the cases
(versus 24.5% for A60), and 4.1% died at the ED or subsequently
during their hospital stay (versus 1.4%). The median length of stay
was 3.1 days at the ED, and 5 days at the hospital wards, which was
similar to younger geriatric patients. Injuries and consequences accounted
for 17.9% of A90 visits. Other important reason for their visits
were specific medical procedures and health care actions (7%).
These were mostly related to surgical and orthopedic follow-up care,
attention to artificial openings, like colonostomy and others and issue
of repeat prescriptions. General symptoms and signs such as fever,
syncope and collapse, malaise and fatigue (6.9%), symptoms and
signs involving the digestive system and abdomen (6.9%), influenza
and pneumonia (6%), and heart diseases (5.4%) followed in frequency.
Conclusion: ED visits by patients over 90 had the greatest increase
among older adults. The primary motivations for their visits
were injuries, specific medical procedures and health care actions.
Further discussion of adequate settings to provide care for these patients
is needed.
A56
Cause of Death among Older Adults with Cognitive Impairment
with and without Dementia: The Aging, Demographics, and
Memory Study.
T. Okura, 1 K. M. Langa. 2 1. Bajikoen Clinic, Tokyo, Japan; 2.
University of Michigan, Ann Arbor, MI.
(Background) Hypothesizing that older individuals with dementia
die from different causes compared to those with the milder levels
of cognitive impairment, we compared the cause of death for those
with dementia to those with normal cognition or cognitive impairment
without dementia (CIND) using longitudinal data from a nationally
representative sample of older adults in the United States.
(Methods) We used data from the Aging, Demographics, and
Memory Study (ADAMS), a sub-study of the Health and Retirement
Study (HRS) focused on cognitive impairment and dementia. We
identified individuals aged 71 or older diagnosed as normal, CIND, or
demented by the ADAMS consensus diagnosis panel. Date and cause
of death during the 9-year study period were obtained from the HRS.
(Results) 91.3% of those with dementia died during the followup
period compared to 67.5% and 28.1% of those with CIND and
normal cognition, respectively. Heart disease was the most common
cause of death across all cognitive categories, accounting for about
25% of deaths in each group. Those with dementia were more likely
to die from stroke (13.5% vs. 4.3% for CIND, 4.6% for normal cognition,
p

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incidents (64%) regardless of age or the presence of alcohol.The odds
of an injury being due to a fall or motor vehicle accident in BAL+ patients
compared to BAL- patients can be seen the table below.
When controlling for the selected demographic factors and the
presence of alcohol, the odds of an injury being the result of a fall increased
significantly as patient age increased. Conversely, the odds of
an injury being from a motor vehicle accident decreased significantly
as the patient age increased.
Conclusions: Age as well as alcohol does influence the odds of
an injury being due to a fall or a motor vehicle accident in older
adults. Our findings suggest that alcohol related injury prevention
programs should be tailored to the age group targeted.
Unadjusted odds of injury being due to falls or motor vehicle accident
by age group
A58
Long term treatment with metformin in patients with type 2 diabetes
and risk of vitamin B-12 deficiency.
V. Nurpeisov. Emory, Dunwoody, GA.
Background: Identification of risk factors for metformin-related
vitamin B12 deficiency has major potential implications regarding the
management of DM.
Methods: A case-control study was conducted from a database
in which the source population consisted of subjects who had levels of
both serum vitamin B12 and hemoglobin A1C checked in a laboratory.
63 cases of diabetes mellitus (HbA1C>7) and vitamin B12 deficiency
secondary to metformin treatment were identified. 73 controls
which were identified as HbA1C>7 with normal vitamin B12 greater
than 200pmol/L served as the comparison group.
Results: After adjusting for confounders, we found a clinically
important and statistically significant association of vitamin B12 deficiency
with duration of metformin use. After adjusting for confounders,
we found a clinically important and statistically significant
association of vitamin B12 deficiency with duration of metformin use.
Among those using metformin for 1 year or more compared with
those receiving metformin for less than 1 year, the adjusted odds ratio
was 8.91 with a CI(4.1; 19.4),(P

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A BSTRACTS
cancer (84%), liver cirrhosis (2%), end stage renal disease (2%),
and AIDS (2%). Overall, 38% of the patients seen by palliative
care died at home, 24% in the hospital, 5% in a nursing home, and
4% at an inpatient hospice. Sixty percent of patients who received a
palliative care consult went on to choose hospice for EOL care. In
multivariable analyses, patients with cancer (AOR: 2.23, 95% CI:
1.88, 2.65), those who had a social work assessment (1.39, 1.20,
1.62), and those with an advance directive (1.72, 1.41, 2.08) or DNR
order (2.11, 1.59, 2.80) were more likely to use hospice. Race and
ethnicity were not statistically significant predictors of hospice use
in this cohort.
Conclusion: In this cohort, once patients received a palliative
care consult, there were no racial and ethnic disparities in hospice
use. This suggests that despite being historically underutilized, palliative
care and hospice services are viable EOL care options for
URMs and persons of low SES. Though cancer sufferers often receive
palliative care consultation, continued efforts should be
made to encourage consultation for patients with other life-limiting
illnesses.
A61
Physical Restraints of Home-dwelling Elders: Perception by Home
Care Providers.
S. Kurata. Gerontological Nursing, Hamamatsu University School of
Medicine, Hamamatsu, Japan.
Supported By: Grant-in-Aid for Research Activity Start-up from
the Ministry of Education, Culture, Sports, Science and Technology
of Japan
Background: Family caregivers may unconsciously use physical
restraints on home-dwelling elders, which could include or lead to
abuse. Home care providers need to grasp the conditions and specificities
of physical restraints in home care and to support family caregivers.
I investigated how the home care providers perceive physical
restraints.
Methods: A self-administered questionnaire survey was conducted
for home care providers (home helpers, visiting nurses, visiting
physicians, and care managers) of home-dwelling elders: the Japanese
version of the perceptions of Physical Restraint Use Questionnaire;
whether or how they recognize 12 physical restraints prohibited in institutions
and 10 harmful effects of physical restraints; and whether
they have taken courses of physical restraints.
Results: Total 568 home care providers responded: 201 home
helpers, 78 visiting nurses, 131 visiting physicians, and 158 care managers.
The number of physical restraints recognized as prohibited was
significantly different among visiting physicians (5.2±2.9), visiting
nurses (5.9±3.2), home helpers (6.3±3.3), and care managers (8.4±2.6;
p

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TNF-R1 levels were compared across tertiles of IL-6 levels using a
Hodges-Lehmann non-parametric K-sample median test.
Results: The analytic sample included 1429 participants with
available data for both inflammatory markers and all adjusted covariates,
among whom 408 were HIV-infected and 1021 were HIV-uninfected.
In an adjusted model, a one log increase in ln(IL-6) was associated
with a 0.123 (95% confidence interval [CI] =0.102-0.145, p <
.001) log increase in ln(TNF-R1). This association was further
demonstrated by a 0.115 log increase in ln(TNF-R1) for every one
standard deviation change in ln(IL-6) (95% CI =0.095-0.135, p <
.001). Moreover, higher median TNF-R1 levels were observed in the
top tertile of IL-6 levels (1753 versus 1404 pg/ml, p < .001), regardless
of HIV status and changes in CRP.
Conclusions: IL-6 and TNF-R1 levels were positively associated
in the ALIVE study. These findings provide initial insight into the relationship
between IL-6 and TNF-R1 in this unique population and
suggest further investigations into potential mechanisms leading to
generalized inflammation and immune activation in HIV infection
and aging.
A64
Care of the Vulnerable Elder Practice Improvement Module: Chart
Review Alone as a Valuable Educational Experience.
E. Oleson, S. McGee, M. Zanetti, S. Barrett, M. Pugnaire,
J. Gurwitz, C. DuBeau. University of Massachusetts Medical School,
Worcester, MA.
Supported By: Supported by the Donald W. Reynolds Foundation
Background: The Care of the Vulnerable Elder Practice Improvement
Module (COVE-PIM) was developed by the American
Board of Internal Medicine for maintenance of board certification
and has been adapted for residency programs. The COVE-PIM includes
chart review of geriatric care to identify any gap in care, evaluation
of the care system, and a quality improvement (QI) project to
address the gap. We included COVE-PIM into a new required Ambulatory
Care Block rotation for Medicine residents at UMass Memorial
Medical Center as part of the geriatric medicine curriculum. Care
system review and QI projects were not feasible in our setting, therefore,
we adapted COVE-PIM as a formative exercise with chart review
and a reflective evaluation on changes the residents would make
make in the care of their older patients as a result of the exercise.
Methods: Residents were asked to complete chart reviews on
five patients > 60 years in their continuity clinic using the standard
COVE-PIM review of documented chronic medical conditions,
health habits, screening measures, physical exam, and advanced directive
discussions. The reflective evaluation consisted of the resident’s
anticipated changes in care of the elderly in screening for geriatric
syndromes, such as cognitive impairment and falls, and documenting
surrogate decision makers and advanced directives by completing the
COVE-PIM chart review.
Results: A total of 31 PG1 and PG2 Medicine residents completed
112 chart reviews across 9 different clinical sites. Ninety percent
of residents reported that the formative experience was useful
and 100% of the residents felt the exercise increased the likelihood
they would screen for common geriatric conditions. In the chart review,
34% of residents reported documentation of wishes for life-sustaining
care and 39% had recorded surrogate decision makers. In the
reflective evaluation, 90% of residents felt that the exercise would
improve their likelihood of documenting surrogate decision makers
and discussions regarding end-of-life care.
Conclusions: COVE-PIM chart review alone with added reflective
evaluation helped residents identify gaps of care among their
older patients and was considered a valuable educational experience
that residents anticipated would impact future care. This modification
may be more suitable for shorter ambulatory rotations.
A65
Integration of Geriatric Medicine into a Multi-Year Ambulatory
Care Block Curriculum.
E. Oleson, S. McGee, E. Murphy, G. Manchester, C. DuBeau.
University of Massachusetts Medical School, Worcester, MA.
Supported By: Supported by the Donald W. Reynolds Foundation
Background: We describe the successful transition of a PGY1
geriatric medicine block rotation for Medicine residents into an integrated,
multi-year PGY1-3 Ambulatory Care Block (ACB) curriculum.
The ACB was developed as a yearly, one-month required rotation
incorporating elements of geriatric medicine, gender medicine, a
primary care core curriculum and intensive continuity clinic experience,
with a 3-year cyclical curriculum.
Methods: A review of literature, online geriatric modules, and
previous geriatric medicine curriculum was done to expand the ACB
geriatric medicine educational content. Required GeriaSims modules,
didactics, and an Evidence-Based Medicine (EBM) exercise
were adapted from the previous PGY1 experience. We designed a
progressive curriculum with PGY-specific objectives in the context of
a specific theme (Curriculum Year 1 - geriatric assessment; Year 2 -
transitions in care). Geriatric clinical experiences were PGY-specific
(e.g., PGY1 - skilled nursing facility, PGY2 - geriatric clinic, PGY3 -
home visit and Elder Services). A PGY4 chief resident designed a
geriatric morning report as his CRIT project. Residents also completed
a formative COVE-PIM chart review of their continuity clinic
patients. These were added to primary care didactics, quality improvement
project, and continuity and subspecialty clinics. An online
Wiki was created as a resource for schedules, lectures, and independent
assignments.
Results: The ACB pilot year included 28 PGY1 and 29 PGY2
residents. Feedback from residents and faculty was quite positive and
90.5% of the residents agreed or strongly agreed that the integrated
ACB was a better learning experience than the previous separate
components. Feedback led to changes in clinical site scheduling, required
online modules, and structure of the EBM session in the second
year of this rotation.
Conclusions: A geriatric medicine curriculum was successfully
integrated into an ambulatory block rotation for Medicine residents.
Now in its second year the block has been expanded to include PGY3
residents and a new set of didactic sessions and home care clinical experiences
for what will eventually be a three year rotating curriculum.
Overall, we found a valuable geriatric medicine experience may be
incorporated into the ambulatory curriculum for Medicine residents.
A66
Development and Validation of a Novel Geriatric Skills Assessment
Tool (GSAT) to Identify Training Needs of Internal Medicine
Residents and Faculty.
N. Jamshed, 1 P. Zeballos, 1 S. Sinha. 2 1. Internal Medicine,
WHC/Georgetown University School of Medicine, Washington, DC; 2.
University of Toronto, toronto, ON, Canada.
Purpose: This study reports the pilot data and preliminary validation
of a novel, learner-focused, Geriactic Skills Assessment Tool
(GSAT), in assessing training needs in geriatrics at a large academic
community hospital. Methods: A voluntary survey was conducted
amongst the IM faculty and residents using the GSAT. GSAT was developed
based on 15 basic competencies identified by the American
Board of Internal Medicine (ABIM) for IM trainees. Faculty and residents
were each asked to rate their confidence in performing, confidence
in teaching and interest in further training, in each skill set. We
assessed the cronback alpha coefficient for reliability of the GSAT.
Fisher’s exact test was used to evaluate the participant confidence in
performing and teaching particular skills, as well as their interest in
pursuing further training around them. Results: 27 faculty and 27 residents
completed the survey. The cronback alpha coefficient for the
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AGS 2012 ANNUAL MEETING

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reliability of the GSAT was 0.96. 70% participants identified high
need for training in medication management and in differentiating
delirium, dementia and depression (p〈0.05). Residents were significantly
more likely to report interest in training in differentiating
delirium, dementia and depression (p〈0.05) when compared to faculty.62%
of all participants reported low confidence in performing
fall risk assessment with no statistically significant difference between
the groups (p〈0.05). Lowest confidence in teaching was in modifying
management, assessing fall risk, and use of antipsychotics (p〈
0.05). There was no statistically significant difference between the
groups. Residents with high interest of training in medication management,
fall assessment, differentiating delirium, dementia and depression,
and end of life care discussions also had high confidence in
teaching and performing these skills (p〈0.05). It appears that residents’
further interest in training was independent of their confidence.
IM Faculty had no statistically significant interest in further
training in any geriatric skill set.Conclusion: GSAT is reliable at identifying
training needs in geriatric competencies. In this cohort the
need was greater amongst the residents than the faculty. This pilot
data supports the reliability and validity of this tool for curriculum
development in geriatrics.
A67
An Alternative to the Geriatric Physical Diagnosis Lab for Second
Year Medical Students.
N. A. Kayani, S. Hazelett. Summa Health System, Akron, OH.
Background: Previous physical diagnosis labs (PDL) in our institution
involved mock physical exams of community-dwelling elderly
volunteers and were not found to be valuable teaching tools for
second year medical students. Building on an idea from an AGS education
swap in 2009, we developed a new format to teach the important
aspects of basic geriatric care within a limited 2 hour timeframe.
Purpose: To describe a novel interdisciplinary curriculum for
second year medical students that allow students to practice, visualize
and experience for themselves some of the material they have
learned in the classroom setting prior to exposure to real patients.
Methods: During the PDL, the students rotate through a series
of 5 stations each of which is precepted by one of the following Geriatric
Medicine specialists: a physician, a pharmacist, a Fellow in training,
a Clinical Nurse Specialist, Social Worker and an Occupational
Therapist. Six students attend 20 minute sessions at each of the following
stations:
1) Cognitive assessment tools
2) Pharmacology of aging
3) Role of PT and OT
4) Problems with transitions of care using an investigator generated
“price is right” (sources of payment) interactive game
5) Sensory changes with aging
A survey was administered at the end of the PDL where students
were asked to rate from 1-5 the value of the information
gained.
Results: The PDLs have been offered for the last 3 years, with
120 students participating per year. When asked to rank how well
each session helped them become more prepared for assessments or
gain insights into geriatric issues on a scale of 1-5 with 5 being the
best, the average for the cognitive assessments for years 1, 2 and 3
were 4.4, 4.4 and 4.3, respectively. For pharmacology of aging/sources
of payment averages were 4.1, 4.5 and 4.4. For the role of PT and OT
averages were 4.4, 4.5 and 4.4. For transitions of care averages were
4.5 and 4.3, measured in years 2 and 3 only. For sensory changes the
average score was 4.4, measured in year 3 only. Overall value of the
PDL as a learning experience averaged 4.5 each year.
Conclusion: We have combined some standard PDL sessions
with some sessions unique to our program (e.g., the “price is right”
game for the transitions session) which has resulted in a highly valuable
learning experience as reported by students.
A68
Image Atlas of Aging: Highlighting Normal Age-Related Gross and
Histologic Changes.
P. J. Bonavitacola, G. P. Blanchard, S. McGee, K. Johansen,
V. Vanguri, K. Cornejo, A. Khan, C. Burnham, J. Gurwitz,
M. Pugnaire. Division of Geriatric Medicine, University of
Massachusetts Medical School, Worcester, MA.
OBJECTIVE: The Image Atlas of Aging is an original UMMS
educational product developed to highlight normal age-related
anatomic and histologic changes within the renal system. Our goal
was to integrate the Image Atlas into the existing MS1 “Disease,
Structure, and Function” (DSF) curriculum, emphasizing: 1) Normal
anatomic, physiologic, and histologic differences between the young
and aged kidney; 2) The principle of homeostenosis, illustrating how
the renal system becomes more susceptible to acute injury with the
loss of age-related functional reserve (but that disease is not inevitable
with normal aging).
BACKGROUND: There is a dearth of existing educational resources
that pictorially contrast normal age-related anatomic and histologic
organ system changes. Most available resources demonstrate
normal versus pathologic.
METHODS: Pivotal to Image Atlas completion was developing
partnerships with the UMMS Pathology Department and UMMS Division
of Anatomy and Cell Biology. UMMS’ Advancing Geriatrics
Education (AGE)/Reynolds summer student forged new working relationships
with two pathology chief residents and the co-DSF course
director.
Drawing from existing histological and anatomic images generated
by the UMMS Department of Pathology (histologic slides,
culled from recent autopsies and a legacy slide collection) and the
UMMS Division of Anatomy and Cell Biology (dissection images),
and online textbooks, a MS2 student compiled, annotated, and produced
an online module to be used by anatomy students/faculty and
geriatricians.
After discussions with UMMS’ AGE team, the DSF course directors
agreed to integrate the Image Atlas into the DSF curriculum.
The Atlas served as the student prep material both for two UMMS
geriatrician visits to the anatomy lab during abdominal cavity dissections
and an introductory lecture given by an academic geriatrician.
EVALUATION: All MS1s (n=125) will complete an end-ofcourse
evaluation for DSF that will encompass the Image Atlas
module.
CONCLUSIONS: The Image Atlas was successfully incorporated
into the existing DSF curriculum, introducing the concepts of
normal aging and homeostenosis to first year medical students. Our
goal is to have the Image Atlas serve as a prototype to illustrate normal
aging in other organ systems that will also be integrated within
the DSF curriculum.
A69
The Effects of a Pre-Clinical Geriatrics Curriculum on Attitudes
Towards and Interest in Geriatric Medicine.
P. Borker, A. Talati, E. O’Toole, P. DeGolia. Case Western Reserve
University School of Medicine, Cleveland, OH.
Supported By: MacGregor Foundation and the Health Resources
Services Administration, Bureau of Health Professions Geriatric
Education Centers Program
BACKGROUND: It is projected that by 2030, 20% of the U.S.
population will be over age 65. Since 1978, the IOM has called for improvements
in geriatric education for health care providers, most recently
re-addressing this issue in 2008. In this study, we assessed the
effects of a multi-year, pre-clinical geriatrics curriculum on student’s
interest in and knowledge of care for geriatric patients.
METHODS: Cohort study of fourteen volunteering medical
students during their second years immersed in a six-week geriatrics
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curriculum between 2010–11 and 2011–12. Students met twice per
week for the following activities: (1) focus group sessions discussing
clinical and personal experiences with older adults; (2) interactive
group sessions with geriatric specialists; and (3) shadowing activities
with volunteering physicians and geriatric patients. Students participating
in 2011 – 2012 also participated in a first year introductory
course to geriatric patients and self-selected to participate during the
second year curriculum. Students are surveyed regarding interest in
geriatrics and examined using a geriatrics knowledge test pre and
post intervention. Weekly focus group sessions are recorded and analyzed
using grounded theory methodology.
RESULTS: Pre-intervention geriatric interest survey for
2011–12 show that 60% of students ‘strongly agree’ with the statement
“I understand the unique issues involved in care for the elderly,
compared to 22% of students from 2010–11. Furthermore, 20% of
participating students reported that they are interested in pursuing a
career in geriatrics during the 2011–12 curriculum; by contrast only
11% of students reported interest in geriatrics from 2010–11. Pre-Intervention
use of the Geriatrics Knowledge Test showed mean score
of 50% (sd = 11%) during 2011–12; no significant change from
2010–11 in which mean score was 48% (sd= 9%).
CONCLUSION: Current data suggests longer exposure
through a focused curriculum may improve interest and comfort with
older adults, both within geriatrics or other medical fields, although
study lacks power to comment on significance. Data collection, including
career interest surveys for the class of 2010-11 and post intervention
surveys for 2011–12, is in progress. Further investigation, including
use of a 2:1 matched comparison control group is also
pending, but may help eliminate selection bias and further validate
study results.
A70
Fulfilling an ACGME Competency: Impact of a Novel
Communication Skills Curriculum.
R. Ramaswamy, 1,2 A. Williams, 1,2 A. S. Kelley, 1 E. M. Clark. 2,1 1.
Brookdale Department of Geriatrics and Palliative Medicine, Mount
Sinai School of Medicine, New York, NY; 2. GRECC, James J. Peters
VA Medical Center, Bronx, NY.
Introduction: Effective communication is essential to health
care delivery, especially in care of the elderly, and is associated with
increased adherence to treatment and patient satisfaction. The
ACGME has designated communication skills as a core competency.
Following a needs assessment, we developed an evidence-based communication
skills curriculum with the objective to increase confidence
and expertise among Internal Medicine interns in communicating
with older patients.
Methods: The communication skills curriculum was integrated
in the 4-week Geriatrics block in the first year of Internal Medicine
residency training at the Bronx VA. Developed and facilitated by 2
geriatrics fellows, the curriculum consists of 2 small group sessions,
1.5 hours each, involving 2 interns at a time. The sessions include didactic
learning, discussion, role-play and self-study. Skills taught include
Active Listening, Ask-Tell-Ask and SPIKES [1]. Participants
complete questionnaires at baseline, after the course and at 3 months.
Baseline data include demographics, past training in communication
and self-identified communication challenges. Self-reported confidence
with specific communication tasks is also measured on a 4-
point Likert scale (1= minimal confidence, 4= high confidence).
Results: To date, 9 interns have completed the curriculum. Five
were ≥ 30 years old and 5 had medical school training in English.
Only 3 reported any prior training in communication skills. Respondents
found developing rapport and building trust with older patients
most challenging. Compared to baseline, the interns’ average overall
confidence in communicating with older patients increased by 25%
(from 3.0 to 3.75); comfort level in delivering bad news to an older patient
increased by 50% (from 2.0 to 3.0); comfort level in discussing
advance care planning with an older patient and in conducting a family
meeting both increased by 48% (from 2.11 to 3.13). SPIKES was
felt to be the most useful skill and 71% respondents preferred the
small group format as a safe way to learn and practice the skills.
Conclusion: Implementation of a structured, standardized communication
skills curriculum in Internal Medicine internship has
been effective in improving confidence and comfort in communicating
with older adults.
[1] Baile WF, et al., Oncologist 2000; 5:302–311.
A71
An Intervention to Improve Medical Students’ Interprofessional
Acumen.
R. M. Wright, 1 J. H. Lingler, 2 J. P. Pschirer, 3 J. F. Mahoney, 4
D. A. Nace. 1 1. Medicine/Division of Geriatrics, University of
Pittsburgh, Pittsburgh, PA; 2. School of Nursing, University of
Pittsburgh, Pittsburgh, PA; 3. School of Pharmacy, University of
Pittsburgh, Pittsburgh, PA; 4. School of Medicine, University of
Pittsburgh, Pittsburgh, PA.
Supported By: Josiah P. Macy Foundation
Health Resources and Services Administration (GACA)
Background: Teamwork and interdisciplinary collaboration are
essential to providing the best geriatric care but are challenging to
teach medical students. We compared pre- and post-course knowledge,
skills, and attitudes toward interprofessional (IP) teamwork
among medical students who underwent a multimodal, IP team education
intervention and among students who did not.
Methods: 197 3rd-year medical students, nurse practitioner
(NP)students, and pharmacy students, were divided into 6 IP teams
(intervention group) and 10 non-IP, medical student-only teams (controls).
Each IP team consisted of 4 or 5 self-selected medical students,
4 or 5 NP and 1 or 2 pharmacy students. All teams received a lecture
on transitions of care (TOC) and participated in a geriatric case TOC
simulation and debriefing session. IP team instruction included a lecture
on effective teamwork and IP competencies, a video demonstration
of ineffective IP teamwork, and self-assessment of videorecorded
teamwork. Before-and-after team performance surveys
assessed students on perceived IP teamwork knowledge, skills, and
attitudes. Paired t-test analyses assessed within-group pre- and posttest
differences.
Results: 18 (67%) IP and 83 (61%) non-IP medical students returned
both 28-item surveys. Both groups demonstrated significant
improvement on multiple items. Knowledge items that improved only
within the IP group were “teams are more responsive to the complex
needs of geriatric patients;” “team approach makes the delivery of
care more efficient;” and “I see caring for older patients as a unique
challenge.” Despite having lower pre-test ratings on 9 teamwork
skills items, IP students rated post-test skills on average as “very
good” or better for 10 of 11 skill items while non-IP students rated
their post-test skills as “very good” or better on only 4 out of 11 items.
Conclusion: Medical students generally considered themselves
knowledgeable but not skillful at working in teams. A multimodal, experiential
IP curriculum effectively improved knowledge, skills and
attitudes toward IP teamwork. Additional analyses from this rich
dataset will be presented. Future directions include testing for retention
and transfer of IP team concepts.
A72
Teaching Fall Risk Assessment to Medical Students Using Meals on
Wheels.
S. Chenna, K. M. Sink, K. Callahan, J. Demons, H. Atkinson.
Geriatrics, Wake Forest University, Winston Salem, NC.
BACKGROUND: The AAMC and John A. Hartford Foundation
have recommended a set of minimum geriatric competencies for
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medical students, which include fall risk assessment. We describe an
innovative method of teaching fall risk assessment using the Meals on
Wheels (MOW) community program.
METHODS: During an intense one week geriatric rotation, 3rd
year students perform a fall risk assessment on a MOW client in their
home. The evaluation includes: history of falls, fear of falling, medication
review, visual acuity, Get-up and Go test, Mini-Cog, and brief
home safety evaluation. ADLs and IADLs are also obtained. 4 of the
8 recommended competency domains are covered in this experience.
A Geriatrics attending reviews the assessment and provides relevant
teaching. Students provided anonymous feedback on the MOW fall
risk assessment on a scale of 1-10 (10=best). Using a retrospective prepost
survey we assessed the self-reported change in the students’ confidence
and perceived competence in elements of fall risk assessment.
RESULTS: In the class of 2012, 110/124 completed the in-home
fall risk assessment. 14 students did not complete it due to logistical
problems. Students rated the MOW fall risk assessment highly (mean
of 7.26 (of 10)). Students commented that it was a unique, “eye opening
experience” to see the depth of need and the services available
and enjoyed the novel opportunity for learning outside of the typical
hospital setting. 60/110 (54%) completed the retrospective survey.
Results on confidence in performing individual tasks are presented in
the Table. 51% of students also report having assessed fall history
since this rotation.
CONCLUSION: The innovative MOW fall risk assessment experience
efficiently teaches 4 of 8 competency domains with minimal
faculty effort, was well received by medical students, and resulted in
much improved confidence in elements of fall risk assessment. Our
MOW falls risk assessment could easily be adopted by most medical
schools.
Percentage of students who reported moderate to very high confidence/competence
BEFORE and AFTER the MOW fall risk
assessment
A73
Evaluation of Medical Student Training and Attitudes towards
Geriatrics at Wuhan Medical School.
S. M. Shi, R. Sherer, I. Morgan, H. Dong, B. Cooper. University of
Chicago - Pritzker School of Medicine, Chicago, IL.
Supported By: Pritzker School of Medicine via Summer Research
Program
Geriatrics is an emerging field in China, with no national certification
or formal specialty training presently. In the past decade,
China has prioritized shifting the delivery of primary care for urban
populations to community health centers (CHCs) rather than larger
public hospitals. The ease of access, closer proximity, and lower outof-pocket
costs make CHC care a more favorable alternative over
sub-specialty care in tertiary hospitals for many elderly. Thus geriatrics
training has become an increasing imperative to effective delivery
of primary care in CHCs. We evaluated faculty and student attitudes
towards geriatrics, and investigated whether a new CHC
Clerkship experience at Wuhan University affected student opinions.
We also explored the delivery of health care in local community settings,
particularly to the elderly.
Students at Wuhan University Medical School were surveyed, as
well as elder care givers at the QingShan Community Health Center.
A total of 18 pilot CHC clerkship students (‘Pilot’) were surveyed,
with questions regarding their perceptions of geriatrics as well as
judgment on current exposure to geriatrics during clinical and preclinical
training. Parallel surveys were administered to 41 fourth year
medical students who did not participate in the pilot (Control). ‘Elderly
patients’ were defined as age over 60 years.
In general, more CHC students reported that their medical
school training, both courses and clinical, prepared them for work
with the elderly. None of these differences were statistically significant
(Mann-Whitney test, no P values

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A75
Geriatrics and Aging through Transitional Environments (GATE):
A Longitudinal, Competency-Based Medical Student Curriculum.
S. Limaye, S. Williams, S. G. Smith, A. Baron. Medicine, University of
Chicago, Chicago, IL.
Supported By: Pritzker School of Medicine Dean’s Award,
University of Chicago
Background:
The AAMC requires medical schools to address 26 minimum
geriatric competencies. GATE targets 17 of these in a 4 year, systemsbased
curriculum focused on geriatric assessment and transitions of
care. Goals of the GATE curriculum are to improve medical students’
geriatric assessment skills, develop competency-based evaluation
tools, and integrate nationally recognized geriatrics curricula into
existing ones.
Methods:
In a 2 year pilot integrated longitudinally into existing medical
school courses from MS1-4, the GATE curriculum teaches geriatric
assessment skills pertinent to different care settings: in-home geriatric
functional history and home safety assessments; outpatient geriatric
assessments (e.g. MMSE) and clinical skills (e.g. advance directives);
hazards of hospitalization and transitions of care; and nursing
home assessment and interdisciplinary care planning.
Teaching methods include: lectures, in-home interviews with
trained patients; reflective essays; skills-based practice workshop;
simulated patient experiences; pocket cards; inpatient teaching
rounds; podcast, and; geriatrician-led nursing home rounds.
GATE evaluation is curriculum year specific and longitudinal,
with periodic assessments of students’ knowledge of ADLs/IADLs,
attitudes towards older adults, and confidence in skills in select competency
domains.
Results:
Students’ knowledge of ADLs/IADLs improved after GATE
intervention. Pre GATE-1 mean score = 5.58 (14 possible correct).
Post GATE-2 mean score =11.70; t(121) =-6.9, p

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RESULTS:To date 20 IM residents have completed the rotation
and 85% have completed an evaluation. The average overall
score was 4.6/5. The case presentation and transitional care clinic received
the highest scores of 4.75. Resident feedback has been positive
and constructive, and the module has been modified in response.
Example comments include, “more experiences like this
week would be helpful,” and “great experience and rotation definitely
helps me understand what to focus on and recognize in the
care of elderly patients.”
CONCLUSION:Medical residents express a strong need to
learn about systems-based practice. A geriatrics rotation designed to
underscore competency in systems-based practice has been well received
and helped to address attitudes and gaps in knowledge about
the care of older adults.
A78
Health professional students’ perceived need for interprofessional
geriatric education.
S. B. Bhattacharya, 1 M. Rosso, 1 V. Villareal, 1 C. Obering, 2 M. Eng, 3
M. Peterson, 1 D. Ebbert, 1 R. Bhattacharya. 4 1. Family Medicine,
Division of Geriatric Medicine, Univ of Kansas Medical Ctr, Kansas
City, KS; 2. Pharmacy Practice, Univ of Missouri Kansas City, Kansas
City, MO; 3. Pharmacy Practice, Univ of Kansas Medical Ctr, Kansas
City, KS; 4. Internal Medicine, Univ of Kansas Medical Ctr, Kansas
City, KS.
Background
An Institute of Medicine core competency for all healthcare
professions is the ability “to work in interdisciplinary teams”. In addition,
the Cochrane Library asserts that delivery of care will require
the involvement of multiple health professions due to an aging
population and a shift from acute to chronic care. Consequently,
good interprofessional collaboration to coordinate patient care is
critical.
The Geriatrics Champions Program began in the Fall of 2011 at
the University of Kansas Medical Center to build interprofessional
collaboration in geriatric care utilizing a Team-Based Learning
(TBL) format. This 8 session program was based on the “Minimum
Geriatrics Competencies for IM-FM Residents” (released 6/09). Targeted
audiences were family medicine residents and nurse practitioner,
pharmacy and social work students. Prior to Session 1, we assessed
their perception of the need for interprofessional education
(IPE) in geriatric care and their familiarity with TBL. Here, we present
our results.
Methods
Prior to Session 1, learners completed 2 voluntary and confidential
electronic surveys. The 1st 6 item survey asked about their school
and source of program knowledge. The 2nd 11 item Likert scale survey
asked about their interest and expectations in learning geriatrics
in an IPE and TBL format, as well as their prior experience and perceived
benefit of IPE and TBL.
Results
Eighty-seven of 133 completed the survey including 47 Nursing
(54% of total), 30 Pharmacy (34%), 9 Resident (10%), and 1 Social
Work (1%) student. Most (72%) heard about this program from faculty
and 91% were glad to participate in the program. Despite 53%
and 68% knowing about IPE and TBL, this was the first IPE opportunity
for 87%. Eighty-five (97%) anticipated learning something
new. Most (95%) felt that IPE, and 78% and 76% felt that TBL, was
useful and necessary, respectively.
Discussion
The majority were new to the IPE format, yet anticipated a good
experience. Most felt that IPE was useful, but were less optimistic about
TBL.This data shows learner willingness to engage in IPE and TBL for
geriatric education, in concert with national recommendations.
A79
Geriatrics and Aging through Transitional Environments (GATE)
MS2 Curriculum: Introduction to Geriatric Assessments.
S. Williams, S. Limaye, S. G. Smith, A. Baron. Medicine, University of
Chicago, Chicago, IL.
Supported By: Pritzker School of Medicine Dean’s Award,
University of Chicago
Background:
The GATE curriculum is a 4 year, systems-based curriculum
teaching geriatrics across the spectrum of care settings to medical students.
GATE-2 focuses on outpatient geriatric assessment and communication
skills. Goals are to enhance skills in targeted AAMC
competency domains (falls/balance/gait, health care planning and
promotion, and cognitive and behavioral), and to develop competency-based
evaluation tools and methods.
Methods:
GATE-2 includes a lecture on geriatric assessments and strategies
for: communicating with patients with dementia and caregivers;
conducting advance directive discussions; addressing health literacy,
and; administering geriatric screening tests for depression, physical
function, and cognition. A two hour skills based workshop facilitated
by inter-disciplinary faculty allows role play and skills assessment.
Geriatric SP encounters present challenges assessing patient’s cognition,
depression, and physical function, addressing advance directives
and health literacy, and jointly interviewing patients with dementia
and collateral historian. Encounters are videotaped. Student’s performance
is evaluated verbally by preceptor and SP. Student, SP and
preceptor complete a written, competency-based evaluation of student’s
clinical and interviewing skills.
Results:
Eighty-seven Pritzker MS2 participated in geriatric SP encounters.
In a 360 degree evaluation of geriatric interviewing skills across
cases, there was no difference in self, preceptor and SP evaluations for
Depression, Health literacy and Dementia cases. SP scores were
lower than both preceptor and student self-evaluations for MMSE
and Physical Function cases. Student self-evaluation was lower than
SP evaluation for Advance Directives case. In evaluation of case specific
clinical skills, there was no difference in self, preceptor and SP
evaluations for Depression, Health literacy, Dementia and Advance
Directives cases. For Physical Function and MMSE cases, SP evaluation
was lower than both preceptor and student self-evaluation.
Conclusions:
A 360 degree criterion-based assessment tool provides variable
perspectives of student competencies in discrete assessment and communication
skills. Future work will focus on inter-rater reliability in
assessments via training students, preceptors and simulated patients
on use of instrument.
A80
Increasing Residency Training of Goal-oriented Treatment Options
in Patients with Life-Limiting Illnesses.
T. Lee, 1 Q. Cao, 1 S. Hayes, 2 P. Austin, 1 M. Zafar, 1 R. Newman. 1 1.
Family Medicine, East Carolina University, Greenville, NC; 2. Family
Medicine, Naval Hospital, Jacksonville, FL.
Supported By: HRSA:K01 HP20471, Geriatric Academic Career
Award
Objectives: For many patients with life-limiting illnesses, defining
and discussing goals of future medical care (advance care planning)
are very important. This study measures the effects of education
to the in-training residents of family medicine (FM) and internal
medicine (IM) residency programs at East Carolina University
(ECU).
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Design: Based on the results of the informal assessment of need
from the residents and faculty, educational materials were developed.
These included discussion of advance care planning, MOST (POLST)
form, FIVE WISHES, healthcare power of attorney, and living will. A
2-hour education and discussion session was given to all in-training
FM and IM residents at ECU. Pre- and post-tests were administered
to measure their medical knowledge as well as attitudes toward advance
care planning.
Results: A total of 70 pre-test and 53 post-test scores were analyzed.
Overall knowledge improved with the educational sessions
(74.9% vs 90.5% correctly answered pre- and post-test, respectively).
Also, the residents’ own attitude toward advance care planning
changed favoring less aggressive care at the end-of-life (EOL).
Conclusions: Educational sessions significantly impacted residents’
knowledge and attitude about advance care planning and
EOL care.
Knowledge and attitude scores
EOL = end of life
A81
Implementing the Objective Structured Clinical Examination
(OSCE) in a Geriatrics Fellowship Program – a three-year
experience.
T. J. Avelino-Silva, L. A. Gil, S. M. Lin, L. L. Farias, E. L. Kikuchi,
C. K. Suemoto, W. Jacob-Filho. Geriatrics Division, Department of
Internal Medicine, University of Sao Paulo Medical School, São
Paulo, SP, Brazil.
Supported By: None of the authors reported a potential, real, or
perceived conflict of interest or financial disclosure. No sponsors
participated in or funded this research.
Background: The Objective Structured Clinical Examination
(OSCE) appears to be an effective alternative for assessing not only
medical knowledge, but also clinical skills, including effective communication
and physical examination skills. Our purpose was to implement
an OSCE model in a Geriatrics fellowship program and to compare
the instrument with traditional essay examination.
Methods: Seventy first- and second-year geriatric fellows were
initially submitted to a traditional essay examination and scored from
0 to 10 by a faculty member. Subsequently, the same fellows underwent
an OSCE with eight ten-minute stations, covering a wide range
of essential aspects of geriatric knowledge. Each OSCE station had
an examiner responsible for its evaluation according to a predefined
checklist. Checklist items were classified for analysis purposes as clinical
knowledge items (CKI) and communication skills items (CSI);
student responses were scored 0-10.
Results: While essay exams took from 30 to 45 minutes to complete,
180 to 200 minutes were required to evaluate students using the
proposed OSCE method. Students scored an average of 6.2±1.2 on
the traditional essay examination versus 6.6±1.0 on the OSCE
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A83
Preparing to Care for an Aging Population: Medical Student
Reflections on their Clinical Mentors within a New Geriatrics
Curriculum.
T. W. Farrell, 1 R. R. Shield, 3 A. Nanda, 2 S. Campbell, 3 T. Wetle. 4 1.
Division of Geriatrics, University of Utah School of Medicine, Salt
Lake City, UT; 2. Division of Geriatrics, Warren Alpert Medical
School of Brown University, Providence, RI; 3. Center for
Gerontology and Healthcare Research, Warren Alpert Medical School
of Brown University, Providence, RI; 4. Public Health Program,
Warren Alpert Medical School of Brown University, Providence, RI.
Supported By: This work was supported by a grant from the Donald
W. Reynolds Foundation.
Background:
Mentoring relationships between faculty and medical students
are increasingly recognized as key contributors to medical students’
developing clinical expertise and approaches to specific patient populations.
Reflective writing techniques such as journaling help provide
insights into the process by which medical students are mentored in
clinical settings and develop into practicing physicians. However,
medical students’ reflections about their experiences with physician
mentors have rarely been studied.
Methods:
From 2007 to 2010, we collected and analyzed 405 medical student
journal entries regarding students’ experiences with a new geriatrics
curriculum at the Warren Alpert Medical School of Brown University,
including both formal and informal mentored experiences in
community and hospital settings. Thirty preclinical and clinical volunteer
medical student journalers from all class years participated in
this journaling project. We employed qualitative analytic techniques
in which rigor and saturation of categories were achieved. Using an iterative
interdisciplinary team process, key themes were identified relating
to students’ experiences with their clinical mentors.
Results:
Three major themes regarding mentoring emerged from the
journals: (1) Exposure to clinical mentors challenged students’ preconceptions
regarding older adults and geriatric medicine; (2) Students
learned new subject matter and techniques from observing
their mentors; and (3) Students provided both positive and negative
assessments of their mentors.
Conclusions:
Opportunities exist to improve current approaches to clinical
mentoring of medical students learning to care for older adults. Such
mentorship may be particularly relevant to promoting medical students’
interest in older persons and geriatrics. Reflective journaling
provides important insights into the process by which medical students
draw upon mentored clinical experiences during their training.
A84
A New Strategy for Teaching Residents Roles of
Interprofessional Teams.
T. C. James, 1 G. R. Westmoreland, 1 C. Arenson, 2 S. R. Counsell. 1 1.
Section of Geriatrics, Indiana University School of Medicine,
Indianapolis, IN; 2. Family and Community Medicine, Thomas
Jefferson University, Philadelphia, PA.
Supported By: HRSA GACA
Background: New models of interprofessional care have been
shown to improve outcomes for seniors at high risk for functional decline.
However, Internal Medicine (IM) residents have few opportunities
to learn the roles of interprofessional teams (IPTs). The Minnesota
Complexity Assessment Method (MCAM) tool evaluates
person-specific factors that interfere with usual decision-making and
can highlight roles for IPTs.
Methods: For this mini-course, IM residents completed an online
audio PowerPoint lecture describing the MCAM tool and roles of
the IPT. IM residents met with the geriatrician faculty member who
demonstrated how to use the MCAM tool. Residents practiced using
the MCAM tool on a case scenario then were given a real patient to
assess using the MCAM tool. During the IPT conference the MCAM
tool was applied to a patient the resident had researched in preparation
for the meeting. Evaluation included pre- and post-tests assessing
attitudes about IPTs and qualitative responses to questions pertaining
to usefulness of the mini-course.
Results: Twenty IM residents completed the mini-course. Results
comparing pre- and post-tests demonstrate movement towards
greater understanding of IPT care. There were higher average agreement
ratings in the post-test compared to the pre-test for: “interdisciplinary
health professionals know each other’s roles,” “I know when
my patient needs an interdisciplinary team” and “interdisciplinary information
tells us about disease progression;” and lower average
agreement for items “working with colleagues in my own profession
is more efficient” and “the goal of interdisciplinary teams is to support
physician care plans.” Residents agreed that the mini-course was
useful to their practice (40% agreed and 60% strongly agreed) and
that MCAM was a useful tool (70% agreed, 25% strongly agreed and
5% undecided). Residents stated they will look for opportunities to
collaborate with IPTs.
Conclusions: For IM residents, using the MCAM tool for evaluation
of patient complexity in an IPT setting appears to be a successful
strategy to highlight the roles of IPT care. Response to this minicourse
suggests that residents may be receptive to additional
opportunities for learning about, from, and with other health professionals
to improve outcomes for at risk seniors.
A85
Quality Improvement Curriculum for Geriatrics Fellows Using Lean
Methodology.
G. Gupte, 1 J. A. Eng, 2,1 M. Young, 2 R. M. Zitnay, 2 K. James, 2
M. Sissoko, 2 W. Suen. 2 1. Boston University School of Public Health,
Boston, MA; 2. Section of Geriatrics, Boston University Medical
Center , Boston, MA.
Supported By: HRSA: Geriatric Academic Career Award
John A. Hartford Foundation
BACKGROUND: Practice-based learning and improvement
(PBLI) and systems-based practice (SBP) are two out of the six competencies
required by the Accreditation Council for Graduate Medical
Education. However, few curricula exist as examples of how to
teach and evaluate PBLI and SBP. “Lean” is a quality improvement
philosophy replicated in many industries that focuses on maximizing
customer value while minimizing waste throughout a system, using
tools such as process mapping and identification of waste. The authors
describe a curriculum that uses Lean techniques as a framework
to teach and evaluate fellows in PBLI and SBP.
METHODS. Five Geriatric medicine fellows chose to participate
in a project aimed at improving the routine laboratory ordering
process in their home care practice. The fellows met monthly with the
QI mentors to discuss the ongoing project. The interactive sessions included
introducing and applying the Lean tools of process mapping
and identification of waste, identifying stakeholders, designing a pilot
data collection process, brainstorming solutions, and pilot-testing the
solution. Post-curriculum survey and reflection pieces were administered
and analyzed.
RESULTS. All five fellows worked together to complete a QI
project. The fellows enjoyed the interactive curriculum, gained experience
in systematically performing a QI project, identified challenges
involved in the process, and had an increased understanding of the
stakeholders and the system in which they work. The project was
completed within the year-long geriatric fellowship curriculum.
CONCLUSIONS.The year-long QI project using Lean management
principles and tools allowed for a hands-on, interactive QI experience
that fulfilled the PBLI and SBP competencies for Geriatric
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medicine fellows. Future plans include expanding the project to increase
the Geriatric section’s interdisciplinary staff involvement in QI
endeavors and sharing the curriculum with other training programs.
A86
Incremental Value of Cardiovascular Assessment in Patients with
Unexplained Non-Accidental Falls: The Faint and Fall Clinic
Experience.
N. Sanders, 1 T. Jetter, 2 S. L. Wasmund, 2 C. F. Pacchia, 2 M. Brignole, 2
M. Hamdan. 3 1. Geriatrics Division, University of Utah, Salt Lake
City, UT; 2. Cardiology Division, University of Utah, Salt Lake City,
UT; 3. Ospedali del Tigullio, Lavagna, Italy.
Background: Falls cause significant morbidity and mortality.
Due to amnesia and lack of witnesses, some falls may be due to syncope.
We sought to identify the incremental value of cardiovascular
assessment in patients with unexplained non-accidental (NA) falls.
Methods: Patients with NA-falls and no history of syncope underwent
a standardized fall assessment (SA) by a geriatrician. Tilt
Table Testing (TTT) and/or carotid sinus massage (CSM) were recommended
in patients with unexplained falls after the initial evaluation.
If a cause was still not found, insertion of an implantable loop
recorder (ILR) was recommended. The rate of diagnosis was assessed
as a percent of explained NA-falls following each step of the
evaluation.
Results: 51 patients were included in the analysis. Mean age was
73. The number of NA-falls explained after initial SA was 27 (53%).
The use of TTT and CSM identified the cause of falls in 10 more patients
(n=37; 73%). 5 patients consented to insertion of an ILR. After
an 11-month follow up period (mean 5.3 ± 4.8), the diagnosis was
made in 1 additional patient (n=38; 75%)(Figure).
Conclusion: The addition of CSM and/or TTT followed by the
insertion of an ILR to a SA of patients with NA-falls leads to a sequential
increase in the percent of explained falls. These tests should
be considered in the evaluation of patients with unexplained falls.
A87
Matrix Metalloproteinase-9 and the Geriatric Syndrome of Frailty.
N. Guo, D. Halade, M. L. Lindsey, S. Espinoza. Barshop Institute for
Longevity and Aging Studies, UT Health Science Center, San
Antonio, TX.
Supported By: NIA, AFAR, UT Health Science Center at San
Antonio
Background: Aging of the US population comes with an increase
in the incidence of frailty, a geriatric syndrome associated with
adverse health outcomes that can be regarded as an exacerbation of
the normal aging process. Frailty status shows a strong association
with a number of inflammatory molecules, including interleukin-6, C-
reactive protein, and D-dimer. Interestingly, these inflammatory components
of frailty also serve as biomarkers for cardiovascular disease
(CVD), suggesting a correlation between frailty and CVD. Matrix
Metalloproteinase-9 (MMP-9) is secreted by inflammatory cells and
is a known biomarker of CVD. Due to the knowledge of existing
shared inflammatory biomarkers between frailty and CVD, we studied
MMP-9 as a possible frailty biomarker and hypothesized that increased
plasma MMP-9 concentration would be associated with
frailty.
Methods: Subjects were 65 community-dwelling older adults in
San Antonio, TX (mean age= 81 years; range=66-93 years). Frailty
was determined by standardized criteria. Chronic diseases were ascertained
by self-report of physician-diagnosed disease. MMP-9
serum concentrations for each sample were determined by ELISA.
Characteristics by frailty status were analyzed using ANOVA for continuous
measures and chi-squared test for categorical measures
(STATA).
Results: Mean age of the patients was 80.6 ±6.4 years. Of these,
33.8% were non-frail, 47.7% were pre-frail, and 18.5% were frail.
MMP-9 concentrations (ng/mL) were 27.2±8.6, 28.7±11.5, and
33.8±10.2 in non-frail, pre-frail, and frail, respectively (p=.202).
Discussion: Matrix Metalloproteinase-9 (MMP-9), an inflammatory
protein and CVD biomarker, may be increased in frailty; however,
perhaps due to small sample size, the trend of increasing MMP-
9 by increasing frailty status did not reach significance in this study.
Prior studies have shown an association between CVD and frailty;
however, future longitudinal studies will be useful to examine the role
that CVD may play in the development of frailty in older adults.
A88
Interventions and barriers to medication adherence in cognitively
impaired older adults: a systematic review.
N. Campbell, 1,2 M. A. Boustani, 2,3 E. Skopeljia, 3 S. Gao, 2,3
F. Unverzagt, 2,3 M. D. Murray. 1,2 1. Pharmacy Practice, Purdue
University, Indianapolis, IN; 2. Regenstrief Institute, Inc., Indianapolis,
IN, IN; 3. School of Medicine, Indiana University, Indianapolis, IN.
Background: The existence of known cognitive impairment
challenges the ability to adhere to the complex medication regimens
often required to treat the multitude of diagnoses common to older
adults. This report describes a systematic evidence-based review to
accomplish two objectives: 1) identify barriers to medication adherence
in cognitively impaired adults, and 2) identify interventions
aimed at improving medication adherence in adults with cognitive
impairment.
Methods: We searched PubMed, Medline, PsycINFO, Google-
Docs and CINAHL between 1966 and November 1, 2010. Target participants
for both study objectives included adults ≥ 45 years of age
with a diagnosis of cognitive impairment of any degree (mild cognitive
impairment or dementia of any type). Inclusion criteria for the
first objective consisted of any observational study describing risk
factors or barriers to medication non-adherence. Inclusion criteria for
the second objective consisted of any clinical trial with an intervention
targeting medication adherence in cognitively impaired adults.
Studies were excluded if they were not specific to a cognitively impaired
population, lacked a measure of medication adherence, or described
case reports, reviews, or psychiatric or infectious disease populations.
Results: A total of 584 articles were retrieved through the initial
search. Eight studies met inclusion criteria for objective one and
three studies met inclusion criteria for objective two. Two studies
evaluated reminder systems and did not show a benefit in a small
group of participants with cognitive impairment. One study improved
adherence through telephone and televideo reminders at each dosing
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interval. Results are limited to published articles and articles with at
least an abstract published in English.
Conclusions: This review identified that few barriers to medication
adherence have been addressed in the cognitively impaired population.
Future interventions should better address reported barriers
to medication adherence, as well as evaluate the impact on disease
markers and cognitive function as clinical endpoints.
A89 Encore Presentation
Atypical presentation is common in Late Onset Rheumatoid
Arthritis.
P. Chatterjee, A. B. Dey. Geriatrics, AIIMS, New delhi, India.
Background-Presentation of rheumatoid arthritis (onset after
60 years of age) is varied and atypical, posing diagnostic uncertainties.
Objective- To examine the mode of presentation of late onset
rheumatoid arthritis (LORA) and to identify baseline clinical and
laboratory features that would contribute to diagnosis and prognostication.
Methodology- 31 cases of inflammatory arthritis were diagnosed
as RA among the patients attending Geriatric OPD of AIIMS,
using revised American Rheumatology Association criteria for RA
or with clinical (atypical presentation), laboratory and radiologic evidence
of RA. Patients were followed 2 weeks, 3 months then 6
months to see the response to DMARDs by Disease activity score
and development of disability using Stanford Health Assessment
Questionnaire disability index (HAQ DI).
Result- Mean age of presentation 66.32 ± 4.24 years, mean duration
of presentation 20.74 ±30.23 months. Female to male ratio was
1.8. 51.61% had both large and small joint involvement, 29.35% had
exclusive small joint involvement, 19.35% had exclusive large joint
disease, 58.6% had peri-arthritis of shoulder joint and 51.6% had
polymyalgic symptoms on presentation. 67.7% has bilaterally symmetrical
presentation. 74.2% had RA factor positivity; 41.9% had x-
ray features suggestive of RA; 25.8% had anti-CCP antibody positivity;
and 61.3% had ADL impairment on diagnosis. 61.3% of the
LORA patients had more than 3 co-morbidities. 80.6% patient responded
to methotrexate and 19.4% developed deformity during follow-up.
ADL impairment was significantly (p=0.001) associated with
large joint involvement and RA factor positive group had significant
XRAY changes (p=0.02) and ADL impairement(p=0.03)
Conclusion- LORA is associated with female predominance as
in young age. But due to late and atypical presentations, ADL impairment
is common. Response to DMARD is satisfactory. Multiple comorbidities
and early disability compromises the quality of life.
Larger scale prospective studies are required to provide better diagnostic
criteria and treatment recommendations.
A90 Encore Presentation
Factors Associated with Geriatric Syndromes in Older Homeless
Adults.
R. T. Brown, 1,2 D. K. Kiely, 3 M. Bharel, 4 S. L. Mitchell. 3,5 1. Division
of Geriatrics, University of California, San Francisco, San Francisco,
CA; 2. San Francisco Veterans Affairs Medical Center, San Francisco,
CA; 3. Hebrew SeniorLife Institute for Aging Research, Boston, MA;
4. Boston Healthcare for the Homeless Program, Boston, MA; 5.
Division of Gerontology, Beth Israel Deaconess Medical Center,
Boston, MA.
Supported By: 1. NIH-NIA T32 AG000212
2. NIH-NIA K24 AG033640
Background: Although older homeless adults have high rates of
geriatric syndromes, little is known about the risk factors for these
syndromes. We sought to identify factors associated with geriatric
syndromes in 250 homeless adults ≥50 years old recruited from eight
homeless shelters in Boston, Massachusetts.
Methods: Multivariate regression models were used to estimate
the association of subject characteristics with the following outcomes:
1) total number of geriatric syndromes; 2) cognitive impairment
(Mini-Mental State Examination (MMSE) score and Trail Making
Test Part B (TMT-B) duration); 3) fall in the past year; 4) frailty; and
5) major depression.
Results: Total number of geriatric syndromes was associated
with < high school education, diabetes, binge-drinking, drug use problem,
and impairment in Activities of Daily Living (ADL). Lower
MMSE score (worse cognition) was associated with older age, < high
school education, non-English primary language, binge-drinking, and
longer duration of homelessness. Longer TMT-B duration (worse executive
function) was associated with older age, non-White race, <
high school education, non-English primary language and stroke.
Falling was associated with arthritis, binge-drinking, ADL impairment
and depression. Frailty was associated with diabetes and depression.
Finally, depression was associated with younger age, < high
school education, drug use problem, traumatic brain injury, and ADL
impairment.
Conclusions: This study identifies modifiable factors associated
with geriatric syndromes in older homeless adults. This knowledge
can help health care providers identify and assess homeless patients
who may have geriatric syndromes, and may provide targets for interventions
to improve the health of older homeless adults.
A91
A Mystery of Vision & Thrombosis.
S. Hodroge, R. Lands, B. Pearman. Internal Medicine, University of
Tennessee Medical Center, Knoxville, TN.
Introduction:
Unilateral orbital pain, swelling, limitations in ocular motion
and diplopia, are concerning in any patient. This usually signals the
presence of pathology within the orbit or paranasal sinuses. We present
a patient with these symptoms who was found to have a right
spontaneous superior ophthalmic vein thrombosis (SOVT) and a
lupus anticoagulant.
Case Report:
A 56-year-old white female presented to University of Tennessee
Medical Center with a 2-month history of progressive right
sided periorbital redness, swelling, pain and finally opthalmoplegia.
CT scanning revealed periorbital cellulitis. She was treated with several
rounds of antibiotics, steroids, and NSAIDs without improvement.
Upon presentation to our hospital, she had noted worsening of
right-sided headache, photophobia, and vision deterioration with decreased
red color discrimination. She reported no purulent nasal discharge
or fever. She fell three months prior to admission, but denied
loss of consciousness or neurologic symptoms. Risk factors for thrombosis
included the use of estradiol. She had no family history of
thrombophilia. Physical exam revealed right periorbital swelling with
erythema, proptosis, ptosis and a lateral rectus palsy of the right eye.
Dilated fundoscopic exam showed 1+ disc edema as well as abnormally
engorged retinal veins. Pupils were reactive to light but the
right pupil was smaller than the left. Right intraocular pressure was
mildly elevated at 25mm Hg. Lab findings included a normal white
blood cell count and ESR. Magnetic resonance angiography demonstrated
a right superior ophthalmic vein thrombosis. The patient was
anticoagulated with heparin and treated with IV antibiotics pending
return of negative blood cultures. After ruling out carotid cavernous
fistula, arteriovenous malformation, and intracranial aneurysm, she
had a cerebrovascular angiogram that was normal. The patient’s
symptoms improved after the angiogram. Evaluation for acquired hypercoagulable
states demonstrated the presence of a lupus anticoagulant,
which was still present three months later. She remains on Warfarin
and will require anticoagulation indefinitely.
Discussion:
SOVT is a rare condition usually related to inflammation of the
orbit or paranasal sinuses, clinically similar to periorbital cellulitis.
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While we were not able to find another reported case of SOVT associated
with the presence of a lupus anticoagulant, evaluation for hypercoagulation
syndromes is probably warranted.
A92
Spontaneous Retroperitoneal Bleed Presenting as Right leg pain:
Psoas sign.
T. Hashim, A. H. Chaudhry. Hospitalist, Highline Medical Center,
Burien, WA.
We report case of 88year old man with past medical history of
atrial fibrillation on anti- coagulation with Coumadin for chronic
atrial fibrillation. Patient presented to our emergency room with 1
day history of right leg pain and inability to walk secondary to severe
pain and leg weakness. Patient denied any trauma. The pain was in
right groin which was made worse with extension of the hip and was
relieved with hip flexion. All other review of systems were negative.
His medical problems included diabetes, hypertension and history of
CHF.His home medications included Coumadin, Lisinopril, simvastatin
and Carvidelol.
On physical examination, his blood pressure was 122/65 heart
rate 110/min irregular, respiratory rate 22 /min and temperature of
98.7F. His cardio-pulmonary exam was unremarkable. Abdominal
exam was benign. Patient however was constantly keeping his right
thigh flexed. When patient was turned on his left side and an attempt
was made to extend his right leg at the thigh; it resulted in severe pain
(positive psoas sign). He also had sensory loss on the anterior upper
thigh and also has significant weakness of the right Quadriceps
Femoris Muscle.
Laboratory data showed hematocrit of 28 which was a drop
from his baseline hematocrit of 35. The INR was 4.6 and rest of the
chemistry panel was with in normal limits.
A CT scan of the abdomen and pelvis without contrast showed
huge 13cmx5cmx6.5cm complex fluid collection close to the right iliacus
muscle consistent with retroperitoneal bleed. Patient was admitted
to ICU for close monitoring. He was transfused 4 units of Fresh
frozen plasma along with 2 units of PRBCS and 10mg of IV vitamin
K. Surgery recommended conservative management and complete
reversal of anticoagulation and frequent hemoglobin checks.
Over the next couple of days the patient’s condition improved
and his hematocrit stabilized.
On the 5th day of hospitalization, patient was discharged home
with home health for physical therapy.
Conclusion:
Retroperitoneal bleed is a Known complication of anticoagulation
which usually presents with abdominal pain and back pain. However,
sometimes it presents as isolated Psoas sign. Clinicians taking
care of patients on anti- coagulation should have low threshold for
imaging the abdomen (CT or MRI) for patient who present with
groin pain or leg pain.
A93
The Functional Performance Predictors of Adverse Health Outcomes
in Community-Dwelling Older Adults: A preliminary study.
T. J. Tseng, 1 P. S. Lin, 1 H. S. Cheng, 2 B. H. Gi. 1 1. Department of
Physical Therapy, Graduate Institute of Rehabilitation Science, Chang
Gung University, Taoyuan, Taiwan; 2. Internal Medicine, Chang Gung
Memorial Hospital, LinKou Branch, Taoyuan, Taiwan.
Background and Purpose: The number of older adults keeps increasing
in Taiwan. “Frailty” is a newly defined syndrome, the declined
physiologic reserve capacities will make older people highly
vulnerable to adverse health outcomes, such as hospitalization and
mortality. Finding predictors is one of the solutions to prevent or
defer those adverse health outcomes. There are two purposes of this
study: (1) To examine the differences of the occurrence of the adverse
health outcomes in different levels of frailty for 2-year period. (2) To
examine the functional performance predictors of older adults’ adverse
health outcomes after 2-year period. Method: A convenient
sample of 337 older adults, aged 65 years and older, living in the community
participated in this study. The baseline evaluation included
demographic and health status, functional tests, mental and depressive
status. The subjects will be followed up annually and finally, medical
record confirms of the occurrence of adverse health outcomes, including
hospitalization, emergency visit, and fall. Results: Among the
337 enrolled, 96 of whom were “non-frail”, 191 were “pre-frail”, and
50 were “frail”. Results of preliminary analyses showed, at baseline,
the three groups were significantly different in height, weight, comorbidity,
GDS, MMSE and all functional tests. The frail older adults
have significantly higher percentage of falls (X2= 13.305, p=0.01). The
5-meter gait speed test, functional reach (FR) and 6-min walking test
(6 MWT) were the tests that could significantly predict older adults’
hospitalization, emergency visit and falls 2 years later, respectively.
Conclusion: The 5-meter gait speed test, FR and 6 MWT were recommended
for use to identify community-dwelling older adults who are
at risk of future adverse health outcomes.
A94
Older Minority Persons Living with HIV/AIDS (PLWHA) The
Influence of Social Support on Willingness to Participate in HIV
Clinical Trials.
R. Arakawa, 1,2 G. Corbie-Smith. 2,3 1. University of Hawaii John A
Burns School of Medicine, Honolulu, HI; 2. The Program on Health
Disparities Cecil G. Sheps Center for Health Services Research, The
University of North Carolina Chapel Hill, Chapel Hill, NC; 3. School
of Medicine, The University of North Carolina Chapel Hill, Chapel
Hill, NC.
Background: Racial and ethnic minorities are disproportionately
affected by the AIDS epidemic, yet have been underrepresented
in HIV research, including clinical trials. Older adults are increasingly
infected, and the population over 50 years old living with
AIDS is expected to grow. The unique experience of being an older
minority person living with HIV/AIDS (PLWHA), in the context of
clinical trial participation, is poorly understood. This study looked for
age-related differences in willingness to participate in a clinical trial
and specific facilitators of participation.
Methods: A cross-sectional, stratified analysis of baseline survey
data was conducted as an aspect of Project EAST (Education and
Access to Services and Testing), a community-based research project
devoted to increasing rural minority participation in research in
North Carolina. Textual data from interviews with PLWHA was
queried for qualitative support of the findings.
Results: Age was not associated with willingness to participate
(WTP), and study participants demonstrated a high level of baseline
willingness. Older age was associated with high levels of perceived social
support from church & religious faith, but lower levels of perceived
support from friends. Older participants had lower perceived
pressure from their doctors to participate, but most believed their
doctor would support their decision to enroll. Both age groups received
a higher frequency of support from other resources, including
their spouse/partner and other family.
Discussion: This study provides no empiric basis for excluding
older minority PLWHA from clinical trials research. The high baseline
willingness demonstrated by the survey participants is encouraging,
but social desirability should be examined as a possible con-
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founder. Future efforts to maintain participation should include engagement
of faith leaders and doctors to lead discussions about HIV.
Additionally, peer-lead interventions to increase knowledge amongst
friends may increase subsistence-type support associated with better
engagement in care.
A95 Encore Presentation
Hypertension Control in all Age Groups – a VA 10 Year Multicenter
Analysis.
R. Fletcher, 1,3 V. Papademetriou, 1 R. Kheirbek, 1,2 R. Amdur, 1,2
C. Faselis, 1,2 R. Jones. 1 1. Veterans Affairs Medical Center, Washington
DC, DC; 2. George Washington University Medical Center,
Washington DC, DC; 3. Georgetown University Medical Center,
Washington DC, DC.
Introduction: While the benefits of blood pressure (BP) control
are well known, BP control is rarely studied in large populations.
Elderly patients have been considered difficult to control. We reviewed
blood pressure control in a large cohort of VA patients.
Methods: From September 2000 to August 2010, we assessed
BP control in 582,851 hypertensive patients from 15 VA hospitals
in various geographic locations around the United States. Patients
were divided in 4 groups based on age: G1:

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and knowledge promoted advance care planning. Illness awareness,
perceived barriers about advanced care planning, knowledge, access
to medical care (esp palliative) influenced decisions about EOL and
hospice, not one’s ethnicity. Patient & family education by health professionals
led to increased awareness of disease and better EOL decision
making. The international studies revealed the following: In a
Korea study most subjects viewed advance directives positively which
was not influenced by information disclosure, ICU experience, prognosis
or gender. In a Taiwan study, knowledge of palliative care &
hospice increased willingness to execute advance directives & many
elderly cancer patients preferred to die at home with hospice care in
their last year. In a China study, less awareness of prognosis increased
anxiety and communication difficulties with family members.A survey
of Chinese medical interns felt they had received insufficient palliative
care education in medical school. Both individualistic and family
autonomy models were observed in the US and International
studies.
Conclusion: Ethnicity or geography did not influence decisions
regarding EOL, hospice, palliative care and advance directives.
Rather, education and awareness improved outcomes. Asian populations
both in the US and internationally could benefit by having active
dialogue among health care professionals, patients and families.
Clinicians should be more culturally sensitive in accepting a familycentered
decision making process along with the autonomy model
A98
Neighborhood Socioeconomic Disadvantage and Walking: the
Cardiovascular Health Study.
T. Yan, 1 M. Cheung, 2 L. Liang, 3 S. D. Vassar, 1 W. T. Longstreth, 4
S. S. Merkin, 5 J. J. Escarce, 3 A. F. Brown. 3 1. Department of
Neurology, University of California, Los Angeles, Los Angeles, CA; 2.
John A Burns School of Medicine, Honolulu, HI; 3. Division of GIM
& HSR, University of California, Los Angeles, Los Angeles, CA; 4.
Departments of Neurology and Epidemiology, University of
Washington, Seattle, WA; 5. David Geffen School of Medicine,
University of California, Los Angeles, Los Angeles, CA.
Background: We examined the association between neighborhood
socioeconomic status (NSES) and walking in older adults and
assessed variation in the relationship by race and gender.
Methods: We used data from the Cardiovascular Health Study, a
multicenter study of cardiovascular disease in older adults 65 years
and older, to examine the association between NSES (the summed z-
scores of census variables representing income, wealth, education and
employment) and self-reported blocks walked in the prior week. We
constructed race- and gender-stratified multilevel binomial models
adjusted for clustering by NSES quartile, sociodemographic, behavioral,
and clinical characteristics.
Results: The sample included 4005 whites (57% female) and 844
African Americans (62% women). Overall, adjusted mean blocks
walked was higher among whites than African Americans and among
men than women (p

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patients (age ≥65) in outpatient settings in the USA using the
NAMCS data from 2000 to 2007.
Methods: Patients 65 years or older who visited outpatient clinics
for non-malignant pain management were identified by one of the
following methods: i) documented either by patients’ self-report of
reason for visit; or ii) ICD-9 code for assessments recorded by physician
for that visit or iii) prescription received for pain management
during that visit.
Results: A total of 206,879,848 weighted (5968 un-weighted)
outpatient visits for older patients with non-malignant pain from
2000-2007 were analyzed. About 89% of these visits recorded
NSAIDs prescriptions. The mean age for the NSAIDs prescription
receivers was 75.4 years and majority of these patients were women
(68%) and Whites (87.6%). Half (50.6%) of the NSAIDs prescriptions
were given by primary care providers. A large percentage of the
NSAIDs users had Medicare (75%) while 15% had private insurance.
Most patients (68.8%) received a total of 4 prescriptions during the
outpatient visit and only 0.9% of the NSAIDs users had a diagnosis
of kidney disease.
Conclusions: A large percentage of older adults were prescribed
NSAIDs for non-malignant pain management in outpatient
settings. While pain severity and length of treatment are not reported
in NAMCS to fully determine appropriate use of NSAIDS in older
adults, it is imperative to further explore if appropriate guidelines
are used for pain management in these patients who are at higher
risk of ADRs.
A101
Effect of “as needed” dosing of antipsychotics and benzodiazepines
for delirium on hospital length of stay and readmissions N.
Rodgers,1 K.Young 1, V. Argento, Department of Medicine
Bridgeport Hospital, Bridgeport, CT.
N. Rodgers, K.Young,V.Argento. Bridgeport Hospital, Bridgeport, CT.
Background: Despite the initial 2005 FDA advisory against antipsychotics,
conventional and atypical antipsychotics as well as benzodiazepines
continue to be used for the treatment of acute agitation/delirium
in demented seniors. Few studies have explored the
effect of cumulative as needed dosing of these medications on patient
outcomes. This study seeks to determine if PRN dosing of antipsychotics
and benzodiazepines is associated with increased hospital
length of stay and more frequent 30 day hospital readmissions.
Methods:
Retrospective database review was performed on seniors (n=
245, average age: 85) with baseline dementia who were admitted to
the Bridgeport Hospital Inpatient Medical Units between 2006-2010
with a diagnosis of delirium. Controls were matched for age, gender,
and co-morbidities stratified using the Charleson index. Subjects
were grouped into 5 categories based on prn medication given: typical
antipsychotics, atypical antipsychotics, benzodiazepines, combinations
of typical and atypical antipsychotics, any combination of the
above, and no prn doses. Length of hospital stay and 30 day re-admission
rates were compared.
Results:
The average length of hospitalization in patients with no prn
medications was 14.1 days. Those receiving prn atypical antipsychotics
had an average stay of 24.7 days (CI 4.0-17.3 p=0.0018). Dual
antipsychotic administration had a stay of 24.0 days (CI 2.8-17.1
p=0.0068). Mean hospital stay was longest for patients receiving combinations
of benzodiazepines and antipsychotics with a mean stay of
28.2 days (CI: 7.9-20.3 p= 0.0001). Comparison of 30 day readmission
rates did not meet statistical significance, except for the prn benzodiazepines
group having an 11 fold greater readmission rate (OR=
11.3; CI: 1.6-64.8). Cumulative data for all prn medications showed a
non-significant trend toward increased re-admissions (OR=2.1; CI:
0.8-5.5).
Conclusion:
Hospital length of stay and readmissions may be adversely impacted
by cumulative prn dosing of: atypical antipsychotics, dual antipsychotics,
and triple combinations of antipsychotics with benzodiazepines.
In addition to non-pharmacological management of
agitation whenever possible; this study reinforces the need for more
standardized prn administration practices among geriatricians and
nurses.
A102
A Retrospective Study of Basal Insulin Analogs in Elderly Nursing
Home Residents with Type-2 Diabetes.
K. L. Davis, 1 W. Wei, 2 J. Meyers, 1 B. S. Kilpatrick, 3 N. Pandya. 4 1. RTI
Health Solutions, Triangle Research Park, NC; 2. sanofi-aventis U.S.,
Bridgewater, NJ; 3. AnalytiCare, San Francisco, FL; 4. Nova
Southeastern University, Davie, FL.
Supported By: This study was funded by sanofi-aventis U.S.
Background: Guidelines recommend long acting basal insulin
use when oral agents fail to control type 2 diabetes (T2DM) in elderly
patients.
Methods: This retrospective, cross-sectional study examined the
use of basal insulin analogs in long term care (LTC) facilities and the
associated outcomes. Data were extracted from medical charts and
the Minimum Data Set (MDS). Treatment regimens of patients receiving
insulin glargine (IGlar) or detemir (IDet) were investigated
and indices of glycemic control and other outcomes compared descriptively
between groups. Patients with T2DM were included if they
were resident in LTC for ≥3 months, had ≥1 full MDS assessment and
≥2 records of insulin dispensing. Patients using insulin pumps, receiving
hospice care, or in a comatose state were excluded.
Results: 2,096 patients were identified from 117 facilities, >50%
received basal insulin (N=1142, mean [SD] age 73.5 [11.9], female
60%). The majority (82.5%, N=942) were treated with IGlar. Baseline
characteristics were generally similar between groups. Co-administration
of sliding scale insulin (SSI) was common (IGlar: 53.3%; IDet:
54.5%), either with basal alone (IGlar: 45.3%; IDet: 49.5%) or with
basal-bolus regimens. Treatment with basal-only (23.1%), basal-bolus
(10.6%) and multiple insulin regimens also occurred. Twice daily injections
(BID) were less common in the IGlar group (5.5% vs 22.0%,
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made more eye contact during anxiety-provoking visits, patients
made more eye contact during routine visits. Given the rising prevalence
of prostate cancer (PCa) in the aging population, the likelihood
of PCa communication being anxiety-provoking, and the role of anxiety
in decision-making about PCa, we compared eye contact during
PCa communication with other clinical interactions.
Methods: We analyzed NIA videotapes of older men and male
physician interactions (n=26) during three different types of clinical
visits involving: 1) PCa (n=9), 2) other anxiety-provoking situations
(depression/suicidal ideation, behavioral issues, and acute medical issues;
n=9), and routine situations (n=8). Using NVivo 9 Qualitative
Software, history-taking segments were time-stamped and transcribed
for each tape, enabling simultaneous independent assessment
of eye contact—in terms of length, frequency and quality—and
speech of both physicians and patients.
Results: Compared to other situations, the length and frequency
of physician eye contact was lowest during PCa interactions. The
quality of eye-contact during PCa communication was characterized
by the lowest number of sustained eye contact episodes per visit (1.5),
followed by slightly higher number in routine visits (2), and the highest
during anxiety-provoking visits (3). In contrast, patients made the
most eye contact in PCa and routine visits, and least in other anxietyprovoking
visits. The amount of verbal communication between
physicians and patients was similar. The frequency of eye contact of
physicians and patients was about twice that of verbal speech.
Conclusions: Physicians and patients display different eye contact
patterns during discussions of PCa when compared with other
anxiety-provoking and routine care discussions. While the frequency
of verbal utterances was similar, physicians display least eye contact
while patients display most eye contact during PCa discussions. Understanding
nonverbal communication patterns and designing interventions
to improve eye contact can help enhance patient-centered
communication for this preference-sensitive disease.
A104
QI Reducing 25 OH Vitamin D Ordering.
R. Aminbakhsh, 1 Z. Aung, 1 G. Guo, 1 D. Chau, 1 S. Leong. 2 1. Internal
Medicine, University of Nevada School of Medicine, Reno, NV; 2. Lab
and Pathology, Veteran Affairs, Reno, Reno, NV.
There has been an increase in the 25 OH Vitamin D lab orders
to our VA healthcare system without any clear evidence based data to
document appropriateness, need for general testing, and guidance.
Recently, The IOM [Institute of Medicine]concluded that there’s evidence
of vitamin D benefits for bone, but there is not enough on nonbone
outcomes. Target blood level of 25OH vitamin D- 20 ng/mL
cover the needs of at least 97.5% of the population. Labs for vit. D
have variable ranges & these ranges can mislabel patients. At our Veteran
Affairs approx. 1500 tests are sent per month at a cost of $18 per
test. PARTICIPANTS of the QI project consisted of all ambulatory
and hospital care providers who ordered 25 OH Vitamin D from August
to November of 2011. # 25OHD Labs ordered by provider was
reviewed (2011):August 982;September 1531;October 1078. INTER-
VENTION: The QI team sent an educational letter September 2011
based upon the IOM report, possible unneccessary testing to the VA
primary care providers. This letter provided providers with the education,
guidance, and recs on appropriate 25 OH Vitamin D lab testing.
Following the letter, the team reviewed the lab orders for vitamin D
and provided 1:1 education based on IOM directed towards PCPs
who ordered high #s of tests. 2/10 PCPs ordered 20% of vit.D lab,5x
more # of tests than by endocrinologist. In addition to education, a
new in house lab for vitamin D testing was implemented standardizing
D ranges of lab reported. MEASUREMENTS: We reviewed the
lab orders for vitamin D prior to the quality improvement education
process, the cost of the lab testing pre and post education. RESULTS:
Of the 3591 tests ordered of 25 OHD from August - October only 8%
had abnormal 25 OH vitamin D values, including deficient and insufficient
vitamin D status. After the preliminary intervention, the 25 vitamin
D lab test ordered was reduced from 1531 in the month of September
to 1078 in the month of October a drop of 29.59%.CONCLU-
SION: A QI project using educational email plus 1:1 education to
outlying providers, and internally standardizing 25 OH lab reports
lowered the number of vitamin D testing and abnormal reporting. We
have also proposed to provide more education for primary care
physicians through additional 1:1 and team education.
A105
Does Low Social Support Predict Hospitalization and Outcomes
among Aging Veterans with and without HIV?
R. Greysen, 1 L. I. Horwitz, 2 K. E. Covinksy, 1 R. Desai, 2 M. E. Ohl, 3
M. Duggal, 2 A. C. Justice. 2 1. Dept of Medicine, University of
California, San Francisco, CA; 2. Dept of Medicine,Yale University,
New Haven, CT; 3. Dept of Medicine, University of Iowa, Iowa City, IA.
BACKGROUND: Social isolation is common among aging Veterans,
especially those infected with HIV, and may affect healthcare
utilization and outcomes of care. Our objectives were to compare levels
of social support in aging Veterans with and without HIV and determine
associations between social support and hospital admission,
length of stay, and disposition.
METHODS: Using the Veterans Aging Cohort Study we created a
10-point scale for social support using survey responses about: marital
status, housing status, food security, number of friends/family and frequency
of visits,and involvement in volunteer work,religious or self-help
groups, or other community activities. We stratified data by HIV status
and used multivariable regression to assess effects of social support on
admission, length of stay, and skilled nursing facility (SNF) placement.
RESULTS: Data were available for 1,836 Veterans: age 55-91
(mean=61), 98% male, 68% non-white, 76% annual income

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be more reluctant to do so. However, they do value incorporation of
their concerns and wishes into clinical decisions. Therefore, we developed
a method for discussing goals with frail older people. Here, we
describe primary care professionals’ first experiences with this
method.
Methods: We developed a two-step method for discussing goals
with community-dwelling frail older people. It consists of an openended
question: If there is one thing we can do for you to improve
your situation, what would you like?; followed by an agenda-setting
chart. Primary care nurses and gerontological social workers then
used this method to discuss goals with community-dwelling frail older
people of ≥ 70 years. The research team reviewed the goals elaborated
and studied professionals’ experiences with the method using a
survey. This included questions concerning time spent on discussing
goals; reasons for not formulating goals; and perceived value of the
method.
Results: 140 frail older people described a total of 175 goals.
These most frequently concerned mobility (n=43; 24.6%), well-being
(n=52; 29.7%), and social context (n=58; 33.1%). Professionals (n=18)
were positive about the method, which took about 16 minutes for
each step. 17 (94.4%) agreed with the statement that it had helped
them determine what the frail older person valued and 15 (83.3%)
agreed that it had helped them to put the wishes of frail older persons
first. Goals were not always formulated, frequently mentioned reasons
for this were the frail older person being comfortable with the
current situation; not being accustomed to discussing goals; or not
being able to formulate goals due to cognitive problems.
Conclusions: The first experiences with this brief two-step goalsetting
method have shown that discussing goals with frail older people
helps professionals to gain insight into what a frail older person
values. This can assist professionals, and possibly frail older people, in
choosing the most appropriate treatment or care option, thus increasing
frail older people’s involvement in decision making.
A107
The Relationships between the Type of Long-Term Care Benefits
and Cognitive Function among Long-Term Care Insurance
Beneficiaries with Dementia in Korea, 2008-2010.
T. Lee, 1 J. Chung, 2 E. Cho. 1 1. Dept. of Nursing Environments &
Systems, Yonsei University College of Nursing, Seoul, Republic of
Korea; 2. Dept. of Biobehavioral Nursing & Health Systems,
University of Washington School of Nursing, Seattle, WA.
Supported By: Korean National Health Insurance Corporation
Background: In Korea, the population over age 65 is expected to
double by 2020, and the prevalence of dementia among those will rise
up to about 10%. The Act on Long-term Care Insurance for Senior
Citizens (LTCI) was enacted in 2008 in an effort to fulfill the care
needs of the elderly with chronic diseases, and the number of beneficiaries
with dementia has reached approximately 80,000. In this
paper, we aimed to examine the relationships between the type of
LTC benefits and the level of cognitive function among LTCI beneficiaries
with dementia.
Methods: We assembled a national sample of all LTCI beneficiaries
with dementia aged ≥ 65 years (N=80,293), examined for LTC
rating in 2008 and followed through 2010. A standardized 10-item
scale was used to assess cognitive function, with higher scores indicating
lower cognitive function. Linear mixed models were used to investigate
whether the LTC benefit type (fixed effects) was a significant
predictor for cognitive function improvement over time
(random effects).
Results: There are three benefit types: in-home services (HS, a
physician/nurse visits the homes of beneficiaries and provides services),
aged care facility services (FS, the LTC facility provides services),
and a combined type of in-home services and aged-care facility
services (CS). From 2008 to 2010, there was a decrease in the mean
cognitive function scores (CFS) for HS beneficiaries from 6.25 to 6.20
(p < .001) and for FS beneficiaries from 7.19 to 6.86 (p < .001). However,
the mean CFS of CS beneficiaries increased from 6.25 to 6.58
during the same period (p < .001) (Table).
Conclusion: Older adults with dementia showed an improvement
in their cognitive function after receiving LTC services delivered
at their home or aged care facilities.
Mean Cognitive Function Scores of Long-Term Care Beneficiaries
with Dementia by Benefit Type and Year
A108
Lower Cost of Care for Serious Chronic Disease by Increasing
Services Not Restrictions.
T. Edes, 1 S. Shreve, 2 L. Klepac, 1 B. Kinosian. 3 1. Dept Veterans Affairs,
Washington, DC; 2. Dept of Veterans Affairs, Lebanon, PA; 3. Dept of
Veterans Affairs and Univ of PA, Philadelphia, PA.
Supported By: No research funding support.
Purpose: To demonstrate that systems can increase access, improve
quality and lower total cost of care by adding services rather
than restricting services.
Background: Congressional Budget Office report (2007) noted
the cost per patient per year in the 7 years from 1998 to 2005 rose
29% in Medicare, while costs rose only 1.7% in Department of Veterans
Affairs (VA). The highest cost patients were those with multiple
serious chronic diseases, many of whom were homebound. One factor
attributed for VA’s cost containment was that VA has programs in
place specifically for persons with serious chronic disease. VA has
continued to expand programs specifically for Veterans with serious
advanced chronic disease to receive patient-centered care in the least
restrictive setting. We report an economic impact analysis of two such
VA programs: Hospice & Palliative Care (HPC), and Home Based
Primary Care (HBPC).
Methods: VA databases were used to determine Veterans’ use of
HBPC, use of HPC in all settings, and location of death. Utilization
and costs of care were determined for 2003 and 2010.
Results: Between 2003 and 2010, while the number of VA enrollee
deaths decreased 11% and the number ofVA inpatient deaths decreased
15%,the number of deaths inVA acute medical hospital decreased 36%,
the number in VA inpatient hospice beds increased 179% and the number
of Veterans in VA-paid home hospice increased 592%. 4582 fewer
deaths occurred in acute medical plus ICU, and 5731 more Veterans received
VA-paid home hospice per day. With the cost difference, the net
cost reduction was over $8 million for each day 4500 Veterans received
care in home hospice rather than VA acute medical inpatient care. The
number of Veterans receiving HBPC increased 190%. Total net cost
avoidance for 24,957 HBPC patients was over $70 million, at $2900 per
patient per year largely by reducing avoidable inpatient days.
Conclusion: Increasing access to inpatient hospice care, to VA-paid
home hospice care and toVA-provided HBPC resulted in net reductions
in total VA costs of care, without imposing any restrictions of services.
A109 Encore Presentation
Geriatric Surgery: The Association between Adherence to Processbased
Quality Indicators and Postoperative Complications.
V. Martelli, 3 S. A. Fraser, 1 V. Isabelle, 3 M. Deban, 3 C. Holcroft, 3
M. Monette, 3 J. Monette, 2 S. Bergman. 1 1. Surgery, Jewish General
Hospital, Montreal, QC, Canada; 2. Geriatric Medicine, Jewish
General Hospital, Montreal, QC, Canada; 3. Lady Davis Institute for
Medical Research, Jewish General Hospital, Montreal, QC, Canada.
Supported By: Canadian Institutes of Health Research
Background:
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This study’s purpose was to understand the association between
process- and outcome-based quality of care measurement in elderly
surgical patients. Process measures describe the care that patients receive.
Outcome measures are the result of care.
Methods:
This was a retrospective review of 143 patients over the age of
65, who underwent elective general surgery between November 2009
and July 2010. Adherence to 9 surgical Quality Indicators (QIs) (antibiotic
and anti-thrombotic prophylaxis, euglycemia, early withdrawal
of urinary catheter, central line inspection, early mobilization,
malnutrition screening, medication list, surgical safety checklist) and
6 geriatric QIs (delirium screening, standard delirium work-up, cognitive
assessment, complete discharge planning, level of care documentation,
pressure ulcer prevention) was abstracted from medical
records. Surgical and Geriatric Quality Scores were calculated for
each patient (#QIs passed / #QIs eligible x100). The primary outcome
was 1 or more postoperative complications, recorded by NSQIP. The
association between the Quality Score and complications was determined
using logistic regression analysis.
Results:
The median Surgical Quality Score was 66.7%; the median Geriatric
Quality Score was 20.0%. Descriptive statistics of the Low and
High Quality Groups, stratified by the median Quality Score, are
summarized in Table 1. Multivariate logistic regression analysis, adjusting
for age, gender, comorbidities and functional status, revealed a
higher risk of complications in the High Geriatric Quality Group,
compared to the Low Geriatric Quality Group (OR=2.99,
95%CI=1.21-7.33, p=0.017).
Conclusions:
We have assessed quality of surgical care in elderly patients
using a novel, process-based approach. Better geriatric care was associated
with a higher likelihood of developing complications, although
the latter probably drives the former.
Comparison of Patient Characteristics and Outcome in High and
Low Quality Groups
A110
Depressive symptoms and high levels of stress significantly lower
PSA screening rates in men with long life-expectancies in a
nationally-representative sample.
A. A. Kotwal, 1 S. G. Mohile, 2 W. Dale. 1 1. Department of Medicine,
Section of Geriatrics & Palliative Medicine, University of Chicago,
Chicago, IL; 2. Department of Medicine, James Wilmot Cancer Center,
University of Rochester, Rochester, NY.
Supported By: The National Social Life, Health, and Aging Project
(NSHAP) is supported by grants from the National Institutes of
Health, including the National Institute on Aging, the Office of
Research on Women’s Health, the Office of AIDS Research, and the
Office of Behavioral and Social Sciences Research (5R01 AG021487),
and by NORC, which was responsible for the data collection.
Background: Guidelines recommend informed decision-making
regarding prostate specific antigen (PSA) screening for men having
10 years of remaining life expectancy (RLE), but there remains a high
rate of non-RLE-based PSA screening. Few studies have specifically
examined the relationship of psychological health to cancer screening
behaviors in men. We therefore assessed whether RLE-based screening
is related to men’s psychological health.
Methods: A nationally-representative sample of men over 57
without prostate cancer (N=1,032) was selected from the National
Social life, Health and Aging Project (NSHAP) and stratified into
two RLE categories: 0-9 years (inappropriate to screen) and 10+
years (appropriate to screen). The relationship of PSA screening
rates within these RLE categories with psychological health variables
anxiety, depression, and stress was assessed using multivariable logistic
regression analyses to control for various potential confounders.
Results: Men with 10+ year RLE with moderate/severe depressive
symptoms had a significantly decreased odds of having PSA
screening (OR=0.55 p=0.02). Men with 10+ year RLE with high stress
levels also had decreased odds of receiving PSA screening (OR=0.37
p=0.02). There was no significant difference in PSA screening rates by
psychological variables in the 0-9 year RLE.
Conclusions: Depression and stress significantly lower PSA
screening rates in men with long life-expectancies for whom an informed
decision on screening would be appropriate. Psychological
morbidity may therefore be a barrier to appropriate informed decision
making on PSA screening in healthy men with long life expectancies.
A111
Elder Self-Neglect and Hospitalization: Findings from the Chicago
Health and Aging Project.
X. Dong. Rush University, Chicago, IL.
Supported By: NIH
Objective: The objective of this study is to quantify the relation
between reported elder self-neglect and rate of hospitalization in a
community population of older adults.
Design: Prospective population-based study
Setting: Geographically-defined community in Chicago.
Participants: Community-dwelling older adults who participated
in the Chicago Health and Aging Project. Of the 6,864 participants
in the Chicago Health and Aging Project, a subset of 1,165 participants
was reported to social services agency for suspected elder
self-neglect.
Measurements: The primary predictor was elder self-neglect reported
to social services agency. Outcome of interest was the annual
rate of hospitalization obtained from the Center for Medicare and
Medicaid System. Poisson regression models were used to assess
these longitudinal relationships.
Results: The average annual rate of hospitalization for those
without elder self-neglect was 0.6 (1.3) and for those with reported
elder self-neglect was 1.8 (3.2). After adjusting for sociodemographic,
socioeconomic, medical commorbidities, cognitive function and physical
function, elders who self-neglect had significantly higher rate of
hospital utilization (RR, 1.47, 95% CI, 1.39-1.55). Greater self-neglect
severity (Mild: PE=0.24, SE=0.05, p

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charge summaries at the time of transfer and high readmission rates
for older patients within 30 days of discharge. Methods: Facility leadership
chartered a multidisciplinary “Transition Redesign Team”
(TRT) to examine factors contributing to patient and provider dissatisfaction
after handovers from hospital to the subacute rehabilitation
unit (rehab) at one VA Medical Center. Patients and families cited
lack of advance information about the transfer. Rehab providers reported
discharge summaries were often lacking at the time of transfer
and also cited late times of transfer. Results: The TRT determined
that despite the existence of adequate policies, hospital and rehab
providers frequently lacked important information about factors pertaining
to transfer specifics (e.g. patient information and ideal timing.)
After discussion with the TRT, the rehab charge nurse joined the
hospital team each morning for their “discharge huddle”. Information
was exchanged about bed availability, prospective patient transfers,
and feedback on past transfers. TRT realized that until the attending
physician co-signed the discharge summaries, they were not
visible in the EMR. The hospital team increased their verbal communication
around transition planning, including negotiating time of
transfer directly with the rehab charge nurse, reminding attending
physicians to co-sign discharge summaries promptly, and talking with
patients and families about possible transfer plans in advance. A dramatic
improvement in provider satisfaction with the transition
process occurred over the subsequent 9 months. Upon EMR review
100% (76/76) of discharge summaries and 99% of patient discharge
instructions were complete on the day of transfer to rehab. Patients
and families reported moderately increased satisfaction with timeliness
of information about transfer, and the TRT continues to work
with hospital case managers to improve this communication process.
Conclusion: Direct communication in the form of a discharge huddle
appears to be important in improving provider and patient satisfaction
with handovers from hospital to rehab.
A113
Geriatrics in Primary Care: Integrating Comprehensive Geriatric
Care into the Medical Home.
P. A. Engel, 1,3 A. Morgan, 1 J. Spencer. 2,3 1. Geriatric Research,
Education and Clinical Center, VA Boston Healthcare System,
Boston, MA; 2. Medicine, VA Boston Healthcare System, Boston, MA;
3. Medicine, Harvard Medical School, Boston, MA.
Supported By: This project is funded by the Department of Veterans
Affairs
Background: Most elderly patients are cared for by primary care
physicians rather than geriatricians. In New England 48% of Veterans
are aged ≥65 including 69,000 ≥85, a group in which cognitive and
functional disabilities are endemic. The current healthcare system is
not specifically designed to care for this vulnerable group. As a result
frail aged Veterans may experience care that is fragmented, inefficient,
costly and potentially harmful.
Methods: Geriatrics in Primary Care (GPC), a clinical demonstration
project addresses this problem by integrating geriatric clinicians
and services directly into two large VA primary care practices
that serve nearly 1,800 Veterans aged ≥85.At the heart of the program
is the on-site presence of a consulting geriatrician and geriatric nurse
care manager who combine forces with existing interdisciplinary
teams to offer comprehensive geriatric care within the evolving VA
medical home model known as PACT (Patient Aligned Care Team).
The program promotes recognition of patients at risk, enhanced patient
access, targeted care management, efficient resource use and a
shift in care focus from multiple subspecialty sites to the PACT.
Results: 175 patients have been evaluated and care managed
since project initiation, August, 2010. 37 referrals to GPC versus 15 to
a traditional stand alone interdisciplinary geriatric clinic (August-October
2011) reflects a shift in geriatric consultation site to GPC. Complex,
fragmented care seen in the first 50 patients (aged 82±7) referred
to GPC indicates a need for this service. In the year prior to
referral these patients made 15±14 total clinic visits with 34% attending
≥5 subspecialty clinics. 74% were cognitively impaired, 18%
lacked family caregivers and 40% received care in ≥2 health systems.
Prorated 12 month follow-up of this original sample indicates a shift
in locus of care with reduced total and mean subspecialty visits, (372
to 269, 7.4±8.0 to 5.4±5.0, NS), significantly increased PACT visits
(3.1±1.5 to 3.7±1.6, p=0.038) and use of phone contact by GPC
(2.3±2.0) for follow-up care.
Conclusion: Preliminary data suggests that GPC improves access
to comprehensive geriatric care, reduces subspecialty service use
and embraces clinical efficiencies by effectively creating interdisciplinary
geriatric teams within PACT.
A114
Subset analysis of antidepressant medication utilization among
geriatric patients with depression: Comparison between usual care
and collaborative care using care managers.
R. DeJesus. Mayo Clinic, Rochester, MN.
Supported By: Nothing to disclose
Depression poses significant economic and health burden yet
remained under-diagnosed and inadequately treated. This is particularly
true among geriatric patients. The STAR*D trial under the National
Institute of Mental Health showed that more than one antidepressant
medication is often necessary to achieve disease remission
among patients seen in both psychiatric and primary care settings.
The collaborative care model (CCM), using care managers, has been
showed in numerous studies to be effective in achieving sustained
outcomes in depression management compared to usual care. In
March 2008, this model was implemented at Mayo Family Clinics
Northwest in Rochester, Minnesota and was subsequently rolled out
to other primary care sites. We hypothesized that utilization of antidepressant
medications among patients with depression managed
under the collaborative care management (CCM) model would be
different from usual care even among geriatric patients.
Records of patients who have been enrolled in CCM from
March 2008 until March 2009 were reviewed and compared to those
under usual care. Pattern of antidepressant medications utilization
were compared between patients with depression enrolled in the
CCM model and those under usual care. Sub-analysis was done on
geriatric patients defined as those aged 65 and older.
Those who were followed under CCM had significantly greater
number of antidepressant medication utilization when compared to
those under usual care. After 6 months, mean PHQ-9 score of patients
under CCM was statistically lower than those in usual care.Subset
analysis of patients aged 65 years and older (N=35) showed no statistically
significant difference in mean PHQ-9 score at 6 months (p
value: 0.59) and anti-depressant medications utilization (p value:
0.29) between the two groups. This observation may reflect correlation
between medication utilization and treatment response; however,
sample number is small to account for any statistical difference.
The collaborative care model for depression management is associated
with greater anti-depression medication utilization with increased
response rate compared to usual care. Future similar analysis
on a larger sample of geriatric patients is needed to evaluate the true
impact of CCM on antidepressant medication utilization and response
rate.
A115
Incorporating INTERACT II Tools In Daily NH Practice,
Recognizing Areas of Improvement.
R. Madan, 1,2 F. Washington, 2 Y. Ye, 1 S. Oakes. 1,2 1. Geriatrics, UTH-
SCSA, San Antonio, TX; 2. Buena Vida Nursing Home, San
Antonio, TX.
Background: Hospitalizations of frail nursing home residents
can result in higher costs, complications and death. Research suggests
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that a substantial proportion of these hospitalizations may be avoidable.
INTERACT II(Interventions to Reduce Acute Care Transfers)
has shown to address these issues from the nursing home perspective.
Objective: Decrease the number of inappropriate transfers by
using INTERACT II tools. Recognize areas for future improvement
and cultural change.
Design and Intervention: Quality improvement. IDT was
formed and monthly sessions done by all lead members “on line”
using INTERACT II modules. Cases following care pathways implemented
for staff education. Physicians trained by attending medical
executive committee. Using tools given through INTERACT II, all
transfers that took place from May to September were evaluated.
One preventable and one non-preventable transfer from each month
evaluated in detail. In September there were no preventable transfers
so 2 non preventable transfers evaluated in detail.
Results: 31 transfers took place from May to September. 4
deemed to be preventable and 27 non-preventable. 100% of patients
transferred to the ED were admitted to the hospital. 70% of the patients
transfer came from the hospital in the prior admission. None of
the preventable and 33% non-preventable transfers had end of life
planning. In the preventable transfers 75% used the “stop and watch”
tool, 75% used the “SBAR” tool, 25% followed the “care pathways”
and 75% used the “change in condition cards”. In the non-preventable
transfers 83% used the “stop and watch” tool, 83% used the
“SBAR” tool, 67% followed the “care pathways” and 100% used the
“change in condition cards”.
Discussion: Comprehensive advance care planning will likely
improve number of transfers. Following the INTREACT II tools requires
ongoing commitment and training in all levels of care.
Lessons learned: 1.Ongoing education is needed for physician
and non-physician staff due to turnover and cross coverage issues.
Reinforcing standardized tools and approaches such as care pathways
is needed. 2. Quality improvement projects need to work in
identifying residents that are at increased risk for transfers. 3. Increased
awareness to complete comprehensive end of life planning
(POLST) should be undertaken in all residents, and especially those
who are at increased risk of transfers.
A116
Geriatric Medicine Transfer-of-Care for Older Surgical Inpatients:
Our Experience and Current Trends (2006-2009).
R. Gonzales, A. Khoo, D. Basic. Geriatric Medicine, Liverpool
Hospital, Liverpool, NSW, Australia.
Supported By: No outside funding was used for this project.
OBJECTIVE: To examine statistical trends regarding transferof-care
to Geriatric Medicine for older patients admitted under surgical
teams.
BACKGROUND: Liverpool Hospital, Australia is a 700-bed
teaching hospital in southwest Sydney and is the major surgical and
trauma centre for the region. With older surgical patients having a
longer length of stay and worse overall prognosis than younger patients,
there has been an increasing need for geriatrician involvement
in their care. In reviewing models of care, the literature suggests a
transfer-of-care model improves functional capacity and decreases
likelihood of placement compared with usual consultative care.
METHODS: The Department of Geriatric Medicine, Liverpool
Hospital has been maintaining a comprehensive database of consultation
requests and outcomes since 2001. Statistical tests of trends in
proportions were applied to transfer-of -care cases.
RESULTS: A review of surgical consultations (n=741) to Geriatric
Medicine (2006-2009) showed the majority were from neurosurgery
(25.1% of surgical team consults) followed by orthopaedics
(21.9%). The majority of the consultations were for medical assessment
(39.2%), followed by high-level residential facility placement
(30.1%). Geriatrician response times to surgical consultation remained
similar over the four-year period. The proportion of surgical
consultations leading to transfer-of-care ranged from 13.2-31.7%
over 2006-2009, with neurosurgical patients highest among transfers
(25.2% of all transfers). However, the proportion of all (medical and
surgical) consultation patients whose care was transferred decreased
significantly by year (2006-2009, Mantel-Haenszel trend test,
p

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ratory failure become chronically critically ill, requiring prolonged
mechanical ventilation (PMV). Older adults who are ventilator dependent
and admitted to long-term care hospitals (LTCH) have a
~50% mortality rate at 1 year, are at high risk for hospital and ICU
readmission. But there is scant data about older adults who receive
care at long-term care skilled nursing facilities (LTC-SNF). This study
examines outcomes of adults on PMV, who were not able to be
weaned, 1 year after their admission to a LTC-SNF.
Methods: A retrospective chart review of mechanically ventilated
adults, admitted to a 60-bed ventilator unit at Silvercrest Center
for Nursing and Rehabilitation (SCNR) from 1/1/2009 to 12/31/2009
and their outcomes at 1 year follow up. Demographic and clinical
data were collected at the time of admission. At 1 year follow up, possible
outcomes included: 1) Alive, 2) Dead, and 3) Lost to follow up.
Also examined was number of readmissions.
Results: During the 1 year time frame, there were a total of 167
subjects on PMV. Of these, 98 were excluded (38 were ventilator liberated
and 60 were admitted prior to 1/1/2009); 69 were admitted for
the first time in 2009 and were included in this study. For these 69 subjects,
the average age was 75 (19-104), with 39 female and 30 male.
The ethnic composition was 37.7% White, 23.2% Black, 24.6% Hispanic,
10% Asian and 4% other. The primary reasons for respiratory
failure were: pneumonia (23.2%), CVA (20.3%), sepsis (15.9%),
COPD (14.5%), anoxic brain injury (10%) and other (16%). At 1
year follow up, 40 (58%) subjects died on the ventilator; 16 (23%)
were alive with 15 in SNF and 1 in the hospital; and 13 (19%) were
lost to follow up due to readmission. On average, subjects experienced
3.3 readmissions (range 0-11). For subjects who were alive at 1
year, readmission rate was 4.7 (range 1-8).
Conclusions: Older adults who require prolonged mechanical
ventilation have a high risk of mortality at 1 year and experience multiple
transitions of care, with many resulting in loss to follow up. Subjects
who survive at 1 year follow up have a higher readmission rate
and none were able to go home.
A119
Improving Transitions to Home in Older Veterans after
Hospitalization.
M. Mather, 1,2 T. Patel, 1,2 S. Espinoza. 1,2 1. GRECC, South Texas
Veterans Healthcare System, San Antonio, TX; 2. UT Health Science
Center, San Antonio, TX.
Supported By: GRECC, Veterans Administration
Background: Approximately 20% of Medicare beneficiaries experience
readmission after hospital discharge (DC). Follow-up (FU)
is usually scheduled 7-10 days after DC, although the high risk time
for post-DC complications, such as falls, is 24-72 hrs after DC. The
goal of this quality improvement project was to improve transitions
to home by contacting patients during this time window in order to
increase safety awareness, improve medication compliance, and prevent
readmission.
Methods: Patients were outpatients enrolled in the Geriatric
Evaluation and Management (GEM) clinic at Audie Murphy VA
Hospital. Scripted follow up calls were made 24-72 hrs post-DC over
a 15-month period by a clinical nurse leader (CNL), who asked about
new disability, new medications, social work (SW) concerns, capacity
for self-care, and whether FU was scheduled. All actions resulting
from the call made by the GEM interdisciplinary team (CNL, MD,
SW, clinical pharmacist) were documented. A standardized retrospective
chart review was performed for data collection, and the information
was summarized using descriptive statistics.
Results: 96 patients were called: mean age was 77.3 ±11.5 yrs,
93.8% were male, 53.1% were Non-Hispanic White, and 30.2% were
Hispanic. Medical comorbidity was common: 65.4% had 2 or more of
diabetes, congestive heart failure, chronic obstructive pulmonary disease,
and hypertension. 73.9% had received new medications upon
DC, and 16.7% had a new disability. While most (88.1%) were taking
medications appropriately, 4.8% were taking the wrong medication
or dose, and required medication reconciliation. 12.1% of calls lead to
intervention by the MD, and readmission was prompted by the call in
15.3% of patients. 4.8% experienced a fall after DC and 15.3% were
readmitted within 30 days. Neither falls nor readmission were associated
with any specific chronic disease.
Conclusion: The GEM team identified the need for post DC FU
calls to improve communication with patients and address unmet
needs. Anecdotally, patients reported increased satisfaction and reduced
anxiety transitioning to home post DC as a result of this intervention,
although this was not formally evaluated. Patients and their
families should receive disease and safety education, particularly with
regard to falls, at every encounter.
A120
Improving Care of the Geriatric Trauma Patient.
S. Hobgood, L. Scheider, P. Boling. Geriatrics/Internal Medicine,
Virginia Commonwealth University, Richmond, VA.
Background: Trauma from falls, motor vehicle crashes, and other
mechanisms causes much morbidity, hospital use and mortality. Patients
over age 65 now account for 12% of trauma admissions, rising
to 40% by 2050. While studies have shown benefit from linking Geriatrics
and Orthopedic Surgery services, little evidence exists regarding
outcome impacts by Geriatrics in other surgical areas. VCU Medical
Center admits hundreds of trauma patients aged 65 and older
each year. Every weekday, the Geriatric Consult Service (GCS) sees
and follows Trauma patients on request. We assert that the VCU GCS
intervention benefits trauma patients.
Methods: We conducted a detailed structured electronic record
review of all patients age 65 or older, seen by the GCS at VCU Medical
Center in 2010, including 73 of 251 (29%) geriatric Trauma Surgery
admissions. We studied patient characteristics, financial data, disposition,
and mortality.
Results: The table shows the main results. There were no differences
in sex, race, zip code, or other demographic characteristics.
Conclusions: Trauma patients seen by GCS were older, and were
sicker than other elderly trauma patients based on a significant difference
in DRG weights, and ICU days. GCS patients more often
went to nursing homes which may reflect acuity or GCS intervention
effects, and though the sicker GCS patients stayed longer and cost
more, they had a better financial outcome for the hospital. Despite
the acuity, in-hospital mortality was lower although not statistically
significant in this small sample, an encouraging finding that we continue
to study.
Geriatric trauma patients seen by GCS versus those not seen by GCS
A121
Transition Coaching to Reduce Hospitalization and Emergency
Department Use.
S. Pandey, 1,2 D. Ifon, 2 L. Williams, 2 K. Blackstone, 1,2 E. L. Cobbs. 1,2 1.
Medicine, George Washington University, Washington, DC; 2.
Geriatrics, Extended Care and Palliative Care, Washington DC VA
Medical Center, Washington DC, DC.
Background: Transition Coaching (TC) is a short term program
to help patients with functional decline. TC provides short term case
management using home visits and person- and family-centered care.
TC comprehensively assesses the patient and caregiver situation, provides
meaningful education, improves medication management, and
identifies needed resources. Goals are to achieve a comprehensive assessment,
improve patient and family understanding of the disease,
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articulate goals of care, reduce inefficiencies of care, and reduce caregiver
burden.
Methods: The TC program started in 10/10 and was fully operational
in 2/11. Two nurse practitioners (NP) deliver short term transition
coaching in response to consultation requests. Outcome measures
include patient and family satisfaction, referring provider
satisfaction, hospital and emergency department utilization, advance
care planning documentation (ACP) and additional resources accessed.
Initial funding was obtained with grant support for two NP
salaries. NPs were embedded into an existing geriatric clinic team.
Revenues from the home visits will sustain the TC program.
Results: 63 patients were served by the TC program from 10/10
to 10/11. 52 completed the program. The most common reasons for
TC consult were medication use, averting functional decline, and alleviating
caregiver burden. The mean age was 83, and all were men.
Most were living with a caregiver. The two most common diagnoses
were heart failure and dementia. 100% underwent comprehensive
assessment, 96% had patient-centered medication management, and
83% had ACP documentation. 37% were linked to new resources,
38% received social worker consultation, 75% received durable
medical equipment, 15% enrolled in home hospice, and 13% enrolled
in home-based primary care. To date, hospital and emergency
department use have been reduced by half, when compared with the
year prior to TC. Patient, family and provider satisfaction has been
excellent.
Conclusion: TC appears to add an important piece to the array
of interventions to help patients remain at home. TC helps optimize
medical management, document ACP, and access resources to decrease
hospital and emergency department use.
A122
Use of the Frailty Index to evaluate the risk of death in older
patients presenting to hospital.
S. Evans, 1 A. Mitnitski, 2 K. Rockwood. 2 1. Medicine, Mercy Hospital
of Buffalo, Buffalo, NY; 2. Medicine, Dalhousie University, Halifax,
NS, Canada.
Supported By: Mercy Hospital of Buffalo, NY
Community Health Foundation of Western and Central New York
Dalhousie Medical Research Foundation
QEII Fountain Innovation Fund
Background: The frailty index can identify groups at increased
risk of deathy in older adults, as reported by ours and other groups. In
hospitals, a Frailty Index (FI) based on a Comprehsnive Geriatric assessment
(CGA) can be built from routinely collected data. The objectives
of our study were: 1. To test the predictive validity of the FI-
CGA in relation to length of stay (LOS) and mortality. 2. To compare
the impact of change in health status over a two week period on outcomes.
Methods: This is a prospective cohort study of 754 patients age ≥
75 admitted to a medical unit at Mercy Hospital, Buffalo NY.. Main
outcome measures were mortality and hospital LOS. Kaplan-Meier
survival analysis was performed separately in men and women.The logrank
test was used to assess differences between survival curves. Cox
proportional hazard regression model was applied to analyse the association
of the FI-CGA with mortality, adjusted for age and sex. Multivariate
logistic regression was used to analyse the association of the FI-
CGA with 30-day and 90-day mortality.A generalized linear model was
usedtoanalyseLOSinrelationtotheFI-CGAandotherfactors.
Results: 754 older adults were enrolled, of whom complete data
are available on 751. These patients were older (mean age 84.0
(SD=5.5) and most (480; 60.7%) were women. Their mean length of
stay in hospital was 5.2 (SD=5.1) days. 30-day mortality rate was
11.5% (91/751) which increased to 16.4% (130/751) by 90 days. On
average, patients were moderately frail at baseline (median FI-
CGA=0.35), but their health status had worsened significantly in the
two weeks prior to admission, at which time their median FI-CGA
was 0.46. In Cox regression analysis, age, sex and the FI-CGA score
were significantly associated with mortality (e.g., for the FI-CGA, the
HR=1.04 (95%CI=1.03, 1.05) for each 1% FI-CGA increment. Multivariate
logistic regression also showed the age and sex adjusted risk
of death was highly associated with the FI-CGA (OR=1.06 (1.04,
1.08) for 30-day mortality and OR=1.05 (1.03, 1.07) for 90-day mortality..
Likewise, a higher FI-CGA was significantly associated with
LOS (R2=0.3).
Conclusion: Here, the FI-CGA stratified the risk of death and
long LOS in older adults admitted to hospital.
A123
GHEST-3D: Greenwich Hospital Executive Screening Tool for
Delirium, Depression and Executive Dysfunction. Report on an
observational quality improvement study.
S. Buslovich, 1 G. J. Kennedy. 2 1. Internal Medicine, Greenwich
Hospital-Yale New Haven Health, Greenwich, CT; 2. Geriatric
Psychiatry, Einstein-Montefiore Medical Center, Bronx, NY.
Supported By: Greenwich Hospital funded the part time salary of a
geriatric screening nurse to administer the survey instruments.
Cognitive decline is omnipresent in the geriatric patient population.
The risk of cognitive impairment increases with age and is further
enhanced after hospitalization as supported in the literature.
Screening patients for cognitive impairment during hospital admission
could be the first step in early identification of cognitive impairment,
allowing for implementation of appropriate interventions. Several
conditions that significantly impact functionality and
independence may be subtle and undiagnosed.
We evaluated patients considered to be at high-risk for hospital
re-admissions, such as patients admitted with CHF exacerbations,
acute myocardial infarctions, pneumonia and COPD exacerbations
for delirium, depression and executive dysfunction. A screening tool
was designed utilizing evidence based tools, such as, the Confusion
Assessment Method (CAM), Patient Health Questionnaire (PHQ-9),
Controlled Oral Word Association Test (COWAT), and Oral Trail
Making Test (OTMT) to conduct an oral interview and identify patients
with delirium, depression and executive dysfunction.
The original sample size consisted of 43 case patients and 27 control
patients. Control patients were age, and sex matched surgical floor
patients without history of the high-risk diagnoses. 91.3% (21) of the
23 readmitted (within one year) case patients tested positive for executive
dysfunction; 50% (3/6) original study subjects that tested positive
for depression were readmitted with one year; 75% (3/4) original study
subjects tested positive for delirium were readmitted in the same time
period. The subject pool was inadequate to identify a reliable time to
readmission for each specific diagnosis in this observational study.
This study illustrates the potential value of systemic screening for
cognitive impairment in acute stay hospitalized elderly patients and possible
implications of all-cause readmission rates. Further cohort studies
are needed to evaluate whether recognition and targeted interventions
could contribute to positive outcomes, specifically, follow through with
the discharge plan of care, medication regimen adherence, reduction in
nursing home admissions, depressive symptom remission, hospital readmissions,
mortality and improvements in the patients’ quality of life.
A124
Safety in Transitions of Care; Identifying Needs Among Key
Providers in an Urban Academic Hospital.
U. K. Ohuabunwa, 1,2 S. Shah, 1 Q. Jordan, 2 K. Johnson, 1 C.Tai, 1
J. Flacker. 1 1. Division of Geriatrics, Dept of Medicine, Emory
University,Atlanta, GA; 2. Senior Services, Grady Hospital,Atlanta, GA.
Supported By: HRSA - Geriatric Academic Career Award
Hartford Center of Excellence Clinician Educator Award
Background: Medication errors, poor communication, and poor
coordination between providers are major contributory factors to
failure in transitions of care.
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Objectives: 1. To determine the knowledge, attitude and care
transitions practices of key inter professional providers involved in
the discharge process.
2. To determine their perceived patient, provider and system related
factors contributing to failure in transitions of care
Design: Mixed methods approach using surveys and focus group
sessions
Setting: A 953 bed academically affiliated inner city hospital
Participants: Key providers involved in the discharge process including
physicians, nurses, social workers and case managers.
Procedure: We administered questionnaires to these key
providers exploring their knowledge of care transitions best practices,
attitudes and practices. Focus group sessions were held to further explore
their perceived patient needs; and patient, provider and system
related barriers to safe transitions of care.
Results: 108 participants including 74 medical residents, 12 medical
students, 7 social workers, 5 nurse case managers and 6 inpatient
unit nursing directors /charge nurses completed the questionnaires.
21% of the participants had received no formal training on care transitions
best practices at anytime. Up to 61% reported no training on
effective communication and patient education strategies. The areas
of least training were on determination of patient - appropriate settings
of care (27%) and communication and coordination of care with
outside care facilities (18%). Medication reconciliation and scheduling
of appointments were the most common provider practices reported.
The following themes emerged during the focus group sessions
as provider related factors contributing to failure in care
transitions: 1) Poor communication between members of the healthcare
team.2)Poor understanding of roles of members of the healthcare
team.3) Poor patient education by providers and poor knowledge
as to patient education best practices.4) Poor understanding of
the care transitions process and recommended best practices. Conclusion:
Determination of provider related deficiencies in the knowledge
and practice of care transitions will form a basis for educational interventions
to reduce provider related errors.
A125
Understanding the Southern Arizona Dual-Eligible Special Needs
Patient (SNP) population.
V. Nagaraja, 1 H. Goel, 1 A. Gilligan, 2 J. Mohler, 1 T. Ball, 3 I. Abraham, 2
M. Fain. 1 1. Arizona Center on Aging, University of Arizona, Tucson,
AZ; 2. HOPE Center, University of Arizona, Tucson, AZ; 3. University
of Arizona Health Network, Tucson, AZ.
Background: The dual-eligible population (Medicare and Medicaid
eligible) represents a group of patients with disproportionally
large healthcare expenditures and multiple chronic conditions. They
are likely to have multiple inpatient stays and emergency room visits.
New innovative chronic care models are needed for this population.
The primary objective of this study was to characterize and analyze
the most costly dual-eligible enrollees in a Special Needs Program
(SNP) within a southern Arizona academic medical center and understand
patterns of suboptimal utilization and barriers to coordination.
Methods: This study was retrospective, with data consisting of
patient chart reviews and administrative cost data. Information regarding
socio-demographics, general health status health resource
utilization (HRU), and total cost of care (TCoC) of the top 10%
(n=30) of the most costly dual eligible enrollees assigned to providers
within the hospital’s outpatient programs were collected.
Results: Sixty percent of the sample was female (n = 18). Mean
age was 60 years (SD=13). Mean body mass index (BMI) was 31.9
(SD=9.2), and 14 patients (46.7%) were clinically obese (BMI >30).
Nearly 50% were diabetic. Seventy-five percent had four or more
chronic conditions, with 75% having one or more concomitant psychiatric
illness. The average number of PCP visits was 7.7 per six
months (SD=5.9; 95%CI: 0-23). Average number of hospitalizations
per six months was 1.4 (SD=1.5; 95%CI: 0-6). Thirty-day re-admission
rates averaged 27% (SD=0.45). TCoC averaged $15,955/six months
(SD=$10,890; 95%CI: $6,570-$59,068). Hospital admissions were a
statistically significant contributor to TCoC (p = 0.001). The top 5%
of this population accounted for nearly 50% of total spending.
Conclusion: Finding effective, efficient and high quality means
for coordinating the care of the dual-eligibles could help to assure the
fiscal sustainability of the Medicare and Medicaid programs in the future.
Findings will be used to create inter-professional chronic care
models in collaboration with patients and their families, which address
suboptimal utilization and barriers to coordination and incorporate
value-based, high-touch, high-tech care.
A126 Encore Presentation
Improving quality of care for older veterans through a RHIOenhanced
Care Transitions Intervention (CTI).
W. W. Hung, 1,2 C. M. Dunn, 1 N. E. Moodhe, 1 E. M. Gottesman, 1
B. Morano, 1,2 K. S. Boockvar. 1,2 1. GRECC, James J Peters VA
Medical Center, Bronx, NY; 2. Geriatrics, Mount Sinai School of
Medicine, New York, NY.
Supported By: VA GEC T21 grant
Background: Older veterans who transition from acute care to
home are at risk for adverse outcomes such as readmissions and medication
errors. This is especially true for veterans who use both VA
and non-VA services, which is common in the Medicare-eligible population.
The Bronx Regional Health Information Organization
(RHIO), a regional electronic health information network, provides
an opportunity to improve care coordination between VA and non-
VA systems by providing a platform for sharing clinical data. The objective
of this project was to implement a CTI that used real time
RHIO notification of hospitalization events.
Methods: Our CTI was based on the Coleman model, which had
components of patient education, medication management, tools for
self-management, and patient and caregiver empowerment. Referrals
and case finding were used to identify appropriate older adults aged
60+ discharged from our VAMC. For veterans who agreed to be monitored
through the Bronx RHIO, the CTI team received electronic
notifications from the Bronx RHIO informing them of hospitalization
events at non-VA hospitals in the Bronx. The care transitions coordinator
delivered the intervention with a visit in the hospital, with a
home visit 2 days after discharge, and with 3 follow-up phone calls.
Results: We modified the CTI to adjust education material for
health literacy level and to make additional calls or visits as needed.
Also, for some with poor health literacy, our coordinator needed to
follow up clinical issues with providers. The CTI was associated with a
lower 30-day rehospitalization rate of 17.8% among those served by
the CTI as compared with 24.4% among those referred but not
served. 91% of veterans served had a follow up visit within 30 days at
the VA Medical Center and on average 1.1 unmet needs (such as
medication discrepancy or mishaps) addressed. Projected cost reduction
was $103000 annually which can be used to support the salary of
the coordinator.
Conclusion: Quality of care for veterans across health systems
can be improved through care transitions activities enhanced by the
use of a RHIO, with the potential for cost neutrality or cost savings.
A127
Access to Primary Care Using a Care Transitions Program: a
Cohort Study.
Y. Chen, 1 H. Syed, 1 J. M. Naessens, 2 N. D. Shah, 2 A. S. Rahman, 2
K. M. Swanson, 2 P. Y. Takahashi. 1 1. Internal Medicine, Mayo
Clinic, Rochester, MN; 2. Health Science Research, Mayo Clinic,
Rochester, MN.
Background: Care transitions involve a smooth handoff from
the hospital to the home environment. One important aspect of care
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transitions involves access to primary care which may provide better
care coordination. Our clinical practice has initiated a care transitions
program (CTP) with nurse practitioners after hospital stay in
high risk elders. The aim of this study is to evaluate the number of
primary care visits 60 days prior to enrollment and 60 days after enrollment
in CTP.
Methods: This was a retrospective cohort study of older adults
enrolled in CTP from March 2011 till September 2011. CTP was initiated
after hospital dismissal in high-risk adults over 60. Data was
collected using administrative billing data on primary care (PC) visits
prior to enrollment and after enrollment. Primary outcomes included
the percentage of people with at least one visit to the PC
team and average number of PC visits. Secondary outcomes included
visits to specialists. Analysis used McNemar test and paired t-
test respectively.
Results: 95 patients were identified who had enrolled in CTP in
mid 2011. Subjects visited their PC team 84.2% of the time before enrollment
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A130
The effect of Thai traditional music on cognitive function,
psychological health and quality of sleep among older Thai
individuals with dementia.
P. Sithinamsuwan, 1 S. Saengwanitch, 1 A. Pinidbunjerdkool, 1
S. Ukritchon, 2 M. Mungthin. 3 1. Division of Neurology, Department
of Medicine, Phramongkutklao Hospital, Bangkok, Thailand; 2.
Office of Research Development, Phramongkutklao College of
Medicine, Bangkok, Thailand; 3. Department of Parasitology,
Phramongkutklao College of Medicine, Bangkok, Thailand.
Supported By: 1.Phramongkutklao College of Medicine
2.Department of Medicine, Phramongkutklao Hospital
Background: This study was designed to investigate the effects
of Thai traditional music on cognitive function, activities of daily living,
mood, behavior and sleep quality in demented Thai elderly.
Methods: An 8-week, interventional, controlled, cross-over
study was undertaken in 67 patients with dementia. We randomly allocated
patients into 2 groups; group-1 [intervention (4-week) followed
by control (4-week)], group-2 [control followed by intervention].
During the interventional period, care givers played the music
CD for each patient for at least 30minutes daily. Cognitive function
[Mini-Mental State examination (MMSE)], activities of daily living,
mood, behavior [Behavioral Pathology in Alzheimer’s Disease Rating
Scale (BEHAVE-AD)] and sleep quality [Pittsburgh Sleep Quality
Index (PSQI)], were assessed at 1stvisit (baseline), 2nd and 3rdvisit.
Results: The mean age was 77.6 years and mean initial MMSE
17.5. Average daily listening time was 51.2 minutes. Music significantly
improved scores in MMSE (p = 0.009), 2-domain of BEHAVE-
AD [Diurnal rhythm disturbance (p = 0.021) and Anxiety/phobia (p =
0.025)] as well as the summation of behavioral symptomatology (p =
0.008) and one sleep index [Daytime dysfunction (p = 0.005)]. Also,
there was a trend to improvement in 2 more domains of BEHAVE-
AD [Paranoid/delusion and Aggressiveness], ADL and global sleep
quality index. Median visual analog scale of satisfaction this intervention
was 80. The optimal duration of music exposure to improve cognitive
and neuropsychiatric functions was 15minutes/day.
Conclusions: Thai traditional music is an effective tool for addressing
neuro-psychological symptoms, especially in cognitive function,
behavioral and sleep problems, in elderly Thai with dementia.
This study suggests that regularly scheduled listening to music more
than 15 minute/day promotes a positive short-term effect on emotional
memory.
A131 Encore Presentation
Systemic inflammation inhibits low-density lipoprotein receptorrelated
protein-1 mediated clearance of amyloid-β from blood:
implications for Alzheimer’s disease.
P. E. Hartvigson, 1,2 M. A. Erickson, 2,3 W. A. Banks. 1,2 1. University of
Washington School of Medicine, Seattle, WA; 2. GRECC-VA Puget
Sound Health Care System, Seattle, WA; 3. Saint Louis University,
Saint Louis, MO.
Supported By: Medical Student Training in Aging Research
Program; National Institute on Aging (T35AG026736); National
Institute on Aging (R01AG029839); John A. Hartford Foundation
MetLife Foundation; Lillian R. Gleitsman Foundation; VA Merit
Review (WAB)
Background: Alzheimer’s disease (AD) is a neurodegenerative
disease characterized by the formation of amyloid plaques containing
amyloid-β (Aβ) in brain parenchyma. Neurons produce Aβ constitutively.
In normal physiology low density lipoprotein receptor-related
protein-1 (LRP-1) transports Aβ from brain across the blood-brain
barrier (BBB) into blood (efflux). Aβ is then taken up by peripheral
organs (primarily liver) for degradation. LRP-1 mediates liver uptake
of Aβ from blood. It has been proposed that Aβ in blood may also
contribute to Aβ accumulation in brain, thus liver uptake may play a
significant role in maintaining brain Aβ homeostasis. Lipopolysaccharide
(LPS) -induced inflammation recapitulates many components of
this aspect of the AD phenotype, and evidence suggests oxidative
modification (adding 3-nitrotyrosine (3-NT) and 4-hydroxy-2-nonenal
(4-HNE)) inhibits BBB LRP-1. We tested whether systemic inflammation
inhibits liver LRP-1 and peripheral Aβ uptake by the
same proposed mechanism.
Methods: We injected young CD-1 mice with intraperitoneal
LPS (control: saline) to induce inflammation, and then injected radiolabeled
albumin and Aβ intravenously. Blood, liver and kidney were
collected at various time points. Aβ/albumin uptake and serum clearance
were assessed by gamma counting. Exposure time was calculated
with multiple-time regression analysis. Liver LRP-1 expression
and liver protein carbonyl were determined by dot blot. 3-NT and 4-
HNE modifications on liver LRP-1 were assayed with Western blot.
Results: LPS treatment significantly increased liver protein carbonyl,
liver LRP-1 expression and 4-HNE modification on liver LRP-
1. 3-NT modification on liver LRP-1 increased 38.8%. LPS significantly
inhibited serum Aβ clearance as well as the rate of liver and
kidney Aβ uptake.
Conclusions: These findings support the hypothesis that oxidative
modification on LRP-1 in liver increases circulating Aβ, which
has been shown to increase brain Aβ concentration and contribute to
amyloid plaque formation, hallmarks of AD pathology.
A132
Age, gender and blood pressure predict cerebral cortical thickness in
normotensive and prehypertensive middle-aged adults.
S. Wo,A. Heim, L.Yadlosky, J. Owens, J. R. Jennings. Department of
Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA.
Supported By: National Heart, Lung, and Blood Institute
Thickness of the human cerebral cortex decreases with normal
aging, and accelerated cortical thinning has been demonstrated in
several pathologies, including Alzheimer’s disease. Previous studies
have shown that subclinical levels of cerebrovascular risk factors such
as high blood pressure are associated with decreased regional cortical
thickness in community-dwelling elderly adults. In this study, we examine
the relationship between cortical thickness and blood pressure
in normo- and prehypertensive middle-aged adults. Our sample consists
of 89 adults aged 35-60 years without neurological, cerebrovascular
or cardiovascular histories whose blood pressures were normal
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findings suggest that early control of elevated blood pressure may
promote successful brain aging.
A133 Encore Presentation
A Driving Assessment Clinic: Structure and Statistics.
S. Suraj, G. Madero, M. Shawn, N. Shirley. Geriatrics Department,
Marshall University, Huntington, WV.
OBJECTIVE: The decision whether a patient of advanced age
or with a diagnosis of dementia should stop driving is a complex one,
as there are no firm guidelines. Clinicians do not generally provide
uniform assessments; indeed they rarely do any formal assessment to
decide the answer for each patient. At the Hanshaw Geriatric Center
we reviewed records of the patients from our Driving Assessment
clinic to find whether any general recommendations can be made for
Primary Care Physicians to assist them in planning for driving assessments
for their patients.
PATIENTS AND METHODS: Records where reviewed from
all patients evaluated at our Driving Assessment Clinic at the Hanshaw
Geriatric Center from August 2007 to mid 2010. We first assessed
patterns of appointments themselves (kept/cancelled/“noshowed”),
and subsequently reviewed actual assessment results.
RESULTS: Out of 144 appointment slots available, 109 (76%)
were filled. 26 (24%) of 109 appointments were Cancelled out of
which 16 (62%) rescheduled and were evaluated. 14 (13%) of 109
were “No Shows” out of which 1 (7%) rescheduled and was evaluated.
A total of 49 patients (29 men and 19 women) where evaluated,
3 of whom underwent the testing twice, for a total of 52 evaluations.
Mean age was 75.4. The prevalence of CNS disorders was high
among those tested. In 27 evaluations (52%), the patient had the diagnosis
of dementia at the time of the assessment. Eleven (21%) had
suffered head trauma, four of whom also had a dementia diagnosis.
Nine (17%) had strokes. In two cases, all three diagnoses coexisted,
yet the patients were still driving.
CONCLUSIONS: In spite of the value of having objective data
about our patients’ driving skills, in is difficult to obtain such data.
Formal driving assessment is labor intensive and cancellation and noshow
rates are quite high. We conclude that this is not a process which
can be accomplished in the primary care office, nor even in many
larger institutions. Regional assessment clinics are a possible approach,
but would likely have to be supported by funds other than
fee-for-service.
A134
Identifying the malady of synaptic plasticity-related genes in human
Alzheimer’s Disease.
S. M. Harvey, J. Knebl, J. Simpkins, S. Sarkar. University of North
Texas Health Science Center, Fort Worth, TX.
Early Alzheimer’s disease (AD) pathophysiology is characterized
by synaptic changes induced by degradation products of amyloid
precursor protein (APP). Although there is evidence for synaptic dysfunction
induced by soluble oligomeric Aβ, the pre- or postsynaptic
sites of action and the specific mechanisms responsible for such dysfunction
have not been established. We reasoned that by measuring
pre-and postsynaptic plasticity related gene expression in different
brain regions from age matched control (AMC) and AD patients,
candidate defective gene(s) by the criteria of severe loss of expression
in AD could be identified. Preliminary results from western blot
analysis show region specific severe loss of expression of pre-synaptic
proteins AP-180, synaptogamin and dynamin in AD compared to
AMC. These losses were most profound in the occipital and temporal
cortices, but not significant in the cerebellum. The loss of expression
of pre-synaptic protein molecule could lead to defects in synaptic
function and ultimately to synapse loss that underlies the memory impairment
evident in the early phase of AD.
A135
Defining Dementia Multimorbidity in a National Sample.
T. Sadak, J. Katon, S. Borson. University of Washington, Seattle, WA.
Supported By: JAHF Atlantic Philanthropies Claire Fagin
Fellowship
National Alzheimer’s Diseases Coordinating Center
Background: Clinicians cite clinical complexity as a major challenge
in caring for dementia patients, and no general model of care
has found wide acceptance. Quantifying clinical complexity is a first
step toward developing the necessary infrastructure for populationbased
dementia care. Our goal was to describe dementia multimorbidity,
using prevalence estimates for single and complex dementia
etiologies, neuropsychiatric symptoms (NPS), and co-morbid chronic
psychiatric and medical conditions in a large, systematically diagnosed
national sample.
Methods: Baseline visit data in the National Alzheimer’s Coordinating
Center repository [U01 AG016976] were analyzed for 3851
persons enrolled in an Alzheimer’s Disease Research Center
(ADRC) and diagnosed with one of the four most common primary
dementias (Alzheimer’s (AD), Lewy Body (DLB), behavioral variant
Frontotemporal (BvFTD), and Vascular (VaD)). ‘Complex dementia’
was defined as >1 concurrent etiologic diagnoses; severity
was indexed by the clinical dementia rating (CDR). Co-morbid conditions
(present or absent) included cardiovascular disease (CVD),
cerebrovascular disease (CVAD), diabetes, hypertension (HTN), hypercholesterolemia
(HCL), and primary psychiatric disorders. NPS
were rated using the total NPI-Q score (prevalence X severity
summed across 12 symptoms). Results: The sample prevalence of primary
dementia diagnoses was 3338 for AD, 241 for DLB, 189 for
bvFTD, and 83 for VaD. Overall, 202 persons (5%) had >1 etiology.
Dementia was mild (CDR 1) in 64% of the sample. Almost all patients
(93%) had at least one additional clinical problem; 89% had a
comorbid chronic medical condition and 27% had ≥3. 41% had a psychiatric
diagnosis (nearly all depression), and 88% had at least one
current NPS, with total NPIQ scores varying by dementia etiology
(AD 5.4, DLB 8.7, bvFTD 9.3, VaD 7.0). Severe dementia (CDR 3+)
was more prevalent among persons with complex etiologies (17%)
compared to those with a single etiology (11%, p < 0.05) and mean
NPIQ scores were higher (7.5 vs. 5.8, p < 0.05).
Conclusions: Multimorbidity is part of the reality of dementia,
even among participants in ADRC’s, where the prevalence of ‘pure’
AD is higher and overall clinical complexity is expected to be lower
than in an unselected population. This study points to the need for
conceptual and pragmatic approaches to care that incorporate complexity
and its impact on clinical outcomes.
A136
Reliability of the Rey Complex Figure Test for Identifying Mild
Cognitive Impairment.
T. V. De Beritto, 1 K. D. Tingus, 2 P. H. Lu, 2 E. Teng. 2,3 1. University of
Utah School of Medicine, Salt Lake City, UT; 2. Neurology, UCLA,
Los Angeles, CA; 3. VA Healthcare System, Los Angeles, CA.
Supported By: MSTAR (Medical Student Training in Aging
Research Grant)
Background: Individuals meeting criteria for mild cognitive impairment
(MCI) progress to dementia at higher rates than agematched
controls. However, the optimal operationalization of the
MCI criteria remains uncertain. The Rey Complex Figure Test
(RCFT) is widely used to assess memory and visuospatial functioning.
Previous work indicates that the RCFT has good sensitivity for
identifying cognitive impairment, but RCFT deficits are unstable.
This study explores potential factors limiting the utility of the RCFT
for identifying MCI.
Methods: We identified 182 participants who met criteria for
MCI (n=106) or normal cognition (NC; n=76) and had been assessed
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with the copy and 3 minute delayed recall portions of the RCFT using
the Meyers & Meyers (1995) scoring criteria and normative data (impairment
defined as performance ≤-1.5 SD below normative means).
We evaluated the effects of different scoring criteria and normative
data on diagnostic classification. A rater blinded to prior diagnoses
rescored RCFT figures using Taylor (1969) criteria, and participants
were reclassified as impaired or unimpaired using Boone et al. (1993)
and Van Gorp et al. (1990) norms. Concordances between different
diagnostic classifications were calculated using Cohen’s κ.
Results: The proportion of participants defined as having impaired
RCFT performance was dependent on which scoring criteria
and normative data were used. RCFT analyses using Taylor criteria
yielded higher rates of impairment with the Boone norms (copy:
31.8%; recall: 27.4%) than with the Van Gorp norms (copy: 17.0%; recall:
8.2%). Concordance between norms was moderate for RCFTcopy
(κ=0.47) and fair for RCFT-recall (κ=0.38). Use of the Meyers &
Meyers criteria and norms yielded intermediate rates of impairment
on the RCFT-copy (25.8%) and recall (21.9%) subtests.
Conclusions: Although the RCFT may be sensitive to cognitive
impairment, the use of different normative means yielded different
proportions of impaired participants. Differences seen with different
normative data sets were greater than differences seen with different
scoring criteria and may reflect subjective differences in scoring between
studies. Investigations of inter-rater reliability with this data set
are ongoing. These findings suggest that the RCFT may have limited
reliability when used in isolation to identify MCI.
A137
Normal aging, neuroinflammation, and the brain-a sheep in wolf’s
clothing?
T. Harris. University of Nebraska Medical Center, Omaha, NE.
Neuroinflammation is known to occur in clinically significant
neurodegenerative processes including Parkinson’s and Alzheimer’s
disease. Moreover, prior studies of aging and CNS transcriptome expression
have implicated neuroinflammation as a potential process
observed in normal CNS aging. Our earlier work has shown that
overexpression of immunne/defense-related gene transcripts may be
associated with age-related loss of important functional behaviors.
Since many of the gene trascripts showing age-related changes in expression
are well-known molecules used by the immune system (e.g.
complement, class I histocompatibility molecules, cytokines,
chemokines), this process has been assumed to be neuroinflammatory
as well. However, no studies have been performed to specifically
localize these molecules in the microglia-the resident immune cell-of
the aging brain. In the current study, I extracted and purified microglia
from the hypothalamus and cerebellum of C57BL/6 and
BALB/cBy mice in a minimally stressful manner. Using RT-qPCR, I
measured and analyzed the expression of several inflammatory genes
in microglia. I found that the expression of these genes remained similar
between young, middle-aged, and aged mice, with a few genes
even decreasing in expression. This finding suggests that even though
CNS aging is characterized by increased expression of multiple immune
transcripts, neuroinflammation is not the underlying etiology.
A138
Effects of Multimedia Fall Prevention Training in Persons with
Dementia.
V. Panzer, 1,2 J. Burleson, 1 F. Into, 2 H. Waite, 2 P. Atwood. 3 1.
Community Medicine & Health Care, University of Connecticut
Health Center, Farmington, CT; 2. Brookside Research &
Development, North Salem, NY; 3. Dementia Care, Hebrew Health
Care, West Hartford, CT.
Supported By: University of Connecticut TRIPP Center
Background: Persons with dementia (PwD) in long-term care
(LTC) experience 4.05 falls/year compared to 2.33 for those without
dementia. Falls are attributed to the lack of safety awareness and patient
education is the most common intervention attempted by LTC
nursing staff. We examined the influence of multimedia fall prevention
(MFP) training on safety awareness in PwD as demonstrated by
recognition of circumstances that could result in falls.
Methods: Ten LTC residents (age 77-95,mean(M)=88;MMSE
10-20,M=15; Katz ADL 1-4,M=2) with a history of falls were asked to
identify ‘Fall Threats’ that could make someone fall in 5 video clips.
Participants received 3-4 once-weekly 15 minute standardized MFP
training sessions, incorporating a total of 3-5 multimedia vignettes
which concerned daily activities and included common Fall Threats.
In post-tests 3-5 weeks AFTER the last training session, participants
were asked to identify Fall Threats in 5 novel video clips that did
NOT include circumstances featured in pre-test clips OR in the training
vignettes. Usual care nurses who were not involved in study procedures
recorded falls per state regulations. Repeated-measures
ANOVA was used to compare pre and post-test results and assess
awareness. Fall records were examined for 2 month periods prior to,
during (including the 3-5 week period before post-testing) and after
the study.
Results: Participants recognition of Fall Threats in 5 novel video
clips improved dramatically, (p

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and its sum of boxes. DLB patients without Capgras were able to tolerate
and continue taking cholinesterase inhibitors (p=0.03) without
other significant differences in medication management.
Conclusions
We found that DLB-C patients had more visual hallucinations,
and that caregivers of DLB-C patients endorse greater caregiver burden.
We were unable to discern specific patient characteristics or psychometric
performance data to help us predict who may be at greater
risk of developing Capgras syndrome. Future research is needed to
evaluate management and treatment options for the clinically challenging
behavioral sequelae of DLB and Capgras syndrome.
A140
Computational Modeling of Aging in Cardiac Myocytes.
P. Dalal, E. Sobie. Pharmacology and Systems Therapeutics, Mt. Sinai
School of Medicine, New York, NY.
Supported By: This research is supported by the Medical Student
Training in Aging Research (MSTAR) at Mount Sinai School of
Medicine.
BACKGROUND: The risk of susceptibility to more serious
forms of cardiac arrhythmia rises significantly with normal aging.
These forms of arrhythmia can manifest as palpitations, fibrillation,
and even sudden death. One indicator of arrhythmia risk is action potential
duration in cardiac myocytes. Specifically, the prolongation of
action potential leads to a larger vulnerability period towards after
depolarization. Such rogue depolarization can result in dangerous,
self-sustaining circular currents. Animal studies in the past have
shown that age associated molecular changes in cardiac myocytes include:
a 40% reduction in SERCA pump protein, a 20% reduction in
the transient outward current, a 59% increase in the peak L-Type calcium
channel current, and a 142% increase in the inactivation time
constant of the L-Type calcium channel. Additionally, the action potential
is prolonged by 92% in older rats when compared with
younger rats and the calcium transient decay is slower in aged rats
while its amplitude remains the same.
HYPOTHESIS: Implementing the molecular changes in rat myocytes
into the computational models of Hund (2004), et al and Ten
Tusscher (2004), et al will prolong the action potentials and slow the
calcium transient decay of these models, creating a computational
tool to study age associated arrhythmia risk.
RESULTS: After implementing the four major molecular
changes associated with cardiac aging, the action potential was prolonged
by 4% in the Hund (2004) model and by 77% in the Ten Tusscher
(2004) model. The calcium transient decay was slower in both
models while the calcium transient amplitude was only unchanged in
the Ten Tusscher (2004) model. In the Hund (2004) model, the amplitude
was increased.
CONCLUSIONS: It is possible to generate a computational
model that replicates the age associated changes seen in cardiac myocytes.
The Ten Tusscher (2004) model more accurately replicates
these changes than the Hund (2004) model.
A141
Isolated CNS Post-transplant Lymphoproliferative Disorder in a
Kidney Transplant Recipient.
S. Dahiya, W. Ooi, A. Asik. Internal Medicine/Division of Hematology
and Oncology, Baystate Medical Center, Springfield, MA.
Introduction
Post-transplantation lymphoproliferative disorder(PTLD)is a
very well recognized complication of solid organ transplantation. Its
incidence varies, depending on the graft recipient’s age,the type and
intensity of immunosuppression, and the organ type transplanted.
Extranodal involvement is common in PTLD, although the central
nervous system (CNS) is an uncommon site of disease, especially in
isolation. Literature review suggests less than handful of cases in geriatric
population.
Case
65 year old female presented with complaints of intermittent expressive
aphasia. Her medical history was remarkable for polycystic
kidney disease leading to kidney failure and thus requiring transplant.
Her transplant history includes, failed first transplant in 1995
from a deceased donor and subsequent living-related donor transplant
in 2005 from her son with unrelated blood type requiring heavy
immunosuppresion. She was on mycophenolate, tacrolimus and prednisone
for immunosuppressive regimen. Her neurological exam was
significant for word finding difficulty and left eye ptosis. Rest of the
physical exam was within normal limits. A spinal tap showed slight elevation
of proteins to 149mg/dl and decreased glucose to 36mg/dl,
raising a question of ongoing infectious process. An urgent MRI was
obtained which showed multiple discrete enhancing lesions throughout
the supratentorial and infratentorial white matter with leptomeningeal
involvement. An extensive infectious workup looking
for various causes of enhancing lesion in this severely immunosuppressed
patient was negative. A brain biopsy was eventually performed,
which showed monomorphic PTLD, categorized as EBV-associated
diffuse large B-cell lymphoma. Given her kidney disease, she
was started on a rather unconventional regimen with weekly rituximab
for 8 weeks and 4 cycles of monthly intrathecal cytarabine. Her
immunosuppresive regimen was changed to sirolimus only. She has
been in remission since last 1 year, but unfortunately developed allograft
rejection because of reduction in immunosuppressive regimen.
Discussion
Isolated CNS-PTLD following kidney transplant is exceedingly
rare. However, it must be considered as a differential in transplant patients
with CNS symptoms to avoid delay in diagnosis. Advanced age
is considered as a poor prognostic factor, but this elderly patient did
rather well with the unconventional regimen as outlined above.
A142
Deep Vein Thrombosis and Pulmonary Embolism (DVT/PE) with
JAK2 positive Polycythemia Vera (PCV) and mild hematologic
findings.
R. Lands, S. Kelley. Department of Medicine, University of Tennessee,
Knoxville, TN.
An 81-year-old man came to the emergency room after becoming
suddenly short of breath while taking a shower. Any exertion
after that exacerbated his dyspnea but was relieved by lying down. He
did not have chest pain, pleuritic or otherwise. He had no preceding
illness, immobilization or prolonged travel. He was previously
healthy with a history of hypertension and gout, but he was on no
meds at the time of admission. Physical examination showed him to
be in no distress at rest while wearing oxygen. Lungs were without
rales or rhonci and his respiratory effort was normal. There was no
edema of either lower extremity. High sensitivity D-Dimer was
greater than 5000 ng/ml. EKG demonstrated right heart strain. Chest
x-ray demonstrated elevation of the hemidiaphragm. Creatinine was
1.9 mg/dl. Ventilation perfusion scan of the lungs was interpreted as
high probability for left and right lower lobe pulmonary emboli.
Doppler venous studies demonstrated bilateral deep vein thromboses
of the lower extremities.
Hgb was 17 g/dl and Hct 53%. WBC was 32,000 without basophilia
or eosinophilia. Cells containing JAK-2 V617F mutation
were present. BCR/ABL was absent. Erythropoietin was 1 mIU/ml.
No further imaging was performed given his marginal renal function.
Review of his old records demonstrated a very mild leukocytosis and
upper normal hemoglobin levels for several years prior to this admission.
One month after discharge, he followed up in the hematology
clinic where his WBC was 15x103 and his hemoglobin 15.8mg/dL.
Discussion: JAK2 is a gain of function mutation with tyrosine kinase
activity that is present in 90% of patients with PCV. While it is
primarily a diagnostic marker now, there is evidence that it might
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have inherent procoagulant effect by itself. Prior to this admission,
our patient’s blood findings were only mildly abnormal. When he was
stable and on treatment for the DVT/PE, his blood findings reverted
to their previous levels. We believe this case demonstrates that even
mild elevations of blood elements should be investigated to rule out a
myeloproliferative syndrome in the context of thrombosis, and further
molecular testing might be warranted in some patients whose
blood counts are mildly, but consistently abnormal. Myeloproliferative
disorders, especially those that are JAK2 positive, should be considered
in the differential diagnosis of acquired hypercoagulation
syndromes.
A143
JAK2 positive Polycythemia Vera in a patient with sleep apnea.
Competing causes for erythrocytosis.
R. Lands, S. Y. Bae. Department of Medicine, University of Tennessee,
Knoxville, TN.
In the course of having blood work in her health maintenance, a
75-year-old woman was found to have an elevated hemoglobin. She
was not hypertensive, but had been treated for hyperlipidemia for
several years. She had a left body stroke about a year prior to the
clinic visit from which there was no residual and for which she was
taking aspirin. She had never smoked cigarettes. She complained of
fatigue and daytime sleepiness. Her husband noted that she snored,
but he had not observed apnea. She did not complain of restless legs.
Oxygen saturation was 98% on room air. The tongue was of normal
size. There was no abdominal organomegaly.
CBC demonstrated a hemoglobin of 17mg/dL and hematocrit of
50%. The white blood cell count and platelet counts were normal although
the platelets were quite large. The bone marrow demonstrated
panhyperplasia. Megakaryocytes were increased with prominent
pleomorphism. There was no increase in reticulin. JAK-2 V617F
was found to be present in a population of cells tested. BCR/ABL
was absent. Erythropoietin was 31mIU/ML (4.2-27.8), and the CT abdomen
demonstrated an enlarged spleen. She was placed on hydroxyurea
and one phlebotomy was performed.
In the interim, she reluctantly accepted a referral to a sleep specialist.
Sleep studies demonstrated mild to moderate sleep apnea. She
was prescribed C-PAP and quickly noted a remarkable improvement
in her fatigue and in her daytime somnolence. Furthermore, her hemoglobin
dropped into the low normal range, more than expected
from just one phlebotomy. The hydroxyurea and the phlebotomies
were discontinued. She has been compliant with her C-PAP has not
required resumption of hydroxyurea or phlebotomy in one year.
Discussion: With a hemoglobin greater than 16.5mg/dL and the
presence of JAK2, the patient met WHO diagnostic criteria for Polycythemia
Vera. The history of cerebrovascular accident and
splenomegaly further support a diagnosis of the myeloproliferative
syndrome. The inappropriately high normal erythropoietin level together
with the rapid improvement in her hemoglobin after treatment
for sleep apnea suggest that the predominate cause of her erythrocytosis
at the time of diagnosis was due to her sleep apnea. Myeloproliferative
syndromes may be quite subtle in their presentation and may
accompany other diseases that mask and delay their diagnosis.
A144
Calcium Supplement May be Associated with Optimal Responses to
Vitamin D Supplementation in Adults.
V. Heh, 1 C. Forman, 2 J. Gau. 2 1. Office of Research and Grants, Ohio
University Heritage College of Osteopathic Medicine, Athens, OH; 2.
Geriatric Medicine, OU-HCOM, Athens, OH.
Background: Deficiency of vitamin D is a common problem in
adult patients. There are efforts in aggressively treating these patients
as benefits have been shown in reducing the risk of falls and fractures.
Clinical observation suggests that some patients receiving a high-dose
supplement may not have achieved an optimal serum 25-hydroxy
(OH) vitamin D levels with months of therapy. The objective of this
study is to characterize factors that may be associated with patients’
responses to vitamin D supplementation. This characterization is
based on the existence of possible unobserved groups, also called latent
classes.
Methods: Medical records of a geriatric clinic population who
had baseline and follow-up serum 25(OH)D levels during the period
of January 2007 and June 2011 were reviewed. All patients received
vitamin D supplements to achieve levels above 30 ng/mL. Forty-one
adults receiving an average daily dose more than 3,300 IU per day.
These patients were sub-divided into two groups reflecting ideal (i.e.,
> 40 ng/mL; N=24) and suboptimal levels (N=17) of serum 25(OH)D
on the follow-up measurements.A cut-off value of 40 ng/mL was used.
Results: The two groups, ideal respondents and suboptimal respondents
to high dose regimens, were similar in age, gender, weight,
BMI measures, baseline 25(OH)D and serum calcium levels, average
daily dose (5,500 [1,800] vs. 5,100 [1,200] IU; p=0.44), and duration of
therapy (11.9 [7.3] vs. 8.6 [5.3] months; p=0.11). However, those patients
who had ideal levels of follow-up 25(OH)D had significantly
higher baseline serum albumin levels (mean =4.1 gm/dL, SD=0.4 vs.
mean =3.7 gm/dL, SD=0.4, p=0.026); were about 6 times more likely
to be on calcium supplements (12 [50%] vs. 2 [12%], p=0.018, Fisher’s
exact test). The suboptimal respondents were about 3 times more
likely to use oral laxatives; 9(64%) vs. 5(21%), p=0.048. After adjusting
for height, weight, and use of oral laxatives, calcium supplement
was associated with a better response to high dose supplementation.
Limitations of this study: small sample size, unknown compliance
with supplements, and not a controlled clinical trial study.
CONCLUSIONS: Calcium supplement may be associated with
patients’ responses to vitamin D regimens. Nutrition status and better
study design will need to be included in the future study.
A145 Encore Presentation
Nontuberculous mycobacterial infections in elderly patients with
rheumatological diseases.
V. Nagaraja, 1 J. Terriquez, 2 J. Lisse, 3 S. Hoover. 2 1. Arizona Center on
Aging, University of Arizona, Tucson, AZ; 2. Infectious Diseases,
University of Arizona, Tucson, AZ; 3. Rheumatology, University of
Arizona, Tucson, AZ.
Background: Non-tuberculous mycobacterial (NTM) infections
are frequently identified in elderly patients with rheumatologic disease.
Management of these infections can be challenging. The aim of
this study was to describe the management and outcomes of cases of
NTM infections in patients with any form of rheumatologic disease.
Methods: A retrospective chart review of inpatient and outpatient
records was performed at two health-care facilities. ICD-9 diagnostic
codes were used to identify patients with NTM infection. Patients
with any pre-existent rheumatologic disease were included in
the study. The review focused on rheumatologic disease, its treatment,
other co-morbidities, the NTM infection and its treatment, and impact
of the infection on the rheumatologic disease management.
Results: Of 339 patients with NTM infection, 11 with rheumatologic
disease were identified. Ten were females. The median age at the
time of diagnosis of the infection was 67 years. Eight cases were pulmonary
and 3 were extrapulmonary. 5/11 patients had radiologically
pre-existent bronchiectasis. There were patients with rheumatoid
arthritis(5), systemic lupus erythematosus(2), polymyalgia rheumatic(1),
scleroderma(1), polymyositis(1) and sarcoidosis(1). Patients
were on one of the following medications for a significant period of
time: prednisone, methotrexate, and anti-tumor necrosis factor (TNF)
agents. In 4/9 cases who were on immunosuppressive therapy, the implicated
medication was discontinued. In 3/9 it was continued, and in
2/9 it was restarted after a brief discontinuation. Mycobacterium
avium complex was the commonest species isolated. Treatment for
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NTM infection was started in 8/11 patients. 2/8 patients had recurrence
of the infection. 3/11 patients died, with no death directly related
to NTM infection.
Conclusions: This is the first study to describe the natural history
of NTM infections in an older rheumatologic disease patient cohort.
As in the general population with NTM infection, patients tended to
be female with pre-existing bronchiectasis. The infection could often
be successfully treated, but there appeared to be some risk of recurrence
in patients who are continued on immunosuppressive therapy.
Such cases will likely continue to be identified and more studies on
the optimal management is needed.
A146
Lack of Effort Towards Removal of Foley Catheters Before
Transferring Patients For Rehabilitation (Rehab).
M. S. Ashraf, 1 N. Sheikh, 1 V. Kinzie, 2 K. Cochran, 2 C. Faulk, 1
K. Ramsey. 1,2 1. East Carolina University, Greenville, NC; 2. Pitt
County Memorial Hospital, Greenville, NC.
Supported By: Study was supported in part by Centers for Disease
Control and Prevention
Background: Geriatricians commonly admit patients who are
discharged with indwelling foley catheters from the hospitals to subacute
care settings, and often these foleys are no longer indicated. We
designed a study to review the effort of various health care providers
towards removing foleys before discharging patients for rehab.
Methods: A retrospective chart review of hospital and rehab admissions
was performed on all adult patients admitted with an indwelling
foley to a 75 bed rehab facility over a period of 1 year (9/09 to
10/10). Data analysis was primarily descriptive to obtain the frequency
of appropriate documentation for presence of the foley, plan for its
discontinuation, timing of its removal and demographic information.
Results: Total of 114 patients (Median age 65 year, 51% Male)
were admitted in the facility with indwelling foleys and 103 hospital
charts were available for review. A majority (n=61) of them were discharged
by surgical teams as opposed to medical teams (n=42) and all
were evaluated by the rehab service. Rehab providers mentioned
presence of foley in their exams only 30% of the time. Similarly surgery
and medical teams recognized the presence of foleys in less than
half of the cases within 2 days before the discharge (38% & 31% respectively).
In many cases (n=64, 62%) rehab service did not make
recommendation to remove foley during hospitalization. Interestingly,
a third of these patients (n=24, 37.5%) had their foley removed
within 2 days of rehab admission. Even though the rehab providers
recommended removing foleys in 39 (38%) cases, the primary team
did not respond. Eventually 60% (n=23) of these foleys were also removed
within 2 days of rehab admission. Surgical and Medical teams
provided reasons for continuing foley in their final notes in only a
third of cases (34% & 33% respectively).
Conclusions: 1) We have identified that health care providers
frequently under-recognize the presence of foleys in patients who are
being transferred for rehab. 2) When they do identify, efforts are lacking
to remove it in a timely fashion. 3) There is a need for improved
communication among consulting rehab service, primary inpatient
teams and physicians at accepting facilities to promote timely removal
of foleys which should reduce the incidence of subsequent
catheter associated urinary tract infections in this patient population.
A147
Hyponatremia and falls in the elderly in hospital setting Neychelle
Fernandes MD,Mary Musuku MD, Arnold Eiser Md,FACP.
N. Fernandes. Internal Medicine, Mercy Catholic Medical
Center,Drexel university, Darby, PA.
Background:Falls are the most frequently reported adverse
events in inpatient settings.Mild chronic hyponatremia may appear to
be asymptomatic and remain unnoticed by both physician and patient
but has been associated with gait unsteadiness and attention deficits
in the elderly
Methods: The study objective was to determine the incidence of
hyponatremia in patients above 65 years who experienced a fall and
associated risk factors for falls
During a twelve month period from Sept 2009- Sept2010 serum
sodium levels were evaluated in 60 cases of falls in patients aged
65years and older and in 60 randomly selected non fall patients aged
65years and older seen in acute inpatient setting. The following data
were extracted for all patients: age, gender, medical morbidities, and
number of medications, details of medications, serum sodium level
and length of hospital stay. Initial blood chemistry on day of fall was
used for evaluation of hyponatremia. Non-fall group blood chemistry
on day of admission was used. Hyponatremia was classified as Serum
Na level less then 136mmol/l. Fall/nonfall groups who had a glucose
level on chemistry above 200 mg/dl were excluded from study. Use of
medication including drugs potentially associated with hyponatremia
- SSRI, diuretics, antihypertensive, benzodiazepines,psycholeptics
was also analyzed in both groups.
Results:Majority of fallers were female (75%) and mean age of
fall and non-fall groups were 78±8 and 79±7 respectively. Hyponatremia
was detected in 18 (30%) of fall group, compared to 5(18%) in
nonfall group (P value 0.0004). Mean sodium level was 131±3meq/l
and lowest level of serum sodium was 124meql/l in fall group. In fall
group when controlling for other independent risk factors hyponatremic
patients were four times more likely to fall (Pvalue0.004). .
Those in the fall group had a longer length of stay and were more
likely to be nursing home residents. A greater proportion of fallers
had multiple medical co-morbidities (HTN, CHF, AF) and were on
more likely to be on four or more medications at presentation than
non-fallers.
Conclusion:Hyponatremia is an independent risk factor for falls
in elderly acute inpatient setting and should be added to the list of
common conditions causing falls. Screening for low serum sodium
level,finding the etiology and treating it when present may be a step
forward to prevent falls and related injuries.
A148
Osteoporosis awareness in men at risk for fragility fracture and
osteoporosis.
S. Kashan, N. Lecea, G. Bachuwa. Hurley Medical Center, Flint, MI.
Supported By: No author received funding related to this research
project.
Background: Osteoporosis is a major public health problem. Its
hallmark is fragility fractures and increased risk of morbidity and
mortality which are known to be higher in men than in women. In
2001, the direct cost of osteoporosis was $17 billion for Americans
and $3.4 billion of which was related to the care for men. The number
of men age 50 and older with osteoporosis (and osteopenia) in the US
was predicted to increase from greater than 14 million in 2002, to over
17 million in 2010, and to well over 20 million in 2020.
Aim: Evaluate the awareness and knowledge of osteoporosis in
men. Estimate the proportion of men at risk for osteoporosis who received
appropriate screening. Estimate the proportion of men at high
risk for osteoporosis who received appropriate Calcium and Vitamin
D supplements.
Method: Our participants in this study were recruited by consecutive
sampling from the Hurley Medical Center Senior Ambulatory
Clinic. We included only Males who are greater than or equal to 54
years old. Participants were asked to fill a self-administered survey.
The questionnaire included questions about demographic data, Osteoporosis
awareness, diagnosis and treatment, Co-morbid medical
conditions and medications list including OTC and supplements. This
study was approved by the Hurley Medical Center Institutional Review
Board.
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Results: We distributed 250 questionnaires and 105 were returned.
Ninety-seven questionnaires were included based on our inclusion
criteria. On a 13-question examination, subjects with risk factors
correctly answered 5.3 (40.7%) questions correctly, compared to
4.1 (31.5%) by subjects without risk factors. Of subjects with risk factors,
only 15% believed that they were at risk for osteoporosis. Only
6% of subjects with risk factors had a Dexa scan done. Among patients
with a risk factor for osteoporosis, only 27% reported taking a
vitamin D or calcium supplement.
Conclusion: A good proportion of participants were aware of
the term osteoporosis, however many were not knowledgeable of the
disease itself. Having a risk factor for osteoporosis did not increase
the awareness of condition by itself. Only one fourth of patients with
risk factors have been taking Vitamin D or Calcium. A very small
number of patients, regardless of risk factors, had Dexa scan done.
Health care provides must do more to increase awareness of this
common and costly health problem.
A149
The Effects of Aerobic Exercise and Stretching on Self-Reported
Sleep Quality in Community Dwelling Older Adults with Cognitive
Complaints: A Randomized, Controlled Trial.
W. Goodson, 1,2 A. Bloch, 3 W. Santos-Modesitt, 1,2 K. Yaffe, 1,2
A. C. King, 4 D. E. Barnes. 1,2 1. University of California, San Francisco,
San Francisco, CA; 2. San Francisco Veterans Affairs Medical Center,
San Francisco, CA; 3. Alliant University, San Francisco, CA; 4.
Stanford University, Palo Alto, CA.
Supported By: This work was supported by the Alzheimer’s
Association (IIRG-06-27306), the National Institutes of Health
(K01-AG024069, KL2 RR024130), and an AFAR MSTAR Summer
Research Stipend.
Background: Sleeping difficulties are common in older adults
and are linked to poor health outcomes. Sedative use in older adults is
problematic because sedatives have been linked to an increase in
falls. There is an imperative for identifying effective, non-pharmacological
strategies for improving sleep in older adults. Exercise is an
appealing intervention because it is relatively low cost, does not require
a health professional and has potential health benefits beyond
sleep improvement. Few studies have directly compared aerobic exercise
and stretching effects on self-reported sleep quality in older
adults with cognitive complaints.
Methods: Participants were randomized into aerobic exercise
(n=63) and stretching groups (n=63) and completed 12-week interventions.
The primary outcome was a total sleep quality score derived
from 7 questions on the Sleep Disorders Questionnaire of the 2005-
2006 NHANES (Range: 0-28 with higher scores reflecting worse
sleep quality). Baseline characteristics of study participants were assessed
using analysis of variance, chi-square analysis, and Fisher
Exact Tests. Analyses of sleep quality change within groups and between
groups were conducted intent-to-treat and per protocol analyses,
which yielded similar results. Nearly half of participants did not
report any sleep problems at baseline and, therefore, could not improve.
As such, all analyses were repeated in the subgroup that reported
at least some sleep difficulties at baseline.
Results: Sleep quality did not change significantly within or between
the groups when the entire participant population was considered
(n=126). In the subgroup of participants who reported sleep
problems at baseline (n=72), there was a significant different between
the groups (p=.02) in which sleep quality improved within the stretching
group (12.0 to 8.8, p

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death because “nobody told me”. Retrospectively, some families suspected
that the healthcare providers knew death was approaching because
the older adult was moved to the comfort care hospital room or
the palliative care team was brought in, but the rationale for the action
was never disclosed or conferred to the family up front. In some
cases, family members knew death was approaching without being
told and sought out healthcare providers to arrange end-of-life care.
Providers who may or may not be perceptive to approaching death
either disagreed with the family and resisted, or agreed and facilitated
arrangements. In addition, there were inconsistent messages regarding
the end-of-life stage of life by providers.
Conclusions: From family’s perspective, healthcare providers do
not openly communicate about approaching death, do not provide
enough explanation how current condition may lead to death, and
there are variations in healthcare providers’ readiness to communicate
about end of life with patient and families.
A152
Adjustment to Aging: A Validation for Adjustment to Aging
Schedule (ATAS-33).
S. von Humboldt, I. Leal. Research Unit in Psychology and Health,
Instituto Superior Psicologia Aplicada, Lisbon, Lisbon, Portugal.
Supported By: This work was supported by a grant of the
Portuguese Science and Technology Foundation (FCT) [grant number
SFRH/BD/44544/2008].
Background: There has been little attention in the research literature
on adjustment to aging. This research aims at examining the relationships
between older adults’ adjustment and aging.
Methods: The measures used to in the study were selected to assess
the reliability and validity of one new instrument, Adjustment to
Aging Schedule (ATAS-33). Measures were completed using a variety
of culturally appropriate methods, including mail-outs, self-administration
and interviews. For the purposes of this study, the Health
Survey Questionnaire (SF-6D), one measure of cognitive functioning
- the Mini-Mental State Examination (MMSE) and demographics,
were included. All variables had fewer than 1% missing values and
there complete data were available for 709 older adults (mean age
82.4, SD = 6.45, (range 74-102)) from eight different nationalities. Exploratory
factor analyses were run for data reduction and for exploring
theoretical structure. Controlling for age, gender and country of
origin, we assessed the level of adjustment of elderly people, and its
effect on aging.
Results: The sampling adequacy was confirmed by the Kaiser-
Meyer-Olkin test (KMO=0.775) and the total variance explained by
this eight-factor structure is 75.09%. Adjustment to aging appears to
be a catalyst to attitudinal markers of maturity and internal development
which in turn impact quality of life and aging, across cultures.
All estimates were statistically significant (p

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A155
Intensity and Impact of Pain in Military Veterans Following Cancer
Treatment.
W. L. Mills, 1,2 A. June, 3 J. Moye, 3 B. Mulligan, 3 A. Jahn, 3 K. King, 3
J. Gosian, 3 L. Herman, 1,2 A. Walder, 1 A. D. Naik. 1,2 1. Health Services
Research & Development Center of Excellence, Michael E. DeBakey
VA Medical Center, Houston, TX; 2. Baylor College of Medicine,
Houston, TX; 3. VA Boston Healthcare System, Brockton, MA.
Supported By: Veterans Administration, Rehabilitation Research
and Development IIR Grant VA I01 RX000104
Background: According to the National Cancer Institute, more
than 60% of individuals with a cancer diagnosis will survive beyond 5
years, extending the time survivors must contend with cancer-related
complications and treatment, including pain. Poorly controlled pain
can negatively impact quality of life, increasing depression, anxiety,
and sleep disturbance. The purpose of this study was to improve care
provided to cancer survivors through increasing knowledge of the intensity
and impact of pain experienced in the post-treatment period.
Methods: Participants for this study were 120 adults (M age =
65) included in the Veterans Cancer Rehabilitation Study, which assesses
psychological and rehabilitation needs 6 and 12 months after
diagnosis of oral-digestive cancers. The participants, mostly white
(81%) and male (100%), were treated for head and neck cancers
(44%), esophageal (11%), stomach (3%), and colorectal (42%) cancers.
From the larger battery, the current study examines outcomes
from the Patient Reported outcomes Measurement Information System-29,
a self-report measure of quality of life and pain intensity.
Results: At 6 months, 22% of participants reported no pain, 39%
reported mild pain, 31% reported moderate pain, and 8% reported
severe pain. Survivors of stomach cancer reported higher levels of
pain (M=6.0) compared to head and neck (M=3.9), esophageal
(M=4.0), and colorectal (M=3.0) cancers, with differences approaching
statistical significance (p=.07). Participants endorsed interference
from pain, including daily activities (56%), work around the home
(52%), enjoyment of life (51%), and social activities (46%). Intensity
of pain was related to (all p values

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A158
Curved Path Walking Predicts 12-Month Physical Function in Older
Adults without Mobility Limited Physical Function.
R. M. Hibbs, 1 J. M. VanSwearingen, 1 S. A. Studenski, 2 J. S. Brach. 1 1.
Physical Therapy, University of Pittsburgh, Pittsburgh, PA; 2.
Geriatric Medicine, University of Pittsburgh, Pittsburgh, PA.
Supported By: Research/Grant Support: Pittsburgh Older
American’s Independence Center, 1 P30 AG024827; Pitt Clinical
Research Training- Geriatrics/Gerontology T32 AG021885; K23
AG026766
Background: Daily activities involve walking curves to navigate
and participate in the environment, particularly among older adults
who function within their home and community. We examined the
usefulness of measures of curved path and straight path walking to
predict future physical function in community-dwelling older adults
without mobility limited physical function.
Methods: Older adults (n=73, mean age, 77.1±6.0 years) independent
in ambulation and without mobility limited physical function
(Late Life Function and Disability Instrument, LLFDI, function >
mobility limited mean, 48.2) performed curved path walking (Figure
of 8 Walk test, time) and straight path walking (gait speed) at baseline.
Self-reported physical function, (LLFDI function, 0-100) was
recorded at baseline and 12 months. Receiver Operator Characteristic
curves were used to determine a cutoff value that optimized sensitivity,
specificity, and area under the curve (AUC) of the Figure of 8
Walk test time and gait speed for good physical function (LLFDI
function > non-mobility limited mean, 59.8) one year later.
Results: Curved path and straight path walking predicted physical
function at 12 months. Figure of 8 Walk time at an optimal cutoff
of 8.72s, sensitivity, 65.8%, specificity, 65.2%, and AUC=.704, p=.008
predicted LLFDI functioning. Gait speed at an optimal cutoff of
1.12m/s, sensitivity, 65.8%, specificity, 56.5%, and AUC=.667, p=.030
predicted LLFDI functioning.
Conclusion: Curved path walking was a little better than gait
speed in identifying individuals who did not have good physical function
one year later among older adults without mobility limited physical
function. Curved compared to straight path walking may better
represent the complexity of walking in daily life characteristic of activities
of well functioning, community-dwelling older adults.
A159
Dementia, Delirium, and Capacity to Consent to Research among
Older Post-acute Care Recipients.
S. E. Hardy, S. A. Studenski. Medicine/Geriatrics, University of
Pittsburgh, Pittsburgh, PA.
Supported By: NIA, Hartford Foundation
Background: Dementia and delirium present particular challenges
for research in post-acute care (PAC). We examine the relationship
between cognitive function, delirium, and the capacity to
consent to participation in an observational study of older adults
newly admitted to skilled nursing facilities for PAC.
Methods: We assessed capacity to consent with a 5-item instrument
measuring understanding of the study procedures, risks, and
benefits; cognitive function with the Montreal Cognitive Assessment
(MoCA), delirium with the CAM. Among those with significant cognitive
impairment, we assessed pre-hospital cognition via proxy using
the IQCODE. ADL function was assessed on a scale of 0-14 with
higher scores representing greater impairment and depressive symptoms
were assessed with the PHQ-9.
Results: Of the 179 participants assessed for capacity, 138 (77%)
were deemed able to provide consent to participate. Of those able to
consent, 1 declined to consent, 8 were ineligible to participate (for
reasons unrelated to cognition), and 8 withdrew prior to the baseline
assessment. Of the 41 without capacity, 8 were excluded because no
surrogate was available and 2 because the surrogate declined to consent,
2 were ineligible, and 1 withdrew prior to baseline assessment.
The characteristics of the remaining 149 participants by capacity to
consent are presented in the table. Regardless of capacity to consent,
the 51 participants with significant cognitive impairment (MoCA

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A161
Discharge to subacute rehabilitation as a predictor of 30 day
readmission in elderly patients with acute decompensated heart
failure.
W. Qureshi, 1 F. Khalid, 1 Z. Alirhayim, 1 M. Al-Mallah. 2,3 1. Internal
Medicine, Henry Ford Health Systems, Detroit, MI; 2. Department of
Cardiology, King Abdul-Aziz Hospital, Riyadh, Saudi Arabia; 3.
Wayne State University, Detroit, MI.
Background: Acute decompensated heart failure is the admission
diagnosis in 1/10th of all the hospitalization in US. Many of these
patients may be discharged to rehabilitation centers or home with
physical therapy. It is not known if the patient’s discharge disposition
is a predictor for 30 - day readmission. The aim of the study was to determine
if there was a difference in readmissions in patients discharged
to home with physical therapy compared to subacute rehabilitation
center.
Methods: This is a single-center retrospective parallel group cohort
study. Chart reviews of all the patients from 2009 - 2010 with primary
DRG of acute decompensated heart failure was carried out.
Primary outcome was 30-day all cause readmission. Secondary outcome
was 1-year mortality. The baseline characteristic differences
were evaluated by chi-square test and t-test. Logistic regression was
used to adjust for baseline variables hypertension, diabetes, dysplipidemia,
presence of coronary artery disease, age, gender to predict the
binary outcome as readmission versus no readmission based on the
discharge disposition.
Results
Out of 1543 total admissions, 542 were discharged to either
home with home physical therapy or subacute rehabilitation center.
The mean age was 75.3 +/- 7.0 years and females were 61%. Out of
these, 324 (59.8%) were discharged to subacute rehabilitation center
and ischemic cardiomyopathy was present in 335 (61.8%) of the patients.
There were 256 (47%) 30 day readmissions to the hospital.
About 66 (12.2%) of the patients died within 1 - year. Discharge to
subacute rehabilitation was associated with higher readmission rates
(adjusted OR 1.84; 95% CI, 1.19 – 2.83) p = 0.005 while, there was no
difference in the secondary outcomes. There was no significant difference
in the all-cause mortality (adjusted OR 1.56; 95% CI, 0.84 – 2.9)
p = 0.16.
Conclusion
This study shows that even after adjustment for baseline characteristics,
discharge to subacute rehabilitation was a weak but independent
predictor of 30 – day readmission. This might be because of
early detection of an exacerbation of acute decompensated heart failure
at subacute rehabilitation center as compared to at home; however
there was no significant association of mortality with the discharge
disposition.
A162 Encore Presentation
Fighting the weekend trend: increased mortality in older adult TBI
patients admitted on weekends.
S. A. Hirani, 1,2 E. B. Schneider, 2 H. L. Hambridge, 2 E. R. Haut, 2
A. R. Carlini, 2 R. C. Castillo, 2 D. T. Efron, 2 A. H. Haider. 2 1.
University of Texas Southwestern Medical School, Dallas, TX; 2.
Surgery, Johns Hopkins School of Medicine, Baltimore, MD.
Background: Weekend admission is associated with mortality in
cardiovascular emergencies and stroke. We sought to determine
whether weekend vs. weekday differences exist for older adults with
substantial head trauma.
Methods: Data from the 2006-2008 Nationwide Inpatient Sample
were combined and head trauma admissions were isolated. Abbreviated
Injury Scale (AIS) scores were calculated for using ID-
CMAP. Individuals aged 65 to 89 years with head AIS = 3 or 4 and no
other region score > 3 were included. Individuals with missing mortality,
gender or insurance data were excluded. Wilcoxon rank sum
and Student t-tests compared LOS, demographic, and total charge
data. Chi-square tests compared gender and head injury severity. Logistic
regression modeled mortality adjusting for age, gender, injury
severity, comorbidity and insurance status.
Results: Of the 39,728 patients meeting criteria, 10,189 (25.6%)
were admitted on weekends. Mean age was similar but more weekend
admissions were female (51.5% vs. 50.0%, p = 0.011). Weekend
patients demonstrated slightly lower comorbidity (mean Charlson =
1.09 vs. 1.15, p < 0.001) and head injury severity (58.5% vs. 60.9%
AIS=4, p < 0.001). Median weekend LOS was shorter (4 vs. 5 days, p <
0.001), but total charges did not differ. Proportional mortality was
higher among weekend patients (9.4% vs. 8.4%, p = 0.001). After adjustment,
weekend patients demonstrated 17% increased odds of
mortality (O.R. 1.17, 95% CI: 1.08-1.26).
Conclusions: Older adults with traumatic brain injury admitted
on weekends are less severely injured, carry less comorbidity and
generate similar total charges compared to those admitted weekdays.
However, weekend patients demonstrated 17% greater odds of
mortality.
A163
Postoperative Cognitive Complications in the Elderly: Risks and
Outcomes.
S. J. Agarwal, M. G. Erslon, S. D. Kelley. Covidien, Mansfield, MA.
Supported By: Covidien
Background: Cognitive complications occur in elderly patients
following surgery. The burden of postoperative cognitive complications
(POCC) is difficult to assess due to differences in determining
and documenting POCC. We utilized a large administrative database
to assess the incidence, risk factors and patient outcomes associated
with POCC in elderly patients across the top 5 major diagnostic categories
(MDC).
Methods: Inpatient surgical discharges in the top five MDCs for
patients older than 50 years from the Premier Perspective® Database
(Premier, Inc.) for CY2010 were selected. POCC was identified by
ICD9 codes 780.09 and 293.0. We determined incidence and used
multivariate logistic regression to estimate the adjusted risk of POCC
based on age (reference: 50-64 years old), admitting status, general
anesthesia (GA), ICU stay, comorbidity and MDC type (reference:
circulatory system surgeries). We compared mortality, length of stay
(LOS), costs and discharge disposition between patients with and
without POCC.
Results: 576821 discharges were selected, and 6553 (1.1%) were
coded for POCC. The risk of POCC increased with age (85+ years:
311% increased risk), ICU stay (183% increased risk), non-elective
admission (94%), and GA (19%). Compared to circulatory system
surgeries, other surgeries increased risk of POCC: musculoskeletal
(158% increase), digestive system (86%), nervous system (48%) and
hepatobiliary/pancreatic (46%). Patients with POCC had increased
inpatient resource utilization and compromised outcomes (Table 1).
Conclusion: Although the incidence of POCC based upon ICD9
coding was limited, the reported cases were associated with significantly
increased inpatient mortality, facility discharge, LOS and costs
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compared to patients without POCC. Age, emergency admissions,
ICU stay and GA independently increased risk for POCC. Large administrative
databases and coded definitions of POCC should facilitate
studies to determine whether preventing or managing POCC in
elderly surgical patients improves outcomes.
Table1: Outcomes for patients with and without POCC
All comparisons are significant at p < 0.001
A164
Can a simple frailty score predict outcomes in elderly patients
undergoing cardiac surgery?
S. Kim, 1 J. Chikwe, 2 L. Croft. 1 1. Cardiology, Mount Sinai School of
Medicine, New York, NY; 2. Cardiothoracic surgery, Mount Sinai
School of Medicine, New York, NY.
Supported By: MSTAR
Elderly patients tend to have more postoperative complications
and longer lengths of stay following cardiac surgery.They also display
a range of biological statuses that varies from robust to frail, which
makes predicting their surgical outcomes difficult. Frailty is an emerging
concept in geriatrics that can account for a patient’s physiological
reserve, and therefore useful in predicting outcome following cardiac
surgery. As such, the two objectives that were investigated include:
1. Are there easily assessable preoperative variables that can
measure frailty in elderly patients undergoing cardiac surgery?
2. Can such variables be used to predict clinical outcomes in elderly
patients following cardiac surgery?
Data was collected from the New York State Cardiac Surgery
Database and EPIC/EDR for patients ≥ 70 years. Categories of preoperative
variables collected to determine frailty included nutritional
status, functional status, mental status, and social support status. An
unweighted frailty score was calculated with these variables, and patients
with a score ≥ 3 determined as frail. Univariate and multivariate
logistic regression models were used to determine independent
predictors of the major outcomes (Early postoperative mortality &
morbidity; Prolonged length of stay; Discharge to institution). Statistical
analysis was performed using IBM SPSS Statistics for Mac 19.0.
The frailty score was significantly related to whether or not patients
were institutionalized following cardiac surgery (P=.003). Although
the frailty score did not predict any major outcomes, individual
variables used to calculate frailty did predict them. Impaired
mental status significantly predicted early postoperative morbidity &
mortality (OR=8.5, 95% CI: 1.2-58.2), while being dependent in activities
of daily living significantly predicted receiving institutionalized
care (OR=3.2; 95% CI: 1.3-8.1).
The unweighted frailty score by itself does not predict any major
outcomes, but individual variables like impaired pre-operative mental
state and lower Katz index do predict them. These can be used to
identify at risk frail patients early, for whom providers of surgical care
may intervene more aggressively to prevent poor clinical outcomes.
A165
Functional capacity as possible predictor of outcome in older
patients who are undergoing surgery for urological malignancies.
S. Sun, 1,2 V. Shklar, 1 H. Yulico, 1 B. Korc-Grodzicki . 1,2 1. Medicine,
MSKCC, New York, NY; 2. Medicine, Weill Cornell Medical College,
New York, NY.
Background
Urological cancers are disease of the older persons and many
geriatric patients undergo major urological surgeries to achieve curative
treatment. In order to understand their unique physiologic vulnerabilities,
it has become very important to recognize the factors
which lead to poor outcomes in these geriatric patients. Previously,
pre-existing cognitive dysfunction has been shown to predict delirium
and markers of frailty have been shown to predict 6 month mortality.
Method:
This is a retrospective review of patients who are 75 years of age
or older in whom geriatric specific assessment has been performed
prior to major urological cancer surgery in a tertiary cancer center.
Geriatric preoperative assessments were performed by 4 geriatricians
over the course of one year (January 1, 2010 to Decmber 31, 2010).
The evaluation included, independence in basic activities of daily living(ADLs)
and instrumental ADLs(iADLs), Charlson comorbidity
index, albumin, Mini-Cog test, Hb, and falls within last 6 months. Outcome
measures included presence of postoperative delirium, 30 day
and 90 day postoperative mortality.
Results:
Forty seven patients(age 78.3±3.4) underwent geriatric preoperative
assessment prior to major urological surgeries. Fourteen patients(30%)
were female and 41 patients(87%) identified themselves
as caucasians. Twenty six patients (55%) were identified as having
bladder cancer or urothelial carcinoma. Thirty day mortality was 0%
and 6 month mortality was 4.3% (2/47). Fifteen percent(7/47) of the
patients developed delirium postoperatively. Of those seven, 1 patient
died within 90 days of the surgery and both of the 6 month mortality
cases had delirium postoperatively. Three out of 7 patients who
developed delirium were dependent on ADLs or iADLs. More than
91% of the patients who did not develop delirium were independent
of ADLs and iADLs. There were no difference in Hemoglobin level,
albumin level, and Charlson comorbidity index score between the
two groups of patients who developed delirium and who did not. History
of falls and Mini-cog test did not seem to be associated with postoperative
delirium.
Conclusions:
Dependency in basic and/or instrumental activities of daily living
seems to be a candidate for predictor of postoperative delirium.
Patients who developed delirium had greater risk of dying within 6
months of surgery.
A166
Relationship between age and incidence of chronic pain developing
after cardiothoracic surgery.
A. Raju, 1 M. Eckmann, 1,2 M. B. Little. 1,2 1. The University of Texas
Health Science Center San Antonio, San Antonio, TX; 2. University
Health System, San Antonio, TX.
Supported By: AFAR- MSTAR Program
Background:
The effect of age on the development of chronic pain has been
considered, but these studies have been on a limited population. In
addition, studies have indicated that the occurrence of other outcomes
such as depression/anxiety, neurological/cognitive problems,
and sleep disturbances increase post-CT surgery, but these outcomes
have not been quantified, nor have they been analyzed by age. Most
of the existing studies have been in the form of patient questionnaires.
Objective:
To determine if age affects the incidence of post-surgery outcomes
such as chronic pain, depression/anxiety, neurological problems,
and sleep disturbances.
Methods:
A retrospective medical record review at University Health System,
San Antonio was performed for CT surgery patients between
5/15/2006 to 5/15/2009 (n= 412). Post surgery medical records were
analyzed to determine if the patient developed any outcomes of interest
and the date of onset. A Fisher test with a 2x2 contingency table
using p < 0.05 as significant was used to analyze results.
Results:
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The incidence of the high occurrence outcomes were chronic
pain (22.3%), neurological problems (20.4%), and depression/anxiety
(14.1%). Patients above 60 years of age had significantly lower incidence
of chronic pain (p = 0.0129), depression/anxiety (p = 0.0017),
and neurological problems (p = 0.015).
Conclusions:
Patients above 60 years of age had lower incidences of all outcomes,
possibly because of their retired lifestyle being less stressful
and less physically demanding. Another contributing factor is older
patients having more severe health problems such that these outcomes
go unrecognized. In addition, cultural differences between
generations may mean that the older generation is more tolerant of
pain and less likely to seek care for these symptoms.
Presidential Poster Session B
Thursday, May 3
4:30 pm – 6:00 pm
B1
Are osteosarcopenia, sarcopenia and osteoporosis different
syndromes? Results from the Women’s Health and Aging Study
(WHAS) II.
A. Frisoli, 1,2 A. Diniz, 1 J. Diniz, 1 S. Inghan, 1 P. Chaves. 2 1. Cardiology
Division, Federal University of São Paulo, Sao Paulo, Brazil; 2. Center
on Aging and Health, Johns Hopkins University, Baltimore, MD.
Substantial heterogeneity is observed among sarcopenic and osteoporotic
patients, however, the concomitant occurrence of these
two syndromes has not been evaluated. The goal of this study was to
examine the body composition and muscle strength profile among osteoporosis,
sarcopenia and osteosarcopenia in community-dwelling
older women.
Methods: Cross-sectional analysis of data from WHAS 2, an observational
study of the epidemiology of disability onset in community-dwelling
older women, Baltimore, USA. The analytic sample for
this study included all women who underwent DEXA evaluation and
had available data on fat, muscle and bone mass (n=248). Osteoporosis
was defined as a bone mineral density (BMD) t-score

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Methods: We are conducting a 6-week, randomized, 3-arm clinical
trial to compare the efficacy of 2 tailored, multi-component exercise
programs for improving physical performance of older PCa patients
on ADT. Men, aged 70 and older, were randomly assigned to
either an established progressive resistance and walking program
(EXCAP), a similar home-based computer-generated exercise program
utilizing Nintendo’s Wii-Fit technology (Wii), or a usual care
arm (UC). Assessments were completed at baseline and post-intervention.
Primary outcome was a comparison of change scores on the
Short Physical Performance Battery (SPPB) (0-12). Secondary outcomes
were comparisons of changes in lean muscle mass (DEXA),
chest press repetition maximum (CPRM), handgrip strength (HG),
and total body weigh (TBW). T-tests were used to compare change
scores between arms.
Results: Sixteen (of 30 projected) men have completed post-intervention
assessments (7 in Wii, 4 in EXCAP, and 5 in UC). The
mean age of participants at enrollment was 76.9 years (70-87) and
mean SPPB score was 7.6 (4-11). Mean duration of ADT was 57
months. Mean SPPB scores improved by 1.25 in Wii vs UC (p=0.054),
while mean scores improved by 1.33 in Wii vs EXCAP (p=0.061).
There was no significant difference in change of scores between
EXCAP and UC (p=0.903). Mean total body weight decreased by 4
kg in Wii vs UC (p=0.092) and mean handgrip strength increased by
4.37 kg in Wii vs UC (p=0.0274), and mean CPRM increased by 12.9
reps in Wii vs UC (p=0.092). Lean muscle mass improved by 820
grams in Wii compared to UC, although this was not statistically significant
(p=0.42).
Conclusions: Change scores were improved in all measures for
Wii arm, while there were no changes in UC arm. This pilot study
demonstrates the potential of Wii Fit technology to improve physical
performance in older men on ADT over 6 weeks.
B4
REDD in the elderly.
A. Chakka, A. Garrido, T. Iloabuchi, F. Perez. Geriatrics, Indiana
University, Indianapolis, IN.
81 y/o AAF with h/o Dementia, HTN, Gout, Hypothyroidism,
DVT s/p IVC filter and GI bleed was admitted for decreased PO intake
and weakness. She had B/L leg pain and progressive edema. Patient
was only on Levothyroxine as all her medications were stopped
for drug induced hepatitis. On exam- lethargy; Tmax-39.4’ C, BP-
76/40, HR-94. Oral mucous membrane hyperemia; RS- clear; CVS-
RRR; ABD- soft, BS+; CNS- confusion; BLE- 2+ edema; Skin- diffuse
macular erythema. Labs: Wbc- 11.5, Eos- 15, Pl.let- 29, BUN/Cr-
25/1.39 (baseline cr- 0.49), UC+ staph.aureus, BC+ MSSA. TEE, CT
chest/abdomen, and vasculitis work up were negative. Patient was admitted
to ICU with sepsis and treated with cephazolin for 3 weeks.
Patient was stable in a week, erythema resolved but a week later developed
generalized desquamation involving palms and soles with
itching, which resolved in 2 weeks. Ten days later she was re-admitted
for abdominal pain, hypotension and hypothermia. She had a similar
clinical picture associated with myositis and the same diffuse erythema
followed by diffuse desquamation, which continued over 4
weeks till she was discharged.
DISCUSSION:
The Differential Diagnosis consisted of Staphylococcal Toxic
shock syndrome (TSS), Stevens - Johnson syndrome, Toxic Epidermal
Necrolysis, Kawasaki disease, Mercury Poisoning and Syphilis. Patient
was diagnosed with a TSS variant, recalcitrant erythematous
desquamating disorder (REDD)[1]. It is a toxin-mediated illness[2],
usually precipitated by infection with Staphylococcus aureus. REDD
is a presumed variant of TSS and is distinguished from classic TSS by
its subacute presentation and recalcitrant course. Although the majority
of patients described to date have had acquired immunodeficiency
syndrome (AIDS), some cases without AIDS have been reported.
Our patient did not have any risk factors for HIV. The
diagnostic criteria met by our case are: Temp > 38.9 ‘C, SBP < 90
mmHg, Diffuse macular erythema with subsequent desquamation involving
palms and soles and multiorgan involvement. To our knowledge
this is the first case report of REDD in an elderly patient.
REFERENCES:
1. Verbon, A. and C.J. Fisher, Jr., Severe recalcitrant erythematous
desquamating disorder associated with fatal recurrent toxic
shock syndrome in a patient without AIDS. Clin Infect Dis, 1997.
24(6): p. 1274-5.
2. Manders, S.M.,Toxin-mediated streptococcal and staphylococcal
disease. J Am Acad Dermatol, 1998. 39(3): p. 383-98; quiz 399-400.
B5
Fever of Unknown Origin in women with osteoporosis.
B. Peddagovindu, E. Oleson, C. DuBeau. Geriatrics, UMass Med
School, Worcester, MA.
Introduction:
Recognition of atypical presentation of disease and prescribing
cascades from adverse drug effects (ADEs) are tenets of geriatric
care. We present 2 cases of an ADE and the costly investigative cascade
that followed it due to non-recognition of the uncommon pattern
of the ADE.
Case 1:
A 63yo woman with osteoporosis, hypertension, diabetes,
COPD, pneumonitis and anxiety who was a poor historian was hospitalized
due to fever 101.3, malaise, myalgia, nausea/vomiting, cough
and dyspnea of one-day duration. Initial work up for infectious
causes was negative. She received zoledronic acid (ZA) for treatment
of osteoporosis 2 days prior, but it was not on her medication list and
not discovered until 5 days into her stay. She continued to have fevers
spikes to 101F and dyspnea. Empiric antibiotics for pneumonia were
given for 5 days and repeat fever work up was negative. She was discharged
after 1 week with diagnosis of fever from ZA ADE upon exclusion
of other causes.
Case 2:
A 71yo woman with history of non-hodgkin’s lymphoma, cirrhosis,
anxiety, osteoporosis, and nephrolithiasis was hospitalized due to
fever 101F, and nausea/vomiting 1 day after ZA infusion and discharged
in 24h after symptom control and negative infectious work
up. She then developed a rash on her neck thought to be shingles and
was given valcyclovir. She was seen by ID and given doxycycline for
suspected tick borne illness. Due to daily fevers to 101F and worsening
cough she was readmitted 12 days after original d/c. Per ID and
oncology, pertussis titers, serology for tick-borne illnesses and CT
chest/abdomen/pelvis for possible lymphoma recurrence done were
negative. After 20 days, diagnosis of exclusion of fever from ZA was
made. Total duration of fever was more than 20 days.
Discussion:
Fever is the most common ADE of ZA, likely from an increase
in TNF-a and IL-6. In cases presented, patients had extended hospital
stays and costly work ups because 1) ZA use was initially missed, and
2) duration of fever > 72 hrs (usual for this ADE), “atypical presentation”
of ZA ADEs, was not recognized. ZA fever may last 14+ days
with rash and cough. These cases demonstrate the need to keep ZA
on active med lists, understanding and informing patients about ZA
ADEs, and using careful follow-up rather than costly evaluations for
even prolonged fever after ZA. Prevention with acetaminophen or
ibuprofen following ZA infusion can decrease this common ADE.
B6
81 year old man hospitalized with hypercalcemia - of course its
cancer!
C. Hathaway, D. Bynum. Division of Geriatric Medicine and Center
for Aging and Health, University of North Carolina, Chapel Hill, NC.
Supported By: University of North Carolina Division of Geriatric
Medicine and Center for Aging and Health
Introduction: It is very unusual for patients in the geriatric population
to present with sarcoidosis as a new diagnosis, and thus there
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is a paucity of literature about this unique subgroup of patients. Sarcoidosis
is a systemic illness that typically presents in younger populations;
peak incidence is between the ages of 20-40. Typical symptoms
on presentation are systemic malaise, fever, and pulmonary
complaints. There is a gender predilection with women being affected
more often than men, and a racial predilection with African Americans
affected more so than Caucasian populations.
Case: An 81 year old Caucasian man with a medical history of
coronary artery disease, chronic obstructive pulmonary disease, and
laryngeal cancer status post resection presented with a three week
history of decline characterized by weakness, confusion, and frequent
falls. Upon admission the patient was found to have an elevated calcium
level of 13.5 mg/dL. Chest roentogram was unremarkable, but
computed tomography of the chest with contrast revealed mediastinal
lymphadenopathy. Lab results demonstrated parathyroid hormone
(PTH) 20. The captopril challenge test confirmed
the results in 2 patients, while Case 2 had an elevated ratio twice. CT
scans of the abdomen were performed in 2 cases, revealing normal adrenal
glands. All 3 patients were diagnosed with primary aldosteronism
(PA) and were treated medically with spironolactone. In Case 1
and 2, all BP medications were discontinued with the exception of
spironolactone (50 mg daily in Case 1 and 125 mg daily in Case 2). In
Case 3, BP improved with the addition of spironolactone 125 mg daily.
Discussion: Idiopathic PA peaks in the sixth decade of life. PA
has a prevalence of 5-15%. These 3 cases were found within a small
primary care clinic panel of 215 patients. PA can commonly be found
in a community-based primary care geriatric clinic setting (not just in
specialized HTN referral centers). These cases had been treated as essential
HTN for 1-2 years before diagnosis. The diagnosis may frequently
be missed if not considered, including in HTN patients without
hypokalemia. The Endocrine Society recommends that patients
who have BP>160/100, or drug-resistant HTN, or HTN with spontaneous
or drug-induced hypokalemia be screened for PA. In Case 1
and 2, polypharmacy was markedly reduced. In Case 3, although BP
improved, polypharmacy was not reduced, perhaps suggesting PA
plus essential HTN. Even if the diagnosis of PA was a false positive,
spironolactone is an effective BP medication to be considered in
drug-resistant HTN. More importantly, there is now evidence to suggest
that aldosterone excess in PA leads to adverse cardiovascular
and renal outcomes independent of its effects on BP. Treatment
specifically directed against aldosterone excess protects against the
development of these complications more effectively than non specific
BP medications, further emphasizing the importance of not missing
the diagnosis of PA.
B9 Encore Presentation
Bilateral popliteal vein aneurysms: a rare cause of leg pain.
F. Cardona, 1 T. T. Suh, 1 M. Sideman. 2 1. Division of Community
Geriatrics, Department of Family and Community Medicine, UTH-
SCSA, San Antonio, TX; 2. Division of Vascular & Endovascular
Surgery,Department of Surgery, UTHSCSA, San Antonio, TX.
BACKGROUND: Although popliteal vein aneurysms (PVAs)
are the most common reported venous aneurysms, they are still rare
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with only about 125 cases published in the literature. When encountered,
PVAs are usually unilateral, with only 7 reported cases of bilateral
PVAs. The causes of PVA are unclear, but are thought to result
from congenital vascular malformation, inflammation, trauma or degenerative
changes. Age at presentation is variable, ranging from 27
to 79 years. We describe the oldest case of PVAs to date.
CASE: An 81 year old retired mail carrier presented with burning
sensation in his lower extremities and discomfort after prolonged
standing, which began to limit his activities. Physical examination revealed
bilateral lower extremity varicose veins along the greater
saphenous vein and pain on palpation of the right leg. Duplex ultrasonography
showed bilateral PVAs without any evidence of thrombosis.
Three months later, his leg pain became more persistent, with
worsening pain at night. Serial resections of the PVAs were performed,
leading to complete resolution of the leg pain and return to
his previous activity level and independent functional status.
DISCUSSION: First described by Sir William Osler in 1915,
PVAs are uncommon and the exact incidence is unknown. The clinical
presentation of PVAs is widely variable; however, over 50% of the
reported cases present as thromboembolic disease, with pulmonary
embolism being the most common presentation (47% of cases vs. 7%
for deep venous thrombosis). Diagnosisof PVAs because of leg pain
has been reported in only 12% of cases, while 20% have been associated
with the presence of varicose veins. Since only 5% of reported
cases have been bilateral, this case represents an unusual presentation
of PVAs. Duplex ultrasonography remains the diagnostic test of
choice, although newer techniques have emerged such as CT angiography
and MRI. Surgery is indicated whenever thromboembolic disease
is present regardless of PVA size or if the PVA size is greater
than 20mm. Anticoagulation for six months is generally recommended
during the post-operative period. Geriatricians need to be
aware of this condition since it can present in older adults.
B10
Challenges in diagnosing Creutzfeldt - Jakob disease.
G. K. Penmetsa, 1 E. Zamrini. 2 1. Geriatrics, University of Utah hospital,
Salt lake city, UT; 2. Center for Alzheimer’s Care, Imaging and
Research, University of Utah, Salt Lake City, UT.
Background:The rate of progression of cognitive impairment
provides important insight into the differential diagnosis of dementia.
Creutzfeldt-Jakob disease (CJD) is a rare neuro-degenerative disorder
characterised by very rapid decline in cognitive and motor function.
Diagnosis can be challenging
Case history: A 65 year old previously healthy and fully functional
man with no significant past medical problems was admitted to
an outside hospital for sub-acute change in alertness and cognitive
function over a period of 2 weeks. He could no longer engage in any
family activities, communicate fluently or name family members, and
required moderate assistance with all activities of daily living
(ADLs). Extensive inpatient work-up included blood work, CSF
studies and brain MRI, but the patient remained without a specific diagnosis
at discharge on a tapering burst of prednisone. When referred
to the University of Utah neuro-cognitive disorders clinic four weeks
later, he was doubly incontinent and fully dependent in all ADLs. He
also had personality changes, myoclonic jerks, ataxia and falls. CJD
was suspected by the consultant and review of the outside hospital
MRI with adjustment of the contrast windows revealed cortical ribbons
and increased signal in the basal ganglia on diffusion weighed
images (DWI) and FLAIR. The family was counselled. The patient
was placed in hospice and died shortly afterwards.
Discussion: CJD is a fatally progressive prion disease characterized
by rapidly deteriorating dementia. The diagnosis of CJD may be
made by performing an EEG, brain MRI or CSF studies for 14.3.3
protein. MRI findings of cortical ribbons on DWI windows have
higher sensitivity and specificity for CJD. The brain MRI was initially
reported as inconclusive,but further review of the same images by the
cognitive neurologist and a neuro-radiologist demonstrated cortical
ribbons. This case highlights the need to consider CJD in patients
with rapidly progressing dementia. It also offers insight towards the
utility of expediting clinical consultation and expert review of imaging
studies in diagnosing CJD.
B11
Encephalopathy Responsive to Zolpidem.
M. Howard, 1 D. Rye, 2 J. Greene, 2 A. I. Levey. 2 1. Geriatrics, Emory
University, Atlanta, GA; 2. Neurology, Emory University, Atlanta, GA.
Encephalopathy has a wide variety of etiologies and presentations
as in this case of sub acute persistent altered mental status.
Zolpidem is FDA approved for treatment of primary insomnia. A
newer active area of research is exploring its activity in patients with
altered levels of consciousness.
A 64 year old Caucasian woman was referred to a university
neurology memory clinic with sub acute onset of altered mental status
over the preceding 3 months. Shortly following a European vacation,
the previously healthy woman became progressively more paranoid,
anxious, confused, insomnic, and dependent in activities of daily
living. Previous evaluation included brain imaging and lumbar puncture
without definitive diagnosis. She was given empiric treatments
including benzodiazepines, antipsychotics, and antidepressants which
had no effect except for zolpidem which her husband noticed caused
normalization of her behaviors and functional and cognitive abilities
for a few hours following the dose. In clinic, exam showed marked
anxiety with prominent deficits in attention and concentration as well
as problems with memory and language (particularly fluency), increased
rigidity, and frontal release signs.
Upon hospital admission, workup included neurologic examination
on and off of zolpidem, placebo, lorazepam and flumazenil. Objective
improvement in neuropsychological function was noted only
with zolpidem and worsening with flumazenil. Continuous EEG
monitoring was normal. On functional MRI she was unable to do
tasks before medication but after 24 hours on zolpidem she was able
to do tasks and had normal activation of expected areas. FDG-PET
imaging showed improvement in hypometabolism of multiple brain
regions on zolpidem. Whole body imaging, cerebrospinal fluid, and
serum studies were negative for infection, occult malignancy and
paraneoplastic antibodies. Lumbar puncture before and after continuous
zolpidem administration showed a small decrease in protein
level from 60 to 46 mg/dL, and was otherwise unremarkable. She was
discharged on zolpidem CR 12.5 mg three times a day with some improvement
maintained at follow up several weeks later.
The activating effects of zolpidem in the setting of altered levels
of consciousness have been described in a few studies, mainly in the
setting of persistent vegetative and minimally conscious states. This
case appears to represent a case of encephalopathy of unknown etiology
that responds to zolpidem.
B12
ATRIAL TACHYARRHYTHMIA PRESENTING AS
POLYURIA.
N. Maheshwari, 1 S. Anand, 1 D. Kumari, 2 J. Hanoi, 1 E. Ong, 1 E. Roffe, 2
S. Mushiyev, 3 S. Chaudhari. 2 1. Internal Medicine, New York Medical
College Metropolitan Hospital Centre, Manhattan, New York, NY; 2.
Geriatrics, New York Medical College Metropolitan Hospital Center,
New York, NY; 3. Cardiology, New York Medical College
Metropolitan Hospital Center, New York, NY.
INTRODUCTION: Polyuria is associated with atrial flutter and
atrial fibrillation and excessive urine formation associated with any
abnormal atrial rhythm or activity has been seen in few case reports.
We report an unusual case of atrial tachyarrhythmia presenting as
polyuria.
CASE REPORT: 87 years-old female with history of blindness
in left eye presented to the emergency department with complains of
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urinary frequency of more than 10 episodes daily for last 10 days; review
of systems was negative except for polyuria, On physical examination
(PE) revealed tachycardia of 200 beats/min, Cardiovascular
examination revealed tachycardia with irregular pulse, left eye blindness,
rest of PE including genitourinary examination was normal.
Electrocardiogram (EKG) showed atrial flutter and repeat EKG
showed atrial fibrillation (AF), Troponin of 0.17ng/mL, normal renal
bladder ultrasound. She was started on diltiazem drip and subsequently
switched to oral long acting beta blocker (BB) and her urinary
frequency and tachycardia resolved, started on Coumadin for
AF. Echocardiogram showed ejection fraction of less than 25%. Next
day patient again have tachycardia and urinary frequency and BB
dose was increased and she improved. During the hospital stay patient
developed multiple episodes of tachycardia and urinary frequency
until BB dose titrated to achieve a controlled heart rate with
normal sinus rhythm and urinary frequency resolved.
DISCUSSION: Polyuria associated with abnormal atrial activity
like atrial flutter or atrial fibrillation has been reported in few
cases in past, but no exact mechanism is known. Wood suggested that
polyuria is secondary to anti diuretic hormone inhibition; later
Michael J et al speculate that human atrial hyperactivity from an
atrial arrhythmia represents a natural experiment in man simulating
volume expansion, and signaling the kidney to decrease renal tubular
sodium and water reabsorption. The diuresis begins at once and becomes
manifest in few minutes, stops immediately when the attack
ends, as seen in our case. Physicians should keep polyuria as one of the
rare presentation or differential diagnosis of atrial tachyarrhythmia.
B13
Diffuse Lewy Body Dementia (DLBD): Missed diagnosis can be life
threatening.
N. Bansal, D. Manocha, S. Brangman. SUNY Upstate Medical
University, Syracuse, NY.
Background: DLBD accounts for around 20% cases of adults
with dementia. Clinical features include cognitive impairment with
fluctuating course, neuropsychiatric manifestations, motor and autonomic
dysfunction. Heightened sensitivity to neuroleptics is a grievous
complication.
Case Report: We present a unique learning case of a 65 year old
lady with past medical history of remitting relapsing multiple sclerosis(MS)
on betasetron prophylaxis. She had two recent hospitalizations
for worsening agitation and hallucinations at an outside facility
which were interpreted as manifestations of MS flare. Escalating
doses of antipsychotics (19 mg of haloperidol intravenously over 24
hours) were administered besides the therapy for MS. Subsequently,
she was transferred to our institution for need of neuro ICU management
of MS. She was dehydrated, febrile(102 F), had rigidity and myoclonus
on initial evaluation. Her metabolic profile revealed elevated
creatine kinase levels(9812 IU/ L) and acute kidney injury. A diagnosis
of neuroleptic malignant syndrome was made. She responded well
to medical management. After resolution of acute complications, patient
started re experiencing visual hallucinations, depressive symptoms
and memory lapses to create a diagnostic and management
dilemma for the primary team. A detailed geriatric assessment was
then performed. It revealed history of worsening short term memory
loss with fluctuations over the past 1year, complicated by bradykinesia
and depression for 7 months and visual hallucinations for 4
months. The mental status testing revealed impaired visuospatial orientation,
recall and execution. Work up for reversible causes (including
Vitamin B12/ TSH/RPR-VDRL) and brain imaging were noncontributory.
Thus a diagnosis of Diffuse Lewy Body Dementia with
sensitivity to neuroleptics with neuroleptic malignant syndrome was
made. The patient was started on donapezil for cognition, citalopram
for depression and valproic acid for other secondary behavior problems
with partial stabilization of her symptoms. Discussion: Use of
neuroleptics has been associated significant adverse reactions in 54-
81% patients with DLBD. Studies have shown increased mortality
and shortened survival times in affected patients. Compromised nigrostriatal
dopaminergic transmission predisposes to neuroleptic sensitivity
even at modest doses.Co-existing medical conditions may
delay the diagnosis and appropriate management as was the case in
our patient.
B14 Encore Presentation
Getting the Patient Out of the Woods - Near Death from Babesiosis
in an Elder.
R. Jaber, M. Brennan. Internal Medicine, Baystate Medical Center,
Springfield, MA.
Supported By: Baystate Medical Center/Tufts Univ. School of
Medicine
Introduction
Babesiosis is a tick-borne disease common in the Northeast and
Midwest. The parasite, Babesia microti, infects red blood cells and can
cause serious illness. The authors report a case of life threatening infection
in an elder who recovered after prompt diagnosis and aggressive
treatment.
Case summary
An 85-year-old man had 5 days of malaise, lethargy, and fever.
PMH included ischemic stroke, hyperlipidemia and possible
myelodysplastia. He lived in Monson, Massachusetts and had recently
been gardening in a wooded area.
On physical examination he appeared ill, was diaphoretic,
slightly confused and febrile (101.7 F). He had a regular tachycardia
(115 bpm). His bp was 137/75, RR was 20 and his O2 saturation was
93% on 3 ls; there was no rash or lymphadenopathy. He had a few
coarse crackles at the left base but his exam was otherwise normal.
His wbc count was 3.9 K and left shifted with 13% bands. His hemoglobin
was 9.7 gm/dl and the platelet count was 40 K. Most notably,
he had an RBC parasitemia of 10 % classic for Babesiosis.
Chest X-ray revealed left lower lobe atelectasis. Azithromycin and
atovaquone were begun and he was tested for anaplasmosis (Human
Monocytic Ehrlichiosis) since patients often have concomitant infections
and this requires adjusting antibiotics. This was positive, so
doxycycline was added. On hospital day 4, he developed severe hemolysis;
his hemoglobin dropped to 6 and his parasitemia rose to 19
%. Red blood cell exchange was performed; antibiotics were switched
to clindamycin and quinine. The patient improved; at discharge the
parasitemia was under 1 %.
Discussion:
Life-threatening Babesiosis occurs most often in elders (age> 75
yrs) and those who are immunosuppressed or asplenic. Most deaths
are due to hemolysis, thrombocytopenia, DIC, or multi-organ failure.
Early recognition is critical. This patient’s life likely was saved by
prompt diagnosis in a community hospital. This resulted in rapid
transfer to tertiary care thereby facilitating immediate response to
subsequent massive hemolysis. The case also highlights the importance
of assessing for co-infection with Ehrlichia. Failing to identify
all major infections would probably have proved fatal. Geriatricians
often care for immunocompromised, frail elders. To prevent unnecessary
deaths they must be aware of the presentation, natural history,
treatments and complications of Babesiosis and screen promptly for
co-infections.
B15
An Unusual Case of a Prosthetic Joint Infection with Lactobacillus.
R. Zitnay, S. Chao. Section of Geriatrics, Boston University Medical
Center, Boston, MA.
Background: Lactobacillus is a Gram positive organism found
as normal flora in the oral cavity, genital, and gastrointestinal tract. It
is classically a nonpathogenic organism, found in fermented food
products and probiotic supplements. Serious infections are very rare,
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with typical risk factors being an immunocompromised state, malignancy,
or translocation after invasive gastrointestinal procedures. We
describe a patient with a subacute presentation of prosthetic joint infection
with Lactobacillus as the culprit organism. Case: A 95 year old
female with a history of dementia, a left hip fracture with hemiarthroplasty
one year prior, and a clostridium difficile infection now on probiotic
supplementation, developed a new complaint of left leg pain.
The pain was worse with weight bearing, but did not compromise her
walking. Physical examination was remarkable only for superficial
tenderness to palpation of the distal anterio-lateral quadriceps muscle.
Left hip and femur Xrays were normal with her prosthesis in
anatomic alignment. Six months later she developed new difficulty in
transferring from bed to stand, requiring one person assist and skin
breakdown over the left lateral hip. A CT scan showed femoral diaphyseal
cortical defects and subcutaneous and intramuscular enhancing
collections concerning for infected hip prosthesis with sinus tract.
Intra-operative cultures revealed lactobacillus casei/paracasei. Multiple
peripheral blood cultures were negative. She completed a fourweek
course of intravenous penicillin and then was placed on oral dicloxacillin
for long term suppressive therapy. Discussion: This case
demonstrates the subtle history and physical examination findings
that can accompany subacute prosthetic hip infections in advanced
age. The index of suspicion should remain high despite the reassuring
lack of classic local or systemic infectious signs or symptoms. In the
face of suspicion, the history should consider a broad range of potential
pathogens. Current research argues against a link between systemic
disease and probiotic therapy, but this case suggests such a link.
B16
POEMS Syndrome: A Rare Cause of Gait Imbalance.
S. Arshad, J. Angeles, H. A. Arabelo. Geriatrics, St. Luke’s-Roosevelt
Hospital, Academic Affiliate of Columbia University College of
Physicians & Surgeons, New York, NY.
Gait imbalance is very common in the elderly and could result
from multiple causes, some of which are treatable. Loss of balance
can be very debilitating.
An 87 year old patient presented with bilateral leg weakness
and imbalance. He reported trouble walking for the past year accompanied
with ankle edema. Upon admission he was found on the floor
and unable to ambulate. He complained of tingling in his feet &
hands bilaterally. On physical exam he had no fasciculations, normal
muscle tone, mild finger abductor weakness & 1+ bicep reflexes. He
had weakness in both legs, markedly diminished pinprick in the legs
to the mid thigh bilaterally, absent vibratory sensation in his feet, absent
position sense in the toes, absent Achilles reflexes, and cautious
gait with increased base. MRI of the spine showed DJD and mild
compression fracture of T12 with no nerve impingement or cord lesions.
TSH, B12 levels, and the Lyme Antibody were unremarkable.
An EMG showed moderate to severe peripheral neuropathy with significant
slowing in the right tibial and peroneal nerves, consistent
with acquired demyelination. An IgG lambda spike on protein and
immune fixation electrophoresis was noted. The skeletal survey was
without lytic or blastic lesions. The patient had gait ataxia from severe
peripheral neuropathy with monoclonal gammopathy as the etiology.
Our patient has features of POEMS with sensory motor
polyneuropathy, endocrinopathy with recent diabetes mellitus, edema
and IgG lambda protein monoclonal gammopathy. He will follow up
with his Hematologist & Neurologist for treatment and also have
physical therapy.
POEMS is a multisystemic syndrome that occurs in the setting
of plasma cell dyscrasia. It is rare and can be underdiagnosed leading
to recurrent falls. POEMS syndrome occurs because of the growth of
certain clonal plasma cells that produce an abnormal amount of
blood proteins, which damage body organs & result in this acronym
for the syndrome’s most common features consisting of polyneuropathy,
organomegaly, endocrinopathy or edema, monoclonal protein
and skin changes. Not all features of the disease are required to make
the diagnosis. POEMS syndrome begins around age fifty and affects
twice as many men as women. If untreated it is progressive and often
fatal. Only 60% survive five years after onset. However, the symptoms
can improve if the blood disorder is diagnosed and treated.
B17 Encore Presentation
A Rare Etiology of Acute Cardiomyopathy and Respiratory Failure.
S. Lee, S. Bellantonio, D. Joseph. Internal Medicine, Baystate Medical
Center, Springfield, MA.
INTRO
Adult-onset Still’s Disease(AOSD) is a rare systemic inflammatory
disorder of unknown etiology, commonly presenting with fever,
rash, and arthritis/arthralgias. It more commonly affects women; median
age of onset is 25. We report an atypical presentation of an
AOSD flare with possible Macrophage Activation Syndrome(MAS)
associated with extreme hyperferritinemia in a 60 year old male.
CASE
A 60-year-old high-functioning male with history of AOSD presented
with subacute fever, rigors, and diarrhea. His exam was unremarkable,
with no evidence of rash, synovitis or lymphadenopathy.
Labs revealed mild leukocytosis and creatinine of 3.2mg/dL. He was
admitted for acute renal failure and treated supportively with IV fluids.
The next day, he developed acute, progressively worsening respiratory
distress. CXR showed multifocal atelectasis without pulmonary
congestion. There were no ischemic EKG changes, but
troponinT was elevated(0.37). Echocardiogram revealed new diffuse
hypokinesis with depressed systolic function(EF 30%). Serum ferritin
was markedly elevated(103,670). He was transferred to the ICU and
put on noninvasive ventilation. High dose IV steroids were initiated
with impressive improvement in respiratory status. He was transitioned
to PO steroids, and a week later initiated on an IL1 antagonist(anakinra)
and discharged with normal renal function. Hypoxemia
and dyspnea resolved over the ensuing weeks with ferritin
returning to normal. Repeat echo showed normal cardiac function.
Steroids were eventually tapered and anakinra continued.
DISCUSSION
Besides AOSD and MAS, there are few, if any conditions presenting
with this extraordinary degree of hyperferritinemia. MAS,
commonly associated with rheumatologic conditions, is caused by
overwhelming macrophage activation resulting in phagocytosis of
erythrocytic precursors in bone marrow. Both AOSD flare and MAS
can be triggered by infection, and similarly managed with immunosuppression,
as in our patient. The absence of cytopenias and hypofibrinogenemia
militate against MAS. MAS is only confirmed with bone
marrow biopsy, but with high false negative rates.
CONCLUSION
AOSD flare and MAS are rapidly fatal conditions that can
occur in older adults. Both mimic sepsis with multiorgan dysfunction,
and diagnosis is often delayed. Quick recognition and treatment is
vital for favorable outcome.
B18
Dysphagia with a Large Goiter: What You See Is Not Necessarily
What You Get.
S. McCullough, 1 J. Reckrey, 1,2 B. Shah. 1,2 1. Mount Sinai School of
Medicine, New York, NY; 2. Department of Geriatrics, Mount Sinai
Hospital, New York, NY.
Dysphagia commonly accompanies acute presentations of the
elderly. This case illuminates the importance of maintaining a broad
differential for dysphagia and highlights the phenomenon of
pseudoachalasia.
A 90 year old woman with a history of GERD, dysphagia, hyperthyroidism
with a 7-cm multinodular goiter and atrial fibrillation
with rapid ventricular response was transferred from her nursing
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A BSTRACTS
home for altered mental status and percutaneuous endoscopy gastrostomy
(PEG) placement. The patient had dysphagia presumed to
be caused by compression from her goiter. In the month prior to admission
her daughter reported worsening dysphagia with the patient
now unable to tolerate medications. Due to the dysphagia, the patient
planned for ambulatory PEG placement; however, the patient became
delirious and was transferred. Initial evaluation revealed a right
lower lobe pneumonia and an E coli UTI which were treated with antibiotics.
A goals of care (GOC) discussion with family confirmed the
decision for PEG placement. A neck CT done to evaluate for airway
compression showed no change in goiter size. Esophagogastroduodenoscopy
(EGD) revealed stricturing and a fungating mass at the
gastric cardia, identified pathologically as an invasive poorly differentiated
adenocarcinoma. After the procedure the patient remained
somnolent and GOC were readdressed. In accordance with the family’s
wishes, the patient was transferred to the palliative care unit
where she passed away with her family at bedside. In evaluating this
patient’s dysphagia, our premature diagnostic closure attributed her
dysphagia to external compression and failed to consider gastric cancer
with resulting pseduoachalsia. Older age, sudden onset, and
weight loss are clues to differentiating pseudoachalasia from achalasia.
Pseudoachalsia is most commonly due to adenocarcinoma of the
gastric cardia and can result from mechanical compression of the
lower esophageal sphincter or myenteric plexus infiltration. The case
makes clear that the less common causes of dysphagia such as
pseudoachalasia should be considered when evaluating an elderly patient.
The patient’s prior treatment decisions along with GOC discussions
helped the daughter make end of life decisions. This case highlights
a common problem in the elderly and reminds clinicans to
maintain a broad differential, be knowledgable about the causes of
dysphagia, and discuss GOC frequently.
B19
Transitioning into the Weekend, Staffing Constraints and Delayed Care.
W. Colon Cartagena, M. Brennan. Internal Medicine, Baystate
Medical Center/Tufts Univ. School of Medicine, Springfield, MA.
Background
Hospital staffing and specialty care is often reduced on weekends;
studies suggest that certain types of patients have excess mortality
if they are hospitalized on a weekend as compared to a weekday
(1). However, little is known about the impact of delayed
assessments for frail elders in acute care settings. The authors report a
case of one man who was subjected to a lengthy hospitalization and
much suffering due to delays in care over a weekend.
Case
Mr. R. was a 94 year old man with sub-acute, progressing leg
pain and weakness. He arrived on a Friday evening for evaluation
after an MRI showed a mass at L5. He was alert and oriented to person,
place and time and had no motor or sensory deficits. His major
complaint was pain. A CT showed bilateral pulmonary masses and
suspicious lesions in his pelvis; cancer was high in the differential. A
PSA and CEA were unremarkable. A CT-guided mass biopsy was ordered
to identify the pathology and clarify the suitability of palliative
radiation. The procedure was scheduled for Monday due to a lack of
interventional radiology personnel over the weekend. However, Mr.
R. became delirious on Sunday night and was discharged to a nursing
home with ongoing delirium about a week later. His agitation resulted
in an 11 day delay in obtaining the biopsy which eventually revealed
multiple myeloma.
Discussion
Much attention has been paid to transitions of care between different
institutions but the transition through a hospital’s weekly
staffing cycle creates similar challenges. In this case, timely intervention
would have identified multiple myeloma earlier allowing targeted
treatment to improve pain and stabilize function. Hospitalizations
have a disproportionately detrimental effect on older adults,
leading to complications such as delirium and functional decline.
These prolong hospital stay, increase costs and decrease patients’
quality of life. However, it is unclear if these adverse outcomes are
more common for elders admitted during a weekend. This is an important
question for future research by geriatricians, hospitalists, and
health care quality experts.
Bibliography
1. The association between night or weekend admission and hospitalization-relevant
patient outcomes. Khana, R, et al., et al. Jan
2011, Journal of Hospital Medicine, pp. 6(1):10-4.
B20
Understanding Surrogate Decision-makers’ Perceptions of Feeding
Options for Patients with Dementia.
E. A. Snyder, 1 R. Gilliam, 3 A. Caprio, 2 L. . Hanson. 2 1. School of
Medicine, University of North Carolina, Chapel Hill, NC; 2. Division
of Geriatric Medicine, University of North Carolina, Chapel Hill, NC;
3. Cecil G. Sheps Center for Health Services Research, University of
North Carolina, Chapel Hill, NC.
Supported By: Funder: NIH-NINR 1R01 NR009826
Background: Feeding problems are common in advanced dementia
patients, requiring surrogates to make decisions about feeding
options. Little is known about surrogates’ understanding of tube
feeding and assisted oral feeding. Our study explores surrogate perception
of these feeding options and assesses the impact of a decision
aid on their perspectives, knowledge and decisional certainty.
Methods: The study was conducted in 24 skilled nursing facilities
in North Carolina as a part of a larger, randomized controlled trial.
Study population included surrogate decision-makers for nursing
home residents with advanced dementia and feeding problems
(n=255). The intervention group viewed a decision aid about tube
feeding and assisted oral feeding. Baseline interviews included items
measuring knowledge, expectation of benefit from tube feeding and
open-ended questions about the advantages and disadvantages of
feeding options. Answers were compared before and after viewing
the interventional decision aid.
Results: Surrogates varied in their understanding of feeding options,
yet commonly cited maintaining enjoyment, independence and
dignity as major areas of importance. Surrogates provided conflicting
responses regarding the effect of tube feeding vs. oral feeding on prolonging
life and were uncertain of the effects on nutrition. Exposure
to a structured decision aid modified surrogate understanding of
feeding options. Surrogates were more likely to provide responses
consistent with those presented in the decision aid. Detailed interviews
with surrogates following exposure to the decision aid revealed
increased knowledge (15.5 vs. 16.8; p

P OSTER
A BSTRACTS
The aim of this study was to determine if osteoarthritis (OA)-related
biomarker levels were associated with hand symptoms severity
and functional disability as reported by the Australian/Canadian
Hand Osteoarthritis Index (AUSCAN) among middle- and olderaged
adults.
Methods
AUSCAN total scores and biomarker measurements were
available for 661 participants from the Johnston County Osteoarthritis
Project. AUSCAN is a 15-item self-report measure of hand pain,
stiffness, and function that has been previously validated among individuals
with hand OA. Higher AUSCAN scores indicate worse pain
or function in the hand. Commercially-available kits were used to
measure levels of: serum hyaluronic acid (HA), serum carboxy-terminal
propeptide of type II collagen (sCPII), serum type II collagen
degradation product (C2C), urinary C-terminal crosslinked telopeptide
of type II collagen (CTX-II) , and urinary N-terminal crosslinked
telopeptide (NTX); serum cartilage oligomeric matrix protein
(sCOMP) was measured with an in-house sandwich enzyme linked
immunosorbent assay. The ratio of sC2C:sCPII was calculated. Spearman
correlation coefficients were computed between AUSCAN and
each biomarker. Linear regression models were used to estimate associations
between AUSCAN total score and a biomarker, adjusting
for age, race, current smoking status (yes/no), BMI, current alcohol
usage, and radiographic hip, knee, and hand OA, each defined by
Kellgren-Lawrence grade 2-4 in at least one joint in that joint group.
Results
After adjusting for possible confounders, AUSCAN total score
was positively associated with uNTX-1, sCOMP, and negatively associated
with C2C, CPII, and their ratio. The adjusted associations between
AUSCAN scores and uCTX-II and HA were not statistically
significant.
Conclusion
Even after adjusting for other factors and concomitant radiographic
hip, knee, and hand OA, the AUSCAN index for hand symptoms
and function was independently associated with biomarkers related
to type 1 collagen resorption, non-collagenous matrix protein
degradation, and decreased type II collagen synthesis. These findings
suggest that biological processes related to these biomarkers are important
in hand OA and its symptomatic consequences.
B22
Does antipsychotic dose reduction result in worsening behavior
among nursing home residents with dementia: a systematic review of
the literature.
J. Tjia, A. Kanaan, J. Donovan. Geriatrics, University of Massachusetts
Medical School, Worcester, MA.
Supported By: This study was supported by a grant from the Agency
for Healthcare Quality and Research.
Background: While federal regulations require gradual dose reduction
trials of antipsychotics prescribed for behavior management
in nursing home (NH) residents with dementia, widespread concern
about precipitating behavioral disturbances limits implementation.
We conducted a systematic review of the literature to identify clinical
trials of antipsychotic dose reductions. The study aim was to describe
dose reduction practices and evidence for risk of behavior escalation.
Methods: A comprehensive literature search was conducted in
MEDLINE, EMBASE, and International Pharmaceutical Abstracts
between January 1970 and October 2011 using the terms “antipsychotic
agent or neuroleptic agent,” “dementia,” “nursing homes,” and
“withdrawal.” One investigator reviewed abstracts for inclusion
based on: English-language, human subjects, clinical trial, nursing
home site, and reported reduction in antipsychotic medications. We
excluded review articles, commentaries and secondary analysis of
main trial results. The remaining articles were reviewed by 2 investigators
for final inclusion, resulting in 9 articles.
Results: The nine articles meeting inclusion criteria included
randomized controlled trials of both typical and atypical antipsychotics.
Study populations ranged in size from 55 to 183 NH residents
with dementia and dose reductions typically targeted patients who
were not psychotic and did not have a history of violent behavior.
Gradual dose reduction protocols typically followed a strategy of
50% dose reduction per week for 2-3 sequential weeks. Outcomes
measured included behavioral problems, cognitive function, and resumption
of antipsychotic medications. All 9 studies reported that the
majority of residents randomized to gradual dose reductions of antipsychotics
had no overall detrimental effect on functional and cognitive
status, or exacerbation of behavioral symptoms.
Conclusions: Clinical trials evaluating the withdrawal of antipsychotic
medications from NH residents with dementia do not
show evidence of rebound behavioral escalation after gradual dose
reductions.
B23
Is Fracture Risk Assessment Index (HFRAI), an Electronic Medical
Database Derived Tool, comparable to Femur neck Bone Mineral
Density (FNBMD)?
M. Albaba, S. S. Cha, P. Y. Takahashi. Mayo Clinic, Rochester, MN.
BACKGROUND
Femur neck bone mineral density (FNBMD) is the cornerstone of
hip fracture risk stratification in current clinical practice. Other risk stratification
tools use FNBMD with other selected risk factors. We have derived
and validated the Hip Fracture Risk Assessment Index (HFRAI)
(score range 0, 32) that uses electronic medical records data to predict
risk for hip fracture in community-dwelling older adults. Using appropriate
computer program,HFRAI is computed automatically to provide the
clinician with a readily available score that assesses patient’s risk for sustaining
hip fracture, without the need to manually calculate a score, perform
a physical examination or obtain a radiology test.It is unknown how
HFRAI compares to FNBMD and to other FNBMD based risk stratification
tools.The goal of this study was to compare HFRAI to FNBMD.
METHODS
This was a retrospective cohort study. All community-dwelling
subjects over 60 years of age in a primary care panel in Olmsted
County, MN on January 1st, 2005 were enrolled.
Since HFRAI uses electronic medical records data of the previous
two years, we excluded all subjects that did not have a FNBMD
tested during the two-year time frame (01/01/2003, 01/01/2005).
We created two receiver-operating curves (ROC), one ROC
using the HFRAI scores as of 01/01/2005, and the other using the lowest
recent FNBMD T-score. The primary outcome was incident hip
fracture in the subsequent four years (2005, 2008). We computed the
area under the curve (AUC) for each ROC. We used Z statistics to
compare AUC between the two ROCs. We evaluated each of
FNBMD and HFRAI for sensitivity and specificity.
RESULTS
On 01/01/2005 13,457 subjects over 60 years were empanelled in
the practice. 12,650 subjects (94%) consented to the study, among
which 1953 subjects had FNBMD-DXA (dual-energy X-ray absorptiometry)
scan within the previous two years. 83 subjects (4.3%) sustained
a hip fracture between 01/01/2005 and 12/31/2008. AUC for
HFRAI was 0.79, slightly larger than AUC for FNBMD of 0.74
(Z=1.82, p=0.09). The best combined sensitivity and specificity for
HFRAI tool was at a score of >12 (84% sensitive and 55% specific),
and for FNBMD tool was at a T-score of

P OSTER
A BSTRACTS
Femur neck bone mineral density (FNBMD) is the cornerstone
of hip fracture risk stratification in current clinical practice. Other
risk stratification tools use FNBMD with other selected risk factors.
It is unknown whether electronically derived available patient information
is useful in predicting hip fracture. The goal of this study was
to demonstrate the use of electronic medical records to create an
index which is able to risk-stratify heterogeneous older population.
METHODS
This was a retrospective cohort study. All community-dwelling
patients over 60 years in a primary care panel in Olmsted County,
MN on January 1st, 2005 were enrolled (N=12,650).
Subjects were randomly assigned to two groups, a development
cohort (N=8,387) and a validation cohort (N=4,263).
Using the development cohort’s electronic medical records
(EMR), risk factors over the previous two years including demographic
characteristics and comorbidities were evaluated for significance
in univariate and multivariate logistic regression. The primary
outcome was incident hip fracture in the subsequent four years. Risk
factors were assigned a score based on their regression coefficient estimate
and a total risk score was created. We used EMR of the validation
cohort to evaluate the total risk score for sensitivity and specificity
and create a receiver-operating curve.
RESULTS
288 (3.43%) subjects in the development cohort sustained a new
hip fracture. The final model included age ≥75 (odds ratio (OR) 10,
95% CI 4.4, 23), age 70-74 (OR 7.7, 95% CI 3.3, 18.1), age 65-70 (OR
3.8, 95% CI 1.6, 9.4), white race (OR 2.5, 95% CI 1.2, 5.5), female gender
(OR 1.5, 95% CI 1.1, 1.9), prior hip fracture (OR 5.3, 95% CI 3.8,
7.4), liver cirrhosis (OR 2.7, 95% CI 1, 7.6), malnutrition (OR 2.6,
95% CI 1.6, 4.5), peripheral arterial disease (OR 1.7, 95% CI 1.2, 2.3),
Parkinson’s disease (OR 1.6, 95% CI 1.2, 2.1), prior nursing home
stay (OR 1.7, 95% CI 1.2, 2.3), and prior hospitalization (OR 1.4, 95%
CI 1.1, 1.8). Area under receiver-operating curve (AUC) was 0.818,
SE 0.017. Subjects with the highest 10% of the total risk score had
(OR 9.1, 95% CI 6.5,12.6); thus a 9 fold increased risk for acquired
hip fracture versus the rest of the cohort.
CONCLUSION
Electronically obtained, readily available patient information
can be utilized for hip fracture risk stratification, without the need for
further patient evaluation or FNBMD testing.
B25
Comparative impact of continence promotion interventions
targeting older women reluctant to seek care for urinary
incontinence.
R. Agnew, 1,2 E. van den Heuvel, 2 C. Tannenbaum. 1 1. Université de
Montreal, Montreal, QC, Canada; 2. Brunel University, Uxbridge,
United Kingdom.
Supported By: This work was funded by a partnership grant between
the Canadian Institutes of Health Research and the United
Kingdom New Dynamics on Aging Program.
Surveys suggest that only 13% to 50% of older women with urinary
incontinence (UI) talk to a health care practitioner about their
condition or implement evidence-based treatment. Continence
awareness programs exist, but their effectiveness remains unknown.
We sought to determine the comparative impact of a constructivist
learning workshop on UI, an evidence-based self-management tool
for UI, or both, compared to the effects of a sham workshop, on incontinent
women’s perceived improvement in their UI condition.
Methods: a 2x2 factorial open-label cluster randomized controlled
trial testing is currently being conducted in the United Kingdom.
The cluster (unit of randomization) is at the level of each local
community senior’s group, from whence participants are recruited for
the workshops. One of four interventions (3 experimental and 1 sham
intervention) is randomly assigned to each community group, with
randomization achieved by computer-generated random digits, balanced
in block groups of four. Eligible participants are communitydwelling
women 60 years of age or older, who have not sought medical
advice for incontinence symptoms in the last 5 years, and who experience
urinary incontinence with a frequency no less than twice
weekly. One outcome for the trial is an improvement in UI at three
months post-intervention, measured by a rating of improvement on
the Patient’s Global Impression of Improvement questionnaire.
Results: Five-hundred and twenty-four women attended the
workshops and 200 (mean age 70 + 7 years) met eligibility criteria
and were recruited to the trial. At 3-month follow-up, 47% of women
in the combined group reported that their UI condition was very
much or much better, compared to 35% of the constructivist workshop
group alone, 28% of the self-management group, and 14% of
the sham control group (p=0.013). Less than 5% of participants were
lost to follow-up.
Conclusion: Results of this interim analysis suggest that a continence
promotion intervention combining constructivist learning theory
debunking myths about UI being a normal part of aging and use
of a self-management tool has the greatest impact on improvements
in UI in older women with incontinence.
B26
The effects of life review writing on depressive symptoms: A
randomized control trial.
T. Chippendale. Occupational Therapy, Tufts University,
Somerville, MA.
Supported By: American Occupational Therapy Foundation
Background:The purpose of this RCT was to evaluate the effectiveness
of life review through writing with respect to decreasing depressive
symptoms in older adults residing in senior residences. Life
review is an important developmental task and therapeutic intervention.
When executed through writing, the benefits may be multiplied.
This study sought to provide support for this psychosocial intervention
for older adults. Although meta-analysis reveals a number of
studies that have examined the effectiveness of life review as an intervention
for decreasing depressive symptoms (1), some have called for
a refinement and validation of intervention protocols. The intervention
used in this study, the “Share you Life Story” Workshop (2), includes
the added therapeutic benefits of writing. Life review through
writing, as opposed to life review through the oral method, has not
been well studied (3) and may be a more beneficial approach (4).
Methods: Participants: 45 older adults 65 years and older, who
spoke English and who had a negative screen for probable dementia
on the Mini-Cog.Setting:4 senior residences in NYC. Design: A randomized
control trial with participants assigned to the treatment or
wait list control group. Randomized was within each site using randomization
with forced equal sample size. Data was analyzed using
an RMANOVA and SPSS version 17 with a .05 significance level. The
Geriatric Depression Scale was the primary outcome measure. Results:
A statistically significant decrease in depressive symptoms was
found for the treatment group as compared to the control group
(N=45, p=.03, effect size d=.7). Conclusions: The results support the
“Share your life story” writing workshop as an effective intervention
for addressing depressive symptoms in older adults.
(1)Bohlmeijer, E., Smit, F. & Cuijpers, P. (2003). Effects of life review
on late life depression: A meta-analysis. International Journal of
Geriatric Psychiatry, 18(12), 1088-1094.
(2)Sierpina, M. (2002). Share your life story workshops. Galveston:
University of Texas Medical Branch.
(3)Richeson, N. & Thorson, J. A. (2002). The effect of autobiographical
writing on the subjective well-being of older adults. North
American Journal of Psychology, 4, 395-404.
(4)Sherman, E. (1995). Differential effects of oral and written
reminiscence in the elderly. In B. H. Haight, & Webster, J. D. (Eds.),
The art and science of reminiscing (pp. 255-264). Washington: Taylor
& Francis.
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B27
Shared Decision Making in the Selection of Outpatient Analgesics
for Older Emergency Department Patients.
C. G. Isaacs, C. E. Kistler, K. Hunold, G. Pereira, M. Buchbinder,
S. A. McLean, T. F. Platts-Mills. University of North Carolina at
Chapel Hill, Chapel Hill, NC.
Supported By: This study was supported by a Medical Student
Training in Aging Research grant (Isaacs), a National Center for
Research Resources grant KL2 RR025746 (Platts-Mills), an Agency
for Healthcare Research and Quality K12 HS19468-01 (Kistler), and
institutional resources.
Background: Shared decision making has been shown to improve
patient satisfaction and clinical outcomes for chronic disease
management. Given the presence of individual variations in the effectiveness
and side effects of commonly used analgesics in older adults,
shared decision making might also improve clinical outcomes in this
setting. We sought to characterize shared decision making regarding
the selection of an outpatient analgesic for older ED patients with
acute musculoskeletal pain and to examine associations with outcomes.
Methods: We conducted a prospective observational study with
consecutive enrollment of patients age 65 or older discharged from
the ED following evaluation for moderate or severe musculoskeletal
pain. Two essential components of shared decision making, 1) information
provided to the patient and 2) patient participation in the decision,
were assessed via patient interview at one week using fourlevel
Likert scales.
Results: Of 233 eligible patients, 110 were reached by phone and
87 completed the survey. Only 25% (21/87) of patients reported receiving
‘a lot’ of information about pain medications, and only 21%
(18/87) reported participating ‘a lot’ in the selection of the analgesic.
There were trends towards white patients (p=.06) and patients with
higher educational attainment (p=.07) reporting more participation
in the decision. After adjusting for gender, race, and initial pain severity,
patients who reported receiving ‘a lot’ of information were more
likely to report optimal satisfaction with the analgesic than those receiving
less information (78% vs. 47%, p

P OSTER
A BSTRACTS
the use of instruments validated for this particular environment is not
yet widespread. The ideal timing of or interval during which a delirium
screening process should take place has yet to be determined. Future
research in the ED will be needed to both validate delirium
screening instruments that are currently used for investigation and
clinical care as well as to define the ideal timing and form of the delirium
assessment process for older adults.
B30
Pain Care in the Emergency Department: Is it Satisfactory?
M. Barlow, U. Hwang. Department of Emergency Medicine;
Department of Geriatrics and Palliative Medicine, Mount Sinai
School of Medicine, New York, NY.
Supported By: Michelle Barlow was funded by an AFAR grant
through the 2011 MSTAR program.
Ula Hwang is supported by a K23 award from the NIA.
BACKGROUND: Pain is a common reason for emergency department
(ED) visits by older adults. There is evidence that older
adults receive poorer ED pain care than younger patients, but many
of these studies used retrospective data and were unable to assess patient
satisfaction. The objective of this study is to compare the quality
of ED pain care received with patient satisfaction.
METHODS: This is a prospective observational study at an academic,
tertiary care medical center that has been ongoing since July
2011. Adult patients (≥ 20 years), who present to the ED with severe
abdominal pain (pain score 10 out of 10) are surveyed at the end of
their ED visit regarding their pain, care received, and satisfaction levels.
Quality metrics of pain care received as well as covariates (age,
gender, ethnicity, Charlson comorbidity score, etc.) are abstracted
from the medical record.
RESULTS: Between July 7 and November 14, 2011, 90 subjects
meeting inclusion criteria were surveyed. There were no significant
differences between older adults (65+ years, 16%) and younger
adults (20-64 years, 84%) in their surveyed pain scores, time to first
analgesic administration, nor overall receipt of analgesics. There was
also no difference in pain care satisfaction. When comparing the 69%
of patients satisfied with pain care versus the 31% who were unsatisfied,
those who were satisfied had lower surveyed pain scores (5.64 vs.
8.88, p < 0.0001) and were less likely to want more analgesics (37% vs.
86%, p < 0.0001). Unsatisfied patients waited longer for administration
of first analgesic (trend, p = 0.09). There was, however, no significant
difference in analgesic administration (86% of unsatisfied received
analgesics vs. 85% of satisfied).
CONCLUSIONS: Pain care satisfaction is associated with lower
pain scores and decreased desire for additional analgesics. Contrary
to growing evidence of poorer ED pain care for older adults, subjects
in this cohort appear to receive equivalent care to their younger
counterparts. Older and younger adults received and had analgesics
administered in similar time frames; they also had similar pain scores
and levels of satisfaction. This is the opposite of recent studies and
may indicate that both the type (abdominal versus other pain) and
severity of pain described as well as the quality indicators used to define
appropriate care may impact the level of discrepancy observed.
B31
Functional Impairment and Disability during the Last Two Years
of Life.
A. K. Smith,Y. Miao,W. Boscardin, K. Covinsky. Medicine, Division of
Geriatrics, University of California, San Francisco, San Francisco, CA.
Supported By: NIA, NCRR.
Background: We know little about the national prevalence of
disability at varying points across the last years of life.
Methods: Data are from participants ages 50+ who died in the
Health and Retirement Study (HRS) between the years 1995 and
2008. Each participant was interviewed once in the last 24 months of
life. We used the HRS interview closest to death to reconstruct national
estimates of the monthly prevalence of functional impairment
and disability in the two years prior to death. Measures of functional
impairment and disability included: IADL difficulty (Difficulty with
cooking, shopping, using telephone, taking medications, managing
money); ADL dependence (requires assistance with dressing,
bathing, eating, transferring, walking across the room, and toileting).
We estimated the predicted probability of functional impairment or
disability by age at death and gender, adjusting for race or ethnicity,
educational level, net worth, and proxy status.
Results: There were 7624 decedents (mean age at death 80,
52%% women, 84% White, 10% African-American, 4% Latino, 27%
proxy interview). The unadjusted prevalence of all forms of functional
impairment rose linearly over the last two years of life (Table).
The predicted prevalence of disability prior to death rose with advancing
age. After adjustment for gender, race/ethnicity, educational
level, net worth, and proxy status, the predicted prevalence of any
ADL dependency for elders ages 50-69 12 months prior to death was
24% (95% CI 18-29), compared to 29% (24-34) for ages 70 to 79, 37%
(31-44) for ages 80 to 89, and 47% (41-54) for ages 90 and older (p for
trend

P OSTER
A BSTRACTS
SES, adiposity and memory and executive function factor scores were
assessed with multiple regression analyses (with age, sex, and race as
covariates).
Results: Higher levels of education and income were associated
with higher memory (high vs. low education B = .41*** and income B
= .28***) and executive function scores (high vs. low education B =
.82*** and income B = .51***), and lower levels of adiposity. Small, but
significant negative associations were found between adiposity indicators
and cognitive function scores. However, coefficients for SES predictors
remained relatively unchanged with the inclusion of adiposity
indicators into analytic models, suggesting that adiposity indicators did
not mediate observed SES variations in levels of cognitive functioning.
Conclusion: Both lower SES and greater adiposity are associated
with lower levels of cognitive functioning. Those of lower SES
also have significantly greater levels of adiposity. However, results do
not support adiposity as a mediator of SES variations in cognitive
function. An important objective for future research is the identification
of other biomedical and behavioral variables that may underlie
SES disparities in cognitive function.
B33
Prediction of 5-Year Risk of Becoming Dependent in Activities of
Daily Living in Community-Dwelling Older Adults.
D. H. Kim, 1,3 E. Newton, 2 L. A. Lipsitz. 1,2 1. Gerontology, Beth Israel
Deaconess Medical Center, Boston, MA; 2. Institute for Aging
Research, Hebrew SeniorLife, Boston, MA; 3. Epidemiology, Harvard
School of Public Health, Boston, MA.
Supported By: Dr. Kim is supported by John A. Hartford Center of
Excellence Award.
Background: Several risk factors have been identified for activity
of daily living (ADL) dependence, but it remains unclear how to
optimally combine them into a simple clinical prediction model.
Methods: Using data from the Established Populations for Epidemiologic
Studies of the Elderly, a prospective cohort of community-dwelling
older adults, we developed and validated a prediction
model of ADL dependence, based on self-reported information and
brief examination. In the derivation set (n=7,982), we used Cox proportional
hazards regression to develop a risk score that predicted
the 5-year risk of becoming dependent in 3 or more ADLs for at least
2 consecutive years, or at 1 year followed by death in the subsequent
year. We tested the score in the validation set (n=3,993), and examined
its relations to hospitalizations and mortality within 5 years.
Results: During 5 years, the incidence rate of ADL dependence
was 2% in both derivation set (663/34,382 person-years) and validation
set (359/17,128 person-years). A risk score calculated using age,
income, visual impairment, self-rated health, diabetes mellitus, stroke,
cognitive function, and self-reported upper and lower extremity function,
showed good agreement between expected and observed absolute
risks and excellent discrimination (C statistic, 0.80 in the derivation
set and 0.77 in the validation set). The score predicted
mortality as well as recurrent hospitalizations for myocardial infarction,
stroke, cancer, and fracture within 5 years.
Conclusions: A simple risk score based on self-reported information
and brief cognitive assessment can accurately predict a persistent,
severe form of disability within 5 years.
B34
The Utilization of HEDIS High-Risk Medications in Veteran’s
Administration Nursing Homes.
D. M. Dosa, 2,1 O. Intrator, 2,1 S. Hyde. 2 1. Research Enhancement
Award Program, Providence VA Medical Center, Providence, RI; 2.
Medicine, Brown University, Providence, RI.
Supported By: Veteran’s Administration-(Dosa-Career
Development Award)
Background: Nursing homes (or Community Living Centers as
they are referred to within the Veteran’s Administration) have been
identified by the Institute of Medicine (2000) as the most common
site for Adverse Drug Events (ADE) with over 800,000 estimated
prescription related errors annually. Such errors in the long term care
environment have been associated with a high degree of morbidity
and mortality. A common error described in the literature is the utilization
of high risk medications in the elderly—a population most
likely to experience morbidity relative to ADEs. The purpose of this
study was therefore to evaluate the use of prescriptions classified by
the Healthcare Effectiveness Data Information Set (HEDIS) as high
risk medications over time in VA Community Living Centers (CLCs)
and assess variability by region and institution.
Methods: Nursing home Minimum Data Set records from calendar
year 2004-2009 were merged with VA Decision Support System
Pharmacy Data to identify residents of Community Living Centers
who received at least one medication on the HEDIS high risk list for
the elderly.
Results: Between 2004 and 2009, a total of 25,105 out of 186,986
(Average=13.81%, SD=5.93%) veterans admitted to a CLC received
at least one HEDIS high risk medication. Annual proportion of CLC
veterans using HEDIS medications varied among CLCs from 3.6%
to 44.2% and among VISNs from 7.2% (VISN22) to 22.6%
(VISN10). Steady reduction in the use of high risk medications was
noted, however, between 2004 and 2009. In 2004, the average proportion
of veterans using HEDIS medications in any CLC was 15.0%
(SD=7.2, Min= 2.9%, Max=47.1%); by 2009 the average rate was
6.4% (SD=4.6; Min= 0.3%, Max=30.6%).
Conclusions: The utilization of high risk medications at VA
CLCs has improved over time but significant variation exists between
homes. More work needs to be conducted to determine if patient specific
and/or facility factors predict utilization of HEDIS medications
amongst elderly nursing home veterans at high risk for ADEs.
B35
Risk Factors for Readmissions in Patients 65 or Older Admitted For
Pneumonia.
H. Rahbar, 1,2 O. Abreu-Lanfrranco, 1,2 A. Singh, 2,4 M. Tims, 2
B. Ramasamy, 2 C. Biedron, 1,2 L. Mody, 3 K. S. Kaye. 1,2 1. Wayne State
Medical School, Detroit, MI; 2. Detroit Medical Center, Detroit, MI; 3.
University Of Michigan, Ann Arbor, MI; 4. Fuqua School of Business,
Duke University, Durham, NC.
Supported By: MSTAR Grant
Background: Pneumonia is one of the most common infections
leading to inpatient visits and is an important cause of morbidity and
mortality, particularly in older adults. Recently Medicare began decreasing
coverage for all-cause readmissions within the 30-day discharge
period for patients who were admitted with a primary diagnosis
of pneumonia. This study aimed to identify risk factors for hospital
readmission within a 30-day period following hospitalization for
pneumonia in adults > 65 years of age.
Methods: This study was conducted at Detroit Medical Center,
an 8-hosital tertiary care health system. Retrospective chart review
was conducted for patients > 65 years old with primary diagnosis of
pneumonia from January 2010 to March 2011, and data pertaining to
demographics, comorbid conditions, functional status and medications
were abstracted. “Cases” who experienced readmission within
30 days of discharge for any reason were identified; and were compared
to “controls” who were matched to cases by hospital and calendar
time of initial admission.
Results: Eighty cases who were readmitted within 30 days were
compared to 80 controls that were readmitted after an initial pneumonia
diagnosis, after matching a total of 160 patients were analyzed.
Cases and controls had similar demographics (Mean Age of 77.7 +8.2,
54.4% were female; and 55% were African American) and functional
status. Cases were more likely to have diabetes than controls (50%
and 30%, p=.015) and a were more likely to have a Braden Score < 16
(36% and 20%, p=.013). Cases also had a greater severity of illness as
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measured by CURB65, Pneumonia Severity Index [PSI] and Charlson’s
Comorbid Index. Cases also had significantly more discharge
medications than controls (median of 12.36 and 10.53, p=. 009) and
were more likely to have received influenza vaccination in the year
prior to initial hospital admission (59% and 41%, p=.009).
Discussion: Among older adults, Braden Score was an objective,
strong predictor of readmission following pneumonia hospitalization.
The association between prior receipt of influenza vaccination and
increased likelihood of readmission was unexpected and warrants
further investigation.
B36
IS LENS TRANSPARENCY ASSOCIATED WITH
CARDIOVASCULAR OR METABOLIC DISEASE OR
COGNITIVE FUNCTION IN OLDER WOMEN? DEFINING A
NEW BIOMARKER OF AGING.
J. Sanders, A. Nau, Y. Conley, R. Boudreau, L. Niedernhofer,
L. Kuller, A. Newman. University of Pittsburgh, Pittsburgh, PA.
Background: Few primary markers of aging are validated in
human population studies. The lens is of interest because transparency
can be measured accurately, noninvasively, and repeatedly
throughout life. To evaluate the lens as a biomarker of aging we
tested the association of lens transparency and cataract surgery to
markers of aging and disease including risk factors for coronary atherosclerosis,
coronary artery calcium (CAC), fasting plasma glucose
or insulin, cognitive function and ApoE genotype. Methods: We
measured lens transparency with Scheimpflug photography (N=136)
and cataract surgery with self-report (N=231) in participants of the
Healthy Women Study (mean (SD) age 73.3 (1.7) years). Atherosclerosis
risk factors (age, smoking, waist circumference, BMI, lipids,
blood pressure, fasting glucose and insulin, medication use) were
measured concurrently with lens transparency and 13 years previously.
CAC was measured with electron beam tomography at the
time of lens measurements and ~7, 10, and 13 years previously. Cognitive
indicators included the Modified Mini Mental Status Exam and
ApoE genotype. Results: Cross-sectionally, cataract surgery was associated
with larger waist circumference and diabetes (P

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care (OR 1.93, 95% CI, 1.67-2.24 for high-risk antihistamines; OR
5.97, 95% CI 0.76-47.03 for high-risk cardiac drugs; OR 1.99, 95% CI
1.29-3.07 for psychotropics). Index exposure to high-risk cardiac
drugs also significantly increased musculoskeletal adverse outcomes
(OR 2.28, 95% CI 1.76-2.96) but incident exposure to psychotropics
did not significantly increase gastrointestinal adverse outcomes (OR
1.14, 95% CI 0.75-1.72). Conclusion: Incident exposure to HRME is
associated with adverse outcomes within one year following index
day in senior veterans with chronic pain. Further research is needed
to develop intervention measures to limit such exposure.
B39
Novel predictors of new antibiotic resistant organism (ARO)
colonization in nursing home (NH) residents.
L. Min, 1,2 L. Mody. 1,2 1. Medicine, University of Michigan, Ann Arbor,
MI; 2. GRECC, VA Health Care Systems, Ann Arbor, MI.
Supported By: Agency for Healthcare Quality and Research (Min),
VA Healthcare System Geriatric Research Clinical Care Center
(GRECC, Min and Mody), Hartford Foundation (Min), NIA-
Pepper Center (Min, Mody), NIH (K23AG028943 and
R01AG032298 Mody), NIH-LRP (Min), T Franklin Williams
(Mody).
Objective: NH residents with functional disability are at risk for
ARO colonization. We tested (1) whether function predicts AROs independent
of clinical risk factors (co-morbidities, wounds, hospitalization)
& (2) whether specific activities of daily living (ADLs) are
associated with higher risk due to greater nursing contact time (e.g.
feeding) or bodily exposure (e.g. toiling).
Methods: Longitudinal surveillance of 178 NH residents, half
with indwelling device, actively cultured at multiple anatomic sites at
baseline and every 30 days until discharge or 1 yr.
Outcomes: Time to new colonization for methicillin-resistant
Staphylococcus aureus (MRSA), vancomycin-resistant enterococci
(VRE), and resistant gram-negative bacteria (GNB-R). A new ARO
was defined as a positive culture following a negative previous culture
for that ARO. A patient could have multiple new colonizations if
negative cultures were collected in between positive ARO cultures.
Control variables (baseline): device, functional impairment (overall
vs 6 ADLs [Table]), co-morbidity (Charlson index [CCI] vs conditions
from CCI). Time-varying predictors: interval hospitalization or
wound/pressure ulcer. We modeled time to new ARO using multiplefailure
Cox proportional hazard models to allow for fluctuation in
colonization status.
Results: 111 had ≥2 visits (729 follow-up visits total). 76 had at
least 1 new ARO colonization, with multiple new colonizations occurring
in 51 residents.
Conclusions: Besides known risk factors such as hospitalization,
indwelling devices, and wounds, we identified contact-intense ADLs
such as assistance in feeding and walking & chronic conditions such
as heart failure and hemiparesis that predict new ARO colonization
in NH residents.
* p

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of all ACS hospitalized in 1 year in the Florence area, Italy, patients
aged 75+ years with ST-segment or non-ST-segment elevation myocardial
infarction (STEMI, NSTEMI) were selected. Background
risk was assessed with the Silver Code (SC), a validated tool based on
administrative data, which predicts mortality in subjects aged 75+
hospitalized for medical reasons. Multivariable odds ratio with 95%
confidence interval (CI) for PCI application, and hazard ratio (HR)
for 1-year mortality by PCI utilization were calculated. RESULTS: In
698 patients (358 women, mean age 83 years, STEMI=176), for each
point increase in the SC score the odds for the use of PCI decreased
by 11%, while the hazard of 1-year mortality increased by 10%, adjusting
for comorbidity, STEMI vs. NSTEMI, Killip class, low
glomerular filtration rate, anaemia, low platelets and peak troponin
tertile. PCI reduced 1-year mortality progressively more with increasing
SC score, with HR (95% CI) of 0.8 (0.19-1.21), 0.41 (0.18-0.45),
0.41 (0.23-0.74), and 0.26 (0.14-0.48) for SC scores of 0-3, 4-6, 7-10,
and 11+. CONCLUSIONS: Exclusion of older ACS patients from
PCI increases with increasing background risk. This procedure, conversely,
appears to be more effective in older patients with more severe
background risk, as indicated by the SC score.
B42
A meta-analysis of mortality rates associated with comorbid
depression among older adults with diabetes.
M. Park, W. Katon. University of Washington, Seattle, WA.
Supported By: NIMH 2 T32 MH 73553-6
Background: Comorbid depression has shown a strong association
with increased negative health outcomes among those with medical
illness.
Objectives: To examine mortality rates associated with comorbid
depression among the older adults with diabetes.
Methods: A systematic literature search, appraisal, and metaanalysis
were conducted. Using various combinations of keywords
(depression, diabetes, mortality), we searched five databases: Medline,
CINAHL, Cochrane Library, Embase, and Science Direct. Selection
criteria include English-language, peer-reviewed articles published
between January 2000-June 2011, reporting hazard ratio for
mortality from longitudinal and prospective epidemiological studies,
and study of older adults.
From 769 potentially relevant articles, we found four articles
that met the selection criteria. The studies reported outcomes of
29312 elderly persons.
Findings: The weighted hazard ratios were 1.38 (95% CI: 1.24,
1.52). The older adults with comorbid depression and diabetes experience
approximately 38% elevated risk for death from all cause compared
to those with only diabetes.
Conclusion: Screening and treating depression among older
adults with diabetes is important for better health outcomes in older
adults populations
Forest Plot
B43
Epidemiology of Restricting Fatigue in Older Adults.
N. de Rekeneire, L. Leo-Summers, T. Gill. Yale University School of
Medicine, New Haven, CT.
Supported By: No Financial Disclosure
Background: Fatigue is a frequent complaint among older adults
and has been linked to functional decline and disability. Longitudinal
data on fatigue leading to restricted activity are sparse. Our objectives
were to estimate the rate of restricting fatigue among community-living
older adults and to determine whether the rates differ according
to age, sex, race and physical frailty.
Methods: Participants were members of the Precipitation
Events Project (PEP), a longitudinal study of 754 nondisabled community-living
older adults aged 70+ years who were evaluated
monthly for over 10 years. Restricting fatigue was defined as staying
in bed for at least ½ a day and/or cutting down on one’s usual activities
because of fatigue for 3+ consecutive months. Physical frailty was
defined on the basis of slow gait speed.
Results: The mean age of our study sample was 78.4 years; 64.6%
were women, 90.5% were white and 42.7% had physical frailty. During a
median follow-up of 111 months,66 (24.7%) of the men and 171 (35.1%)
of the women developed an episode of restricting fatigue (p= 0.003).
Among the 237 (31.4%) participants with restricting fatigue, the median
(interquartile range) number of episodes was 1.0 (1.0-2.0).The mean duration
of the 459 episodes of restricting fatigue was 3 months (3-4) and
did not differ according to age, sex, race or physical frailty. The overall
rate of restricting fatigue was 6.7 per 1000 person-months. As shown in
the Table, rates were higher in women than men (p< 0.001), participants
80+ yrs than those 70-79 yrs (p=0.045) and participants who were physically
frail vs. not frail (p< 0.001), but did not differ according to race.
Conclusions: Among community-living older adults, restricting
fatigue is common. Women, the oldest old and those with physical
frailty had higher rates of restricting fatigue. Additional research is
warranted to better understand the characteristics associated with the
development and recurrence of restricting fatigue in older persons.
B44 Encore Presentation
Trajectories of Positive Aging: Observations from the Women’s
Health Initiative Study.
O. Zaslavsky, 1 N. F. Woods, 1 B. Cochrane, 1,2 A. LaCroix . 1,2 1.
University of Washington, Seattle, WA; 2. Fred Hutchinson Cancer
Reserach Institute, Seattle, WA.
Background: Our analyses of data from the Women’s Health
Initiative (WHI) participants yielded a two-factor index of positive
aging: physical-social functioning and emotional functioning. These
two factors predicted years of healthy living, years of independent living
and mortality. Based on these findings, we then described trajectories
of positive aging indicators over time and identified those baseline
characteristics that predict trajectory group membership.
Methods: Women ages 65 years and older who enrolled in one
or more WHI clinical trials and had data available on the positive
aging indicators at baseline and years 1, 3, 6 and 9 were included in
these analyses (N=2,281). We used Group-Based Trajectory Modeling
to identify distinct subgroups of individuals, following a similar pattern
of change over time on the two factors of positive aging. Then,
multinomial logistic regression was conducted to identify baseline
predictors of membership in these positive aging trajectories.
Results: A 5-trajectory model was chosen to best represent the
data. These trajectories included Low Maintainer (8.3%), Low Improver
(11%) Moderate Decliner (12.5%), Moderate Maintainer
(29.7%) and High Maintainer (38.6%) groups for Physical-Social
Functioning and Low Maintainer (3.1%), High Improver (8.7%),
Moderate Decliner (8.6%), Moderate Maintainer (29.7%), High
Maintainer (55.8%) groups for Emotional Functioning. Using the
Low Maintainer group as the reference category for Physical-Social
Functioning, the High Maintainer group was younger, predominantly
white, and more physically active. High Maintainers also had lower
BMI, less pain and depression, fewer somatic symptoms, fewer chronic
conditions, higher optimism, and either mild or moderate alcohol consumption.
Similarly, odds ratios using the Low Maintainer group as the
reference category for Emotional Functioning showed that High
Maintainers had less pain and depression, fewer somatic symptoms,
fewer negative life events, higher optimism, and greater social support.
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Conclusion: Aging women are heterogeneous in terms of positive
aging indicators over time. Somatic experiences (i.e., pain, symptoms)
and number of chronic conditions were the strongest predictors
of membership in non-robust trajectories for Physical-Social
Functioning and depression was the strongest predictor of Emotional
Functioning.
B45
Patterns of Comorbid Chronic Diseases and Geriatric Conditions
Associated with Greater Severity of Chronic Obstructive Pulmonary
Disease in Older Adults.
S. S. Chang, T. M. Gill. Geriatrics/Internal Medicine, Yale School of
Medicine, New Haven, CT.
Supported By: This research was funded in part by the John A.
Hartford Foundation for Excellence in Geriatric Medicine at Yale
University (Grant 2007-0009), the Yale Claude D. Pepper Older
Americans Independence Center (National Institute on Aging P30
AG021342), and Clinical Translational Science Award (Grant UL1
RR024139/ KL2 RR024138) from the National Center for Research
Resources (NCRR), a component of the National Institutes of
Health (NIH), and NIH roadmap for Medical Research.
Background:
Chronic obstructive pulmonary disease (COPD) is the third
leading cause of death in the U.S. and increases in prevalence with
advancing age. Extrapulmonary diseases, which occur throughout all
stages of COPD, can complicate its management and negatively impact
long-term prognosis, especially as COPD worsens. Geriatric
conditions, which confer high risk of adverse health outcomes, add to
the complexity of effectively managing COPD in older adults. Identifying
patterns of comorbid chronic diseases and geriatric conditions
which are associated with greater COPD severity will provide
insight into enhanced approaches to optimize outcomes in older
adults with COPD.
Methods:
Data were drawn from the Cardiovascular Health Study, a
prospective multi-center cohort of U.S. community-dwelling adults
aged 65-80 who completed baseline spirometry (N=3583). COPD was
established by spirometric criteria for airflow limitation, using the
Lambda-Mu-Sigma (LMS) method, an approach which accounts for
age-related changes in lung function. We performed ordinal logistic
regression to evaluate the relationships between patterns of comorbidities
and COPD severity, staged according to LMS-derived spirometric
Z scores (mild, moderate, and severe) and the American Thoracic
Society (ATS-DLD-78) dyspnea scale (grades 1-5). Models
were adjusted for age, gender, education, and smoking.
Results:
Of the participants with COPD (13.8%), comorbid hypertension
(HTN) and arthritis (28.0%), atherosclerotic vascular disease
(AVD) and HTN (24.3%), and HTN and polypharmacy (11.1%)
were among the most frequent comorbidity patterns. Individuals with
COPD who had comorbid HTN and arthritis (adjusted OR=1.60,
95%CI=1.08-2.38), AVD and HTN (1.55, 1.03-2.32), and HTN and
polypharmacy (1.95, 1.09-3.46) were more likely than those without
these respective comorbidities to have greater COPD severity, assessed
by spirometry. Similarly, having comorbid HTN and arthritis
(adjusted OR=1.63, 95%CI=1.11-2.39), AVD and HTN (1.65, 1.11-
2.44), and HTN and polypharmacy (2.70, 1.57-4.63) was significantly
associated with worsening dyspnea.
Conclusions:
Specific patterns of comorbid chronic diseases and geriatric conditions
are associated with worsening COPD. These findings could inform
the design of interventions to improve outcomes in older adults
with COPD.
B46
Cognitive Status and Care-seeking Behavior in Elderly Patients with
Acute Heart Failure.
S. N. Levin, 1 A. Hajduk, 2 D. M. Lessard, 2 F. A. Spencer, 3
J. H. Gurwitz, 1,2 R. J. Goldberg, 1 J. S. Saczynski. 1,2 1. Meyers Primary
Care Institute and Division of Geriatric Medicine, UMASS Medical
School, Worcester, MA; 2. Department of Quantitative Health
Sciences, UMASS Medical School, Worcester, MA; 3. Department of
Medicine, McMaster University, Hamilton, ON, Canada.
Background: Heart failure (HF) is a chronic disease characterized
by acute exacerbations and high rates of rehospitalization.
In response to worsening symptoms, patients are advised to
promptly seek medical care. Cognitive impairment (CI) is highly
prevalent in patients with HF and may impact their decision or
ability to seek treatment for an acute exacerbation. We examined
the association of impairment in specific cognitive domains and
time to emergency department (ED) presentation following acute
HF symptom onset.
Methods: The sample included 564 patients hospitalized with
acute HF (mean age = 72 years, 45% female) between 2007 and 2010
at several tertiary care and community medical centers. CI was assessed
in 3 domains (memory, processing speed, executive function)
using standardized measures. Time to ED presentation was collected
from a structured interview during hospitalization. The time interval
between the patient’s latest reported symptoms of HF and ED presentation
was assessed.
Results: More than three quarters (78.2%) of patients were impaired
in at least one cognitive domain. The average pre-hospital
delay for patients who experienced acute symptoms of decompensated
HF was 4.2 days (100 ± 12 hr) while their median delay time
was 14 hours. Over two fifths (43%) of all participants waited at
least one day before presenting to the ED. Compared to patients
with intact cognitive function, those with CI had a longer delay to
ED presentation following symptom onset (median delays: 15.0 hr
vs. 8.6 hr; p = 0.03). Pre-hospital delay times varied according to specific
cognitive domains. Patients with deficits in memory or processing
speed had longer median delay times than unimpaired patients
(memory: 23.2 hr vs. 11.4 hr, p = 0.02; Speed: 19.4 hr vs. 11.3 hr, p =
0.05). Executive function was not associated with duration of prehospital
delay.
Conclusion: Cognitive impairment is common among patients
hospitalized for HF and is associated with delays in seeking emergency
care. Interventions to enhance the care of patients with acute
heart failure should take into consideration the important impact of
cognitive status.
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B47
The Impact of Cognitive Impairment on Mortality in Older Adults
with Heart Failure.
T. Gure, 1 C. Blaum, 1,3 J. Ha, 1 S. Hummel, 4 L. Min, 1,3 C. Cigolle, 6,3
A. Galecki, 1 K. Langa. 2,5 1. Geriatric & Palliative Medicine, University
of Michigan, Ann Arbor, MI; 2. General Internal Medicine, University
of Michigan, Ann Arbor, MI; 3. GRECC, VA Healthcare System, Ann
Arbor, MI; 4. Cardiovascular Medicine, University of Michigan, Ann
Arbor, MI; 5. VA Center for Practice Management & Outcomes
Research, VA Healthcare System, Ann Arbor, MI; 6. Family Medicine,
University of Michigan, Ann Arbor, MI.
Supported By: The National Institute on Aging (NIA) provides
funding for the Health and Retirement Study (U01 AG09740)
which is performed at the Institute for Social Research, University
of Michigan; NIA grants R01 AG027010 and R01 AG030155
(Langa); Ann Arbor VA Geriatric Research, Clinical and Education
Center (Blaum, Cigolle, and Min); NHLBI grant K23 HL109176
(Hummel); AHRQ grants R21 HS017621 and R21 HS 019459
(Min); NIA grant K08 AG031837 (Cigolle); NIA Diversity
Supplement award R01 AG027010-02S1 (Gure); John A. Hartford
Foundation Center of Excellence (Cigolle, Gure, and Min); the NIA
Claude D. Pepper Center Research Career Development Core
(Cigolle, Gure, and Min); National Center for Research Resources
UL1 RR024986 (Gure).
Background: Cognitive impairment (CI) is highly prevalent in
older adults with heart failure (HF), yet our understanding of the impact
of CI on mortality in this population is limited. We aimed to estimate
the risk of death over 4 yrs of follow-up in older adults with
HF, stratified by cognitive function. Methods: We used the 2004 wave
of the Health and Retirement Study (HRS) linked to Medicare
claims. A HF case-finding algorithm identified HRS respondents
with highest likelihood of a HF diagnosis (“HF patients”). CI was assessed
using previously published HRS population-based screening
measures. Death was identified using the HRS data verified by National
Death Index. We tested the relationship between cognitive
function and mortality in HF patients using unweighted Kaplan-
Meier survival curves and Cox proportional hazard models. Results:
Of 707 HF patients identified, 286 (42%) died over the 4 yr-period.
Survival of older HF patients was significantly influenced by their
cognitive status (p

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B49
Prevalence and Correlates of Self-Reported Medication Non-
Adherence among Older Adults with Diabetes Mellitus, Coronary
Heart Disease, and/or Hypertension.
Z. A. Marcum, 1 Y. Zheng, 1 S. Perera, 1 E. Strotmeyer, 1 A. Newman, 1
E. Simonsick, 2 R. Shorr, 3 D. C. Bauer, 4 J. M. Donohue, 1 J. T. Hanlon. 1
1. University of Pittsburgh, Pittsburgh, PA; 2. NIA Intramural
Research Program, Baltimore, MD; 3. VA GRECC, Gainesville, FL; 4.
UCSF, San Francisco, CA.
Supported By: Supported in part by National Institute on Aging
grants and contracts (R56AG 0207017, P30AG024827, T32 AG021885,
K07AG033174, R01AG034056, 3U01 AG012553, N01-AG-6-2101,
N01-AG-6-2103, and N01-AG-6-2106), a National Institute of Mental
Health grant (R34 MH082682), a National Institute of Nursing
Research grant (R01 NR010135), Agency for Healthcare Research
and Quality grants (R01 HS017695, K12 HS019461, R01HS018721),
and a VA Health Services Research grant (IIR-06-062). This research
was also supported in part by the Intramural Research program of the
NIH, National Institute on Aging.
Background: Medication non-adherence is common among
older adults with chronic co-morbidity, but the underlying factors are
largely unexplored. This study examines the prevalence and correlates
of self-reported medication non-adherence among communitydwelling
older adults with chronic cardiovascular conditions (i.e., diabetes
mellitus [DM], coronary heart disease [CHD], and/or
hypertension [HTN]).
Methods: The study sample (mean [SD] age 82.1 [2.8], 52.5% female,
37.0% black) included 897 members from the Health Aging
and Body Composition cohort (n=3075) with any DM (n=338;
37.7%), CHD (n=381; 42.5%), or HTN (684; 76.3%) at year 10. Selfreported
medication non-adherence was measured by the 4-item
Morisky Medication Adherence Scale (MMAS) and 2-item Cost-Related
Non-Adherence scale (CRN) at year 11; these scales separately
assess different reasons for medication non-adherence. We used multivariable
logistic regression models with backward selection to identify
correlates (i.e., demographic, health status, and access to care factors)
of non-adherence for each measure.
Results: Non-adherence by MMAS and CRN was reported by
40.7% and 7.7%, respectively. Non-adherence by MMAS was associated
with black race (adjusted odds ratio=AOR=1.85, 95% interval=1.25-2.74)
and hospitalization in the previous 6 months
(AOR=1.97, 95% interval=1.22-3.17). Non-adherence by CRN was
associated with marital status (married vs. unmarried; AOR=0.47,
95% interval=0.23-0.98) and money-related delay in medical care
(AOR=6.94, 95% interval=2.41-19.97). Age, gender, and the total
number of regularly scheduled medications were not associated with
non-adherence by either MMAS or CRN.
Conclusions: Self-reported medication non-adherence is common
in older adults with chronic cardiovascular conditions, and nonadherence
measured by CRN is less prevalent than MMAS. No correlates
for non-adherence were detected consistently across both
measures. Future studies should evaluate targeted interventions
based on patient-specific modifiable barriers to improve medication
adherence.
B50
Health Care Proxy Involvement and Satisfaction in Decision-
Making for the Treatment of Infections in Nursing Home Residents
with Advanced Dementia.
C. K. Ankuda, 1 J. L. Givens, 2,3 S. L. Mitchell. 2,3 1. University of
Vermont College of Medicine, Burlington, VT; 2. Division of
Gerontology, Beth Israel Deaconess Medical Center, Boston, MA; 3.
Hebrew SeniorLife Institute for Aging Research, Boston, MA.
Supported By: National Institutes of Health (NIH)
Background: Infections are common in advanced dementia, and
health care proxies (HCPs) are often called upon to make treatment
decisions. This study describes the awareness, involvement, and satisfaction
of HCPs in decision making regarding infectious episodes for
a cohort of nursing home (NH) residents with advanced dementia.
Methods: From 2010-2011, data were prospectively collected
from 135 NH residents with advanced dementia and their HCPs at 22
Boston area facilities. For each infectious episode, information was
obtained on whether the HCP: 1. could be contacted by study staff; 2.
was aware of the infection; and 3. was involved in decision making.
Multivariable logistic regression was used to determine resident,
HCP and episode characteristics associated with HCP awareness of
the infectious episode.
Results: Residents experienced 287 infectious episodes (82 respiratory,
114 urinary tract infection, 37 skin and 53 fever). HCPs were
able to be contacted by study staff for 217/287 episodes. Once contacted,
HCPs were aware of 94/217 (43%) of episodes, and of these,
were involved in decision-making for 57/94 (61%). HCP awareness of
the episode was associated with the HCP being the child of the resident
(vs. other relationship) [adjusted odds ratio (AOR) 2.34, 95% CI
1.19 – 4.59], female (AOR 2.79, 1.37-5.66), and the episode being
treated with antibiotics (AOR 3.68, 1.56-8.66).
Conclusions: The majority of infectious episodes in NH residents
with advanced dementia do not involve HCPs in decision-making.
Awareness of infections among HCPs is more likely for episodes
treated with antibiotics, and when the HCP is the resident’s child and
is female. These factors may help target infectious episodes that require
greater attention with respect to better informing HCPs of their
loved one’s health status.
B51
Can a patient navigator get older patients and their oncologists on
the same page?
E. Vig, 1,2 C. Clark, 2 R. Engelberg. 2 1. Geriatrics, VAPSHCS, Seattle,
WA; 2. Medicine, University of Washington, Seattle, WA.
Supported By: American Cancer Society
Background Older patients may approach cancer management
decisions differently than younger patients. Although older patients
may be more concerned about quality of life than cure, oncologists do
not routinely elicit patients’ quality of life concerns. As a result, older
patients and their oncologist may not be on the same page during office
visits.
We undertook a two phase pilot study to test whether a patient
navigator intervention could facilitate shared decision-making between
older patients with cancer and their oncologists.
Methods In the study’s first phase, we interviewed oncologists,
older cancer patients, and their family members about their decisionmaking,
and whether/how a patient navigator might help. Interviews
were recorded, transcribed, and analyzed using grounded theory
methods.
In the second phase, the patient navigator met with an older patient
prior to an oncology appointment to identify his/her quality of
life and other concerns. The navigator then accompanied the patient
to the oncology appointment and debriefed afterwards. Several days
later, an investigator debriefed separately with the oncologist and the
patient/family. Content analysis and descriptive statistics were used to
analyze study data.
Results In the first phase, we recruited 9 oncologists from 2 clinics,
12 of their patients, and 3 of their family members. Oncologists
and patients thought navigators could be helpful by clarifying understanding,
taking notes, and helping patients ask questions.
In the second phase, the 9 oncologists identified 9 additional patients.
Prior to the navigated visits, patients identified their main concerns
(mean 3 concerns, range 1-5). During the visits, the navigator reminded
the patient of concerns in 4 visits, facilitated discussion about
referral to a pain specialist in 1 visit, clarified referral to a cardiologist
in 1 visit, and clarified the follow up plan with the oncologist in 2 visits.
Patients described the navigator as helpful, reported that all their
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concerns had been addressed during the visit, and wished that navigator
involvement could be ongoing. Oncologists described the presence
of the navigator as helpful and not burdensome or intrusive.
Conclusion A patient navigator who identifies older patients’
concerns before an oncology visit, accompanies them to a visit, and
debriefs with them afterwards can help to ensure that their concerns
are elicited and addressed.
B52
Association of Experience with Illness and End-of-life Care with
Advance Care Planning.
H. Amjad, 1 V. Towle, 1 T. Fried. 1,2 1. Yale University School of
Medicine, New Haven, CT; 2. VA Connecticut Healthcare System, West
Haven, CT.
Background: Advance care planning (ACP) remains an underused
tool in medical care, and identifying factors associated with increased
participation in ACP is important for the promotion of this
health behavior. This study examines the relationship between previous
experiences with illness and end-of-life care with the stages of
change for six ACP behaviors.
Methods: 304 individuals aged 65 and older were recruited from
physician practices and a senior center. Participants were asked
whether they had ever faced a life-threatening illness or surgery. They
were also asked whether they had ever made a medical decision for
someone who was dying, whether they knew someone who they believe
had a bad death due to receiving too much or too little medical
care, and whether they had experienced the death of a loved one who
made his or her wishes about end-of-life known. Stages of change
were assessed for six ACP behaviors: completion of a living will and
healthcare proxy, communication with loved ones regarding use of
life-sustaining treatments and quantity versus quality of life, and communication
with physicians about these same topics. Mantel-Haenszel
chi-square analysis was used to examine the association between
each life experience and stages of change for each ACP behavior.
Results: 84% of participants had experiences with their own illness
or end-of-life care for a loved one. Personal experience with lifethreatening
illness was not associated with increased readiness to participate
in ACP behaviors except for discussing life-sustaining
treatments with loved ones (p

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Conclusions: The study demonstrated that MED-SAIL is a valid
brief screening tool to identify older adults with impaired capacity for
remaining safe and independent in their current living environment.
The tool will be useful for health and social service professionals
working in the community.
B55
Differential regulation of mitochondrial biogenesis with Losartan in
the heart and liver of young and aged mice.
B. R. Manwani, H. Yang, C. Lin, J. Walston, P. Abadir. Geriatrics,
Johns Hopkins University, Baltimore, MD.
Supported By: National Institute of Aging
Background
The renin-angiotensin system (RAS) regulates multiple physiological
functions through angiotensin (Ang) II type 1 (AT1R) and
type 2 (AT2R) receptors. We recently identified a functional mitochondrial
RAS, with AT2R located in inner mitochondrial membrane
that decreases in number with age and increases with AT1R blocker
losartan. Given the known relationship between aging and mitochondrial
biogenesis, and the emerging understanding of local mitochondrial
RAS system, we hypothesized that blocking AT1R with losartan
in vivo would increase mitochondrial biogenesis and survival gene
production.
Methods
10 young (20 wks) mice were equally divided into control group
or treated with Losartan for 20 wks. 10 old (50 wks) mice were treated
similarly. All mice were sacrificed at the same time and RNA isolated
from liver and heart. For biogenesis, quantitative PCR was used to
calculate CytB (mitochondrial gene)/GAPDH (nuclear gene) ratio
and to measure mitochondrial survival genes Sirt1, Sirt3, Nampt, and
PGC-1α. All data were analyzed using the Pfaffl method
Results
AT1R blockade increased the CytB/GAPDH ratio in the heart
of treated young and old mice (3.84 fold and 4.37 fold increase respectively)
but significant reduction in mitochondrial level was observed
in the liver where the ratio in treated young and old mice was
only 1.5% and 2.3% as much as their respective controls.
Mitochondrial survival gene expression in the heart was not increased
and PGC-1α, one of the main regulators that drive biogenesis,
was in fact down-regulated by 50% and 55% in young and old
treated mice respectively.
Conclusion
Older mice treated for 20 weeks with Losartan, irrespective of
age, have increased mitochondrial biogenesis in the heart but not in
the liver despite the fact that mitochondrial survival genes were not
up-regulated in the heart. Mitochondrial survival genes and especially
PGC-1α might have been up-regulated in the earlier phases of
the treatment. The role of the RAS system in maintaining mitochondrial
levels might therefore be a key mechanism in promoting
healthy aging.
Effects of AT1R blockade on mitochondrial biogenesis and survival
genes expression in young and aged mice
B56 Encore Presentation
Cellular Senescence in Patients with Barrett’s Esophagus: A Pilot Study.
E. Gorospe, J. Penfield, K. Wang. Department of Medicine, Mayo
Clinic, Rochester, MN.
BACKGROUND: Cellular senescence is an irreversible mechanism
whereby cells enter a non-mitotic state as a response to oncogenic
stress. Barrett’s esophagus (BE) is the leading risk factor for the
development of esophageal adenocarcinoma, one of the fastest growing
cancers in middle-aged and elderly Caucasian men.
AIM: To assess if cellular senescence is present in BE as a tumor
suppressing mechanism
METHODS: We examined esophageal tissue from a series of 11
patients (age 67.3 ± 7.9 y.o) who underwent clinically-indicated endoscopic
mucosal resection (EMR) for BE. Cellular senescence was determined
using the Senescent Cell Histochemistry Kit (Sigma
CS0030, St. Louis, MO) that determines SA B-galactosidase activity,
which is the gold standard for senescence. In addition, we assessed the
expression of cyclins B1, B2, C, D1, D2, E1, F, G1, G2, H, T1 and T2;
CDK 1A, 1B, 2A (p16), 2B (p15), 3, MCM2, MCM3, MCM4, RB1,
RBBPB, RBL1, RBL2, RPA3 in biopsies taken from the Barrett’s
esophagus segment. The biopsies were stored in RNAlater (Qiagen,
Valencia, California) at -80 degrees Celsius until RNA purification.
Tissue was then disrupted and homogenized in buffer solution. The
lysate was then purified using an RNAeasy spin column (Qiagen, Valencia,
California) and rinsed twice with 50 ul of RNAase free water.
The RNA was then used to prepare cDNA using the RT First Strand
Kit (Superarray, Frederick, MD) as per manufacturer’s instructions.
The cDNA was placed with the RT qPCR mastermix with SYBR
green and a reference dye, the mixture was then aliquoted across an
expression array, thermal cycling was performed with real time amplification.
Changes in gene expression were noted while internal array
controls for genomic DNA contamination, efficiency of the RT, and
the efficiency of the PCR were all found to be within specified norms.
RESULTS: We detected senescent cells in 9 (81.85%) patients.
The 2 patients who did not have senescence had non-dysplastic BE.
The presence of senescence was further confirmed by the decreased
expression of cell regulatory genes including a decrease in RB -197
fold, p

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ferent than previously reported to be occurring in aging mice, highlighting
the importance of confirming animal model data in people.
B58
An Isocaloric Low Protein Diet in Rodents: an Experimental Model
of Frailty and/or Sarcopenia.
P. Ammann, R. Rizzoli. Department of rehabilitation and geriatrics,
Division of bone diseases, Geneva, Geneva, Switzerland.
Frailty and sarcopenia are very frequent in the oldest old. Even
if clinical diagnosis criteria are becoming recognized for both conditions,
these disorders are still missing an operational definition and
their pathophysiology remains still unclear. This is partially due to the
lack of experimental models of acquired frailty and/or sarcopenia.
To better understand the pathophysiology and potential therapeutic
strategies of frailty and/or sarcopenia, we set up an experimental
model in adult rats or mice. Animals were pair fed with an
isocaloric low protein diet (50 % of the minimal amount necessary to
maintain sex hormone status) and compared to animals with a normal
protein diet. Both diets differed only by the casein content as the
source of protein, the same amount of calories being provided by carbohydrate
addition.
This dietary modulation resulted in both sexes in a rapid reduction
of GH and IGF-I production and in a resistance to IGF-I action
(somatotrop axis), in a lower sex hormones concentration or function
(gonadotrop axis) and decreased calcitriol levels and higher circulating
PTH independently of the 25OH vitamin D status (vitamin
D/PTH axis). These alterations were associated with a rapid decrease
in bone mass, in alterations in bone microstructure and material level
properties, a reduction in bone strength, and a marked decrease in
muscle mass. A spontaneous reduction of the food intake was also observed.
Under the isocaloric low protein diet, the response to exogenous
IGF-I, growth hormone or PTH was blunted. All the bone, muscle
and hormones abnormalities were corrected by essential amino
acids supplements.
These features in rodents fed an isocaloric low protein diet are
quite reminiscent of the situation in the frail oldest old. This model
should be of help to further study the pathophysiology of frailty
and/or sarcopenia, and to explore preventive or curative measures.
B59
Osteopontin, a marker of sleep disordered breathing in older
individuals.
S. Shah, N. Punjabi, A. Jain, N. Fedarko. Johns Hopkins University
School of Medicine, Baltimore, MD.
Background: Sleep-disordered breathing (SDB), characterized
by recurrent arousals from sleep and intermittent hypoxemia, is common
among older adults. Studies have linked SDB to hypertension,
cardiovascular, cerebrovascular disease, and dementia. Osteopontin
(OPN) is a secreted glycophosphoprotein that plays a role in a diverse
set of processes involved in stress response and/or chronic immune
activation. The levels of circulating OPN have not been studied
in the context of aging or SDB. We hypothesize that OPN levels correlate
with measures of SDB. Additionally we sought to determine
the influences of the covariates of age, gender, race, and BMI on OPN
values.
Methods: The group under study comprised of 205 healthy individuals
ranging from 20 to 82 years. Subjects free of medical comorbidity
had fasting morning serum tested for OPN levels by competitive
ELISA. Full night polysomnography was conducted and the
apnea-hypopnea index (AHI) was calculated. Differences between
groups were assessed by Mann-Whitney t-tests and associations between
OPN and individual covariates by Spearman rank correlation.
Additionally, OPN levels were modeled by multiple linear regression
with covariates including age, BMI, gender, race, and AHI.
Results: The median level of OPN in the total study population
was 56.4 ng/ml with a range of 5.4 to 426.5 ng/ml. OPN levels were
found to differ by race and gender significantly (p 5, Spearman
r = 0.7, p < 0.0001. Multiple regression of OPN values as a function
of age, race, gender, BMI and AHI values revealed that the association
of OPN with AHI remained significant even after correcting
for these covariates.
Conclusions: The observed differences in circulating OPN
levels may be reflecting underlying differences by race and gender
in allostatic load. Because effective treatments for SDB exist,
early identification and treatment in the elderly may represent a
novel management strategy for reducing the morbidity and mortality
burden associated with SDB and its associated comorbid
diseases.
B60
A calcium channel blocker characteristically prevents endothelial
senescence: Possible implication for atherosclerosis.
T. Hayashi, K. Ina, T. Yamaguchi. Geriatrics, Nagoya University
Graduate School of Medicine, Nagoya, Japan.
Supported By: No funders support for this research.
Background: Aging is one of strongest risk factor of atherosclerosis,
and endothelial senescence has been reported to precede atherosclerosis
in vivo. We have reported the important role of glucose and
NO on the endothelial senescence (PNAS 2006, JPET2011). Although
HMG-CoA reductase inhibitor is shown to prevent endothelial
senescence, the effect of anti-hypertensive agents on senescence
was not known enoughly.
Methods: We measured senescence-associated-β-galactosidase
activity, telomerase activity, and telomere length after the exposure of
human endothelial cells(HUVECs) to glucose, oxidized LDL or angiotensin
II for 2days. Anti-hypertensive agents (calcium channel
blocker:CCB, angiotensin converting enzyme inhibitor:ACEI and β
blocker:βB) were pre- or co-incubated with the stimulus as above
(such as high glucose). The experiment using small-interfering-RNA
targeting endothelial-NO-synthase (eNOSsiRNA) was done to investigate
the mechanisms. Finally, streptozotocin-induced diabetes
showed more senescent cells in aortic endothelium of aged rats and
the effect of anti-hypertension agents was investigated.
Results: After the exposure of HUVECs to glucose (22 mM),
oxidized LDL or angiotensin II for 2 days, senescence-associated-βgalactosidase
activity was increased and decreased telomerase activity,
and the effect of glucose is strongest.
Among various anti-hypertensive agents which pre- or co-incubated
with the stimulus as above (such as high glucose), only CCB,
but not ACEI or betaB, preserved telomere
length and delayed endothelial senescence, which was associated
with reduced reactive oxygen species and increased nitric oxide
(NO). The experiment using eNOSsiRNA suggested the role of NO
in the anti-senescence effects of physiological concentration of CCB.
High glucose and oxidized LDL worked additively. Finally, streptozotocin-
induced diabetes showed more senescent cells in aortic endothelium
of aged rats and the effect of CCB was investigated.
Nifedipine is used in this experiment.
Conclusion: The regulatory effects of CCB on endothelial senescence
is observed in high glucose, oxidized LDL or angiotensin II induced
senescence. These interactions may help explain the pivotal
roleof CCB in atherosclerosis in elderly.
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B61
Losartan increases mitochondrial biogenesis in human fibroblast cells.
V. Cheng, 2,1 B. Manwani, 1 J. Walston, 1 P. Abadir. 1 1. Johns Hopkins
University, Baltimore, MD; 2. University of Kansas Medical Center,
Kansas City, KS.
Supported By: American Federation for Aging Research
Mitochondrial function declines with age and is thought to influence
chronic disease and frailty. The renin-angiotensin system (RAS)
acts through angiotensin (Ang) II type 1 (AT 1
R) and type 2 (AT 2
R)
receptors. We recently found a mitochondrial RAS, with AT 2
R located
in inner mitochondrial membranes that decrease with age and
increase with AT 1
R blocker losartan. Given these results, we hypothesized
that the RAS plays a key role in mitochondrial biogenesis.
Human fetal lung fibroblast cells (MRC-5) were grown in culture
and separated into a control and treatment groups with serially
increasing concentrations of losartan and Ang II. Cells given 100nM
Ang II were subjected to losartan (0.01nM to 100nM). After 48 hrs,
we measured mitochondrial gene ND6 and nuclear gene TK2 with
qPCR. A ratio to compare gene expression based on treatment was
generated.
Mitochondrial biogenesis increased with higher doses of losartan.
Cells given Ang II showed an increased ratio with Ang II up to
1nM and decreased fold change above 1nM. Cells with Ang II and
losartan displayed a reversal of AT 1
R effects and increased mitochondrial
biogenesis with losartan up to 10nM.
These results illustrate a potentially important role of the RAS
on mitochondrial biogenesis. While higher concentrations of losartan
increase fold change, our results suggest a level of losartan that maximizes
AT 1
R blocking efficacy. Optimizing mitochondrial biogenesis
via losartan is a novel approach that warrants further study in frail,
older adults.
ND6/TK2 ratio
Cells with higher doses of losartan showed a higher ratio. Cells
given Ang II show an increased ratio up to 1nM. Cells with 100nM
Ang II and losartan showed an initial increase in ratio.
B62
The Hospital to Home Program: A Window into Healthcare
Transitions for Older Adults.
A. Cornell, J. Speice, T. Caprio, R. McCann. University of Rochester,
Rochester, NY.
Supported By: Reynolds Foundation
HRSA GTPD Grant# HP08792
BACKGROUND: Hospital readmission rates and levels of patient
satisfaction have increasingly become a focus of attention as
federal reimbursement policies change. Although a few programs
have increased the efficiency of the discharge process, most hospitals
lack sufficient resources to support a comprehensive discharge planning
program outside the hospital. Data accumulated from the University
of Rochester’s medical resident education program provides
insight into the older adult patient’s perception of the discharge
process.
METHODS: A retrospective analysis from data collected from
20 patients, age >60 years old, who participated in Highland Hospital’s
“Hospital to Home Program” between September 2009 and September
2011. This program focuses on training medical residents to
identify discharge concerns during an inpatient bedside interview
which is videotaped. Residents follow up with the patient one week
after discharge in another videotaped encounter to gather information
about the patient’s discharge experience. Video footage was reviewed
by a clinical psychologist and the medical resident to identify
common themes that contributed to negative discharge experiences.
Learning points are highlighted in a video compilation that is presented
to a group of medical residents during a teaching noon conference
at the hospital to create a shared learning experience.
RESULTS: Five main themes were identified from the patient
feedback obtained during the program: difficulty accessing pain medicine
or medical equipment, unclear discharge instructions, failure to
have barriers to a safe return to home identified, inadequate follow
up from home health nursing services, and difficulty obtaining answers
to medical questions after discharge. One unique theme that
was also identified was an expressed wish by some patients for more
time to recover in the hospital due to preexisting caregiver responsibilities
at home.
CONCLUSION: The Hospital to Home program provides valuable
insight into the problems that older adult patients experience
after discharge from the hospital. Besides the educational value of this
program, the identified themes provide distinct areas of focus for institutions
striving to prevent unnecessary readmissions to the hospital.
B63
Enhancing Access to Palliative Care: An Initiative to Improve
Advance Care Planning Documentation.
A. Beyea, 1 H. Laura, 1,2 A. Caprio, 1,2 G. Winzelberg, 1,2 K. Wessell, 3
C. Rowe. 4 1. Division of Geriatric Medicine and Center for Aging and
Health, University of North Carolina, Chapel Hill, NC; 2. Palliative
Care Program, The University of North Carolina, Chapel Hill, NC; 3.
Cecil G. Sheps Center for Health Services Research, The University of
North Carolina, Chapel Hill, NC; 4. Division of Hematology and
Oncology, The University of North Carolina, Chapel Hill, NC.
Purpose: This prospective study focused on improving documentation
of advance care planning discussions for patients aged 65
and older admitted to an Acute Care for the Elderly (ACE) unit at a
university hospital. The primary aim was to increase utilization of an
Advance Care Planning (ACP) note, a hospital-specific documentation
tool in the electronic medical record (EMR).
Methods: A case-based education session was repeated nine
times from August 2010 to June 2011 to reach all physicians and medical
students providing care to patients admitted to an ACE unit. Education
covered communication and documentation about decisionmaking
and preferences for life-sustaining treatments (LST).
Following education sessions, participants received group performance
data feedback. A gift card incentive was also used to encourage
ACP discussions and documentation. Weekly chart review of patients
discharged was used to collect data on outcomes: frequency of documented
discussions about patient preferences for LST, and frequency
of documentation with the ACP note tool.
Results: Baseline chart review (N=88) showed 27% of patients
had documentation of LST preferences, while only 4% were documented
in the ACP note. Of the 204 charts reviewed during the intervention
phase, 49% had documentation of LST preferences and 14%
had an ACP note. For patients with dementia (N=64), 53% had documented
discussion of LST preferences in the EMR; 41% in an ACP
note. Among patients confused, sedated, or nonverbal (N=95), 56%
had documented LST preferences in the EMR; 32% in an ACP note.
Discussion: ACP note utilization facilitates effective communication
about changes in health status and patient preferences for LST
across a continuum of care. This quality improvement intervention
was associated with an overall increase in frequency of ACP note utilization.
Documentation practices among patients with dementia and
confusion suggest that providers engage in discussions about LST
preferences at least 50% of the time with patients at risk for progressive
decline, adverse outcomes, and death.
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B64
Residency Training in Optimizing Hospital to Nursing Home
Transitions.
A. Nazir, A. K. Chakka, M. Tegeler, A. D. Graves,
G. R. Westmoreland. Medicine, Indiana University, Indianapolis, IN.
Supported By: 1. Dr. Arif Nazir was funded by the Geriatric
Academic Career Award sponsoerd by Health Resources and
Services Adminsitration.
Background: Selecting an appropriate Post-Acute Care (PAC)
venue and ensuring a seamless transition are critical for the recovery
of older hospitalized patients. We implemented a course for Internal
Medicine and Medicine/Pediatrics residents on selection of PAC venues,
best practices in transitional care, and PAC insurance coverage.
Methods: A formal needs assessment helped structure the aims
that included teaching: 1) various PAC options and Medicare and
Medicaid coverage, 2) strategies to help patients and families select
the most appropriate skilled nursing facility (SNF), and 3) best practices
in transitional care. Course pre-work included an online self-efficacy
survey, a pretest and assigned readings. Sessions 1 and 2 of the
course were conducted by geriatricians in 2 local SNFs. Session 1 included
case-based discussions and role-play in a mock family meeting
focusing on description and insurance coverage of various PAC options,
and the physician’s role in helping families select the most appropriate
SNF. In session 2 residents used a formal tool to assess the
quality of patient transitions and patient awareness of their diseases
and PAC goals. The course concluded with residents repeating the online
self-efficacy survey, a posttest and course evaluation.
Results: Twelve residents have taken the course. Preliminary
survey results show that after taking the course the residents who
were ‘aware OR very much aware’ of ‘available PAC options’ increased
from 3 to 12; those who were ‘knowledgeable OR very
knowledgeable’ about PAC insurance coverage increased from 0 to 7;
and those who were ‘familiar OR very familiar’ with ‘transitional care
issues in elders increased from 2 to 11. Similarly, more residents felt
‘confident OR very confident’ to ‘carry out a family meeting regarding
appropriate PAC venue’, ‘facilitate successful transition for an
older patient’, and ‘help a family to select the best SNF’. There was a
16% mean gain in posttest vs. pretest scores and 85% would recommend
this course to others. Most felt the course will impact their practice.
One learner said, “I will check discharge summaries, look up
(star) rating information on facilities and have early discussions
about goals of care.”
Conclusion: Early findings show that a structured course may
improve residents’ knowledge, skills and attitudes about their role in
patient selection of appropriate PAC options and transitional care.
B65
Inadequate Understanding of Code Status Improved by Case-Based
Learning.
A. Sangarlangkarn, M. Drickamer. Geriatrics, Yale School of
Medicine, New Haven, CT.
Multiple studies show continued deficiencies in education on
end-of-life care. However, there is limited literature on whether
providers have an adequate understanding of DNR/DNI, which is essential
in end-of-life care. Our study evaluates the understanding of
DNR/DNI among physicians in training and the efficacy of casebased
learning in code status education.
In Fall 2011, we surveyed medical students and residents at Yale
School of Medicine before and after a course on challenging end-oflife
cases. Constructed using the same standards as the nationally utilized
Yale Office-Based Medicine Curriculum, the course focused on
DNI/not DNR patients, reversibility of code status, and futility of
care. Mcnemar test was used to evaluate changes in responses.
Results from 44 surveys are shown in attached image. After the
course, participants were 9 times more likely to correctly forego
amiodarone in coding DNR patients (p=0.02), and 11 times more
likely to correctly offer ambu-bag in DNI patients (p=0.01). When
asked if participants possess adequate understanding of DNR/DNI
on a scale of 1 (disagree) to 5 (agree), there was a 0.93 point increase
after the course (before=3.26, after=4.19, p=0.00). Ninety-three percent
would recommend the course to others.
Surveys showed that many participants would provide contraindicated
interventions to DNR patients while failing to offer appropriate
interventions to DNI patients. After the course, more participants reported
having an adequate understanding of DNR/DNI. A significant
number appropriately offered manual lung inflation to DNI patients
and correctly withheld antiarrhythmics in coding DNR patients. Our
study showed that physicians in training may benefit from code status
education, particularly case-based learning which may improve their
understanding of DNR/DNI and the quality of end-of-life care.
B66
Development of an Ambulatory Geriatrics Exam for Internal
Medicine Residents.
J. L. Kalender-Rich, 1,2 J. D. Mahnken, 4 I. Dong, 4 A. M. Paolo, 3
S. K. Rigler. 1,2 1. Internal Medicine, University of Kansas School of
Medicine, Overland Park, KS; 2. Landon Center on Aging, University
of Kansas School of Medicine, Overland Park, KS; 3. Office of
Medical Education, University of Kansas School of Medicine,
Overland Park, KS; 4. Department of Biostatistics, University of
Kansas School of Medicine, Overland Park, KS.
Background
Internal Medicine residents must complete geriatric-specific
training. Ambulatory care is now increasingly emphasized in Internal
Medicine residency which has traditionally focused on inpatient care.
Two widely used geriatrics knowledge exams focus mainly on nonambulatory
topics. Our goal was to create a valid ambulatory-focused
geriatrics knowledge exam for residents.
Methods
We created exam questions that cover common clinical topics
likely to be tested on in-training and board exams. Questions were reviewed
by experts in Internal Medicine, Geriatric Medicine, and
Medical Education for content and structure. The exam was administered
to 55 interns and residents after which item analysis was performed
to assess discrimination and level of difficulty; five questions
were discarded based on poor item performance, creating a final 25
question exam. It was also completed by 20 fourth year medical students,
11 general medicine faculty, and 10 geriatrics fellowshiptrained
faculty. We compared the mean correct score for each group
with one-way ANOVA, and also treated group as ordinal and tested
for a trend using simple linear regression.
Results
The mean correct scores for the four groups were 65%, 59%,
60%, 70% and 80% for students, interns, residents, general medicine
faculty and geriatric medicine faculty, respectively. The test of equal
mean scores across groups was rejected (p

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Conclusions
Our overall results demonstrated a gradient of increasing scores
from learners to generalist faculty to geriatrics faculty. Interns and
residents did not score as well as the fourth year medical students;
however, all fourth year medical students at our institution have completed
a required third year geriatrics rotation. In contrast, interns
and residents have a wide variety of backgrounds and many had not
had previous dedicated geriatric exposure. We conclude that this new
exam is an appropriate tool to assess knowledge gained by learners in
an ambulatory geriatric rotation.
B67
A Comprehensive Curriculum to Train Internal Medicine Residents
on Care Transitions.
M. Eskildsen, C. Payne, J. Bonsall, A. Miller, E. Rimler,
U. Ohuabunwa, M. Khosravanipour, A. M. Galvez, J. Stein.
Department of Medicine, Emory University School of Medicine,
Atlanta, GA.
Supported By: John A. Hartford Foundation
Background: Medically complex patients are at risk for complications
during care transitions among providers and hospital units, as
well as in the period after hospital discharge. To address this problem,
Emory’s internal medicine residency program started a new care
transitions curriculum.
Methods: The curriculum, which was developed for medical interns,
addressed patient handovers between providers during a hospital
stay, as well as discharge practices. Components included a two-hour
workshop during intern orientation, two plenary presentations, and a
pocket card outlining preferred practices. A pilot initiative at one participating
hospital also incorporated direct feedback of residents’ discharge
summaries. 71 of 89 interns participated in the curriculum during
the 2010-2011 academic year.We administered pre- and post-course
surveys which addressed confidence in performing care transitions, and
their fund of knowledge on the topic. In addition, the post-course survey
asked about the role the course played in their ability to perform
care transitions. The evaluation also included surveys assessing intern
satisfaction with a pilot discharge summary training program.
Results: Pre- and post-course surveys were completed by 71 and
43 interns, respectively. 16 interns took part in the discharge summary
training pilot and completed a separate questionnaire. Interns’ confidence
in their ability to perform care transitions tasks improved from
19.8 to 25.7 on a 30-point scale (p

P OSTER
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Using this scale, the average score improved from -6.25 pre-curriculum
to -4.95 post-curriculum, p=.000.
Conclusion: We have designed an effective curriculum that improves
both knowledge and self efficacy for residents and medical
students to learn and practice the principles of appropriate prescribing
for older adults that is coordinated and patient-centered.
B70
Identifying the Training Needs of Internal Medicine Faculty in
Geriatrics utilizing the Geriatrics Skills Assessment Tool (GSAT).
P. Yin, 1 N. Jamshed, 2 H. Hu, 1 S. K. Sinha. 1 1. Faculty of Medicine,
University of Toronto, Toronto, ON, Canada; 2. Faculty of Medicine,
Georgetown University, Washington, DC.
Supported By: Mount Sinai Hospital Department of Medicine
Research Fund
Background: As many internists have had no formal training in
geriatrics, improving their geriatrics skills is becoming especially important
given our ageing population. This study assessed the training
needs in geriatrics of faculty across one of North America’s largest
academic Departments of Medicine. Methods: The Geriatrics Skills
Assessment Tool (GSAT) was developed around the 15 core geriatric
skills competencies defined by the American Board of Internal Medicine
(ABIM) for Internal Medicine (IM) residents. A GSAT Survey
was distributed to all active IM faculty at the University of Toronto,
asking each participant to rate each skill in regards to their confidence
in performing, teaching and interest around acquiring further
training in it while also providing some basic demographic information
on training background, sub-specialty etc. Chi-squared, Kendall
Tau-b, and ANOVA tests were used to evaluate associations between
the responses and the demographic profiles of the respondents. Results:
369/491 (75%) faculty members representing 12 sub-specialties
completed the survey, with a minimum response rate of 60%
achieved per specialty. Compared to all other subspecialists, Geriatricians
consistently expressed the highest levels of confidence in performing
and teaching all skills except for those related to end-of-life
care (p

P OSTER
A BSTRACTS
Significant increases in the mean and variability of reaction time
on the SART were significantly associated with both falls (p < 0.01)
and reduced falls efficacy (p < 0.05) in older adults. An increase in
omission errors was also associated with falls (p < 0.01) and reduced
falls efficacy (p < 0.05). Upon controlling for age and gender affects,
logistic regression modelling revealed that increasing variability reflective
of the vigilance (top-down) aspect of sustained attention was
a retrospective predictor of falling in the previous year (p < 0.01, OR
= 1.14, 95% CI: 1.03 – 1.26) and was weakly correlated with reduced
falls efficacy in non-fallers (p = 0.07).
Conclusions
Greater variability in sustained attention is strongly associated
with retrospective falls and to a lesser degree with reduced falls efficacy.
This cognitive measure may provide a novel and valuable biomarker
for falls in older adults, potentially allowing for early detection
and the implementation of preventative intervention strategies.
B73
Under-recognition of Weight Loss in Community-Dwelling Elders.
A. Dobracki, 1,2 W. Zirker. 2 1. Geriatrics, Temple University,
Philadelphia, PA; 2. Geriatrics, Crozer Chester Medical Center,
Upland, PA.
Background: Intentional and unintentional weight loss has been
shown to produce negative outcomes in morbidity and mortality in
older populations, even in the overweight. It has been associated with
a decline in bone mineral density and an increase in fractures. Weight
loss may herald impending Alzheimer’s dementia and earlier institutionalization.
Because weight loss may portend adverse outcomes,
recognition is clinically relevant. This study sought to identify the
scope of under-recognition of weight loss using electronically generated
patient records.
Methods: The electronic database of a community-based health
network was used to retrospectively identify patients age 70 and
older who sustained a 5% weight loss during any 12-month time span
occurring between May 2006 and September 2011. Data included age,
gender, height and weights, documentation by the physician of weight
loss and the number of missed opportunities to document weight loss.
A missed opportunity was defined as an office visit in which weight
loss went unrecognized. Patients were excluded if cancer was an active
problem or if weights were not measured at least twice in a year.
Descriptive statistics were used to analyze the results.
Results: A total of 2387 charts were reviewed, 439 were excluded,
and 1948 charts met inclusion criteria. These included charts
from 143 different physicians. Weight loss occurred in 643 patients
(33%), 237 (37%) were recognized, but 406 (63%) were not. Of those
who lost weight, 133 (21%) were recognized at the first visit by 46 different
physicians, and 95 (71%) of these were recognized by the same
18 providers. If weight loss was initially unnoticed, there was an average
of 2.3 missed opportunities and 4.7 months that elapsed before its
recognition.
Conclusions: In this sample, weight loss in elderly outpatients
was unrecognized in the majority of cases. Only a small number of
providers identified the majority of weight loss cases. Even with the
use of an electronic medical record, most providers did not document
the acknowledgement of weight loss. Given the problems associated
with weight loss, its under-recognition could potentially have serious
consequences in the elderly.
B74
Facilitating frailty identification in clinical practice: Comparison of
two methods among community-dwelling older adults.
A. Islam, 1,2 S. Muir, 2 M. Montero Odasso. 2,3 1. School of Kinesiology,
University of Western Ontario, London, ON, Canada; 2. Geriatric
Medicine, Parkwood Hospital, London, ON, Canada; 3. Lawson
Health Research Institute, London, ON, Canada.
Frailty is characterised by an increased vulnerability for adverse
events such as falls, fractures, nursing home admission, and death.
Several models for the identification of frailty have been developed,
including Fried’s widely accepted Frailty Phenotype Index (FPI). Alternatively,
the 9-category Clinical Frailty Scale (CFS) has been proposed
based on its simplicity for retrieving information from clinical
history and physical exams. The CFS evaluates energy level, mobility
capabilities, comorbidities, self-reported physical activity and functionality.
The CFS scores range from 1 (‘very fit’), to 9 (‘severely
frail’). Each increment in the CFS score increases the risk of death or
institutionalization by approximately 20% (within a six year time
frame). To date, the CFS has not been validated against the FPI. Our
aim was to test the agreement between the FPI and the CFS to identify
community older adults with frailty. Methods: One hundred nine
community-dwelling older adults, aged ≥75, were included in the
study. Participants were first classified as robust, pre-frail or frail
using the FPI. Subsequently, two clinicians blinded from the first assessment,
determined frailty status by applying the CFS to our sample.
Differences amongst assessments were resolved by consensus.
Inter-rater reliability agreement was assessed using kappa statistics.
Frailty status in the same individual by CFS was compared to the
number of FPI components present using Pearson Correlation coefficients.
Results: Analysis of kappa statistics showed a substantial
agreement among raters in applying the CFS to the sample (κ= 0.76,
95% CI (0.68, 0.84)). The CFS was also found to be positively correlated
with an increasing number of frailty components of the FPI
(r=0.69, p

P OSTER
A BSTRACTS
thus, 90% were considered non-adherent with at least one medication.
The mean number of medications that individuals were non-adherent
to was 3.4. None of the cognitive or physical function measures
appeared to be associated with medication non-adherence in this
study.
Medication non-adherence is a very prevalent problem among
elders who self-neglect. Physicians who find high rates of medication
non-adherence should consider the possibility of elder self-neglect in
their patents. Future efforts should focus on studying the underlying
reasons for medication non-adherence in larger samples of elder selfneglecters.
This would facilitate the development of interventions to
reduce medication non-adherence in this population.
B76
Nocturia and overnight polysomnography outcomes among adults
with Parkinson disease.
C. P. Vaughan, 1,2 J. L. Juncos, 3 L. M. Trotti, 3 T. M. Johnson, II, 1,2
D. L. Bliwise. 3 1. Birmingham/Atlanta VA GRECC, Decatur, GA; 2.
Geriatric Medicine & Gerontology, Emory University, Atlanta, GA; 3.
Neurology, Emory University, Atlanta, GA.
Supported By: Supported by NINDS RO1 NS-050595 and PHS
Grant UL1 RR025008 and KL2 RR025009 (Dr. Trotti) from the
Clinical and Translational Science Award program, National
Institutes of Health, National Center for Research Resources. Dr.
Vaughan is supported by a VA Rehabilitation R&D career development
award.
Background: Epidemiologic studies have shown nocturia to be a
frequent and bothersome complaint for patients with Parkinson disease
(PD). Detailed clinical and sleep data have not been available
for this population and may provide insight into the pathophysiology
and bother related to nocturia in the setting of PD.
Methods: PD patients were recruited from university-based
movement disorders clinics for two consecutive nights of in-laboratory
polysomnography regardless of any sleep or voiding complaints.
Nocturia frequency and overall satisfaction related to urinary symptoms
were assessed using the American Urological Association
Symptom Index. Measured sleep characteristics included total sleep
time (minutes) and sleep efficiency (percent). Differences between
those with at least two episodes of nocturia and those with fewer
were determined using chi-square, t-tests, or Wilcoxon signed rank
tests. Linear and logistic regression techniques were used to assess
factors associated with nocturia frequency.
Results: Sixty-three adults (65% male, mean age 63, (range 32-
83)) with PD completed the study. Fifty-nine (93%) participants had
1 or more and 37 (61%) reported 2 or more nocturia episodes nightly.
Unified Parkinson Disease Rating Scale motor score was a predictor
of nocturia occurring at least twice nightly (p=0.02). This association
persisted when controlling for age and gender (p=0.03). MMSE score
did not predict nocturia frequency. Compared to participants with 2-3
episodes of nocturia who were mostly satisfied with their urinary
symptoms (n=13), participants with 2-3 episodes who reported being
dissatisfied with their urinary symptoms (n=12) demonstrated significantly
less total sleep time (372.5 ± 58.7 min vs. 280.5 ± 116.1 min,
p=0.03) and worse sleep efficiency (75.9% ± 11.2 min vs. 59.2% ±
22.7, p=0.04).
Conclusions: Nocturia at least twice per night in adults with PD
is predicted by motor symptom severity, but not cognitive impairment.
PD patients with 2-3 episodes of nocturia and dissatisfaction
related to urinary symptoms have significantly worse sleep compared
to those reporting 2-3 episodes and no dissatisfaction with urinary
symptoms. Improving sleep as part of a multicomponent treatment
strategy for nocturia in PD patients might be an independent target
for therapy.
B77
Consumer-Targeted Drug Information to Reduce Inappropriate
Prescriptions: Feedback from Older Adults and Preliminary
Effectiveness.
C. Tannenbaum, 1 R. Tamblyn, 2 S. Ahmed. 2 1. Université de Montreal,
Montreal, QC, Canada; 2. McGill University, Montreal, QC, Canada.
Supported By: This research was supported by a grant from the
Canadian Institutes of Health Research. There are no financial disclosures
to report in relation to this work.
Previous interventions have targeted physicians and pharmacists
to reduce inappropriate prescriptions. We sought to ascertain
older adults’ response to directly receiving a knowledge transfer intervention
aimed at empowering them to discuss benzodiazepine discontinuation
with their pharmacist and/or physician.
Methods: A written knowledge transfer tool was validated by a
panel of geriatric pharmacists and pilot tested with focus groups of
adults aged 60+. The tool includes a self-assessment component, presentation
of evidence-based risks associated with benzodiazepine use,
knowledge statements designed to create cognitive dissonance about
the safety of benzodiazepine use, education about drug interactions,
peer-champion stories intended to augment self-efficacy, suggestions
for equally or more effective therapeutic substitutes for insomnia and
anxiety, and simple tapering recommendations. The tool was distributed
to eligible participants recruited and randomized to the intervention
group of an open-label cluster randomized controlled trial on
inappropriate prescribing being conducted in Quebec, Canada. Participants
consuming any benzodiazepine > 3 months were contacted
one week after receiving the intervention to ascertain their initial reaction,
change in knowledge with respect to the risks associated with
benzodiazepines and their anticipated course of action.
Results: 50 participants (75% female, mean age 75 + 7 years,
mean duration of benzodiazepine use 11 + 9 years) were contacted
for their feedback. Prior to receipt of the tool, less than 27% correctly
answered questions about the long-term safety of benzodiazepine
use. After receipt of the tool, the proportion increased to 66%
(p

P OSTER
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frailty have increased prevalence and incidence of cognitive impairment,
that those with cognitive impairment have increased prevalence
and incidence of frailty, and that those with both have increased
mortality.
We used data from the 2004, 2006, and 2008 waves of the Health
and Retirement Study (HRS), a nationally-representative longitudinal
health interview survey. The study sample included adults >=65
years who completed physical performance measures in 2004
(n=2,111, representing 35.5 million). We operationalized the frailty
phenotype model and used a performance-based cognitive measure.
We determined prevalence in 2004 and 2- and 4-year cumulative incidence
(2006, 2008) of pre-frailty and frailty and of mild cognitive impairment
(MCI) and dementia. We examined mortality using Kaplan-
Meier survival curves and Cox proportional hazards models.
Prevalences in 2004 were: frailty only, 9%; MCI/dementia only,
20%; frailty and MCI/dementia, 9%. The 2-year cumulative incidence
of MCI/dementia was 16.7% (p=.0009) for the pre-frail and was
18.6% (p=.013) for the frail. Of those with MCI/dementia, the 2-year
cumulative incidences of pre-frailty and of frailty were 54.4%
(p=.002) and 11.0% (p=.002). Both conditions impacted 4-year survival
(Table, p

P OSTER
A BSTRACTS
B81
Antihypertensive Drug Class Use Associated with Urinary
Incontinence in Community-Dwelling Elderly Women?
E. P. Peron, 1 Y. Zheng, 1 S. Perera, 1 A. B. Newman, 1 N. M. Resnick, 1
R. I. Shorr, 2 D. C. Bauer, 3 E. M. Simonsick, 4,5 S. L. Gray, 6
J. T. Hanlon, 1 C. M. Ruby. 1 1. University of Pittsburgh, Pittsburgh, PA;
2. Gainesville VA Geriatric Research, Education and Clinical Center,
Gainesville, FL; 3. University of California, San Francisco, CA; 4.
Johns Hopkins University, Baltimore, MD; 5. National Institute on
Aging Intramural Research Program, Baltimore, MD; 6. University of
Washington, Seattle, WA.
Supported By: This study was primarily supported by National
Institute on Aging grants and contracts (P30 AG024827, T32
AG021885, K07 AG033174, R56 AG027017, R01 AG034056), a
National Institute of Nursing Research grant (R01 NR010135), and
Agency for Healthcare Research and Quality grants (R01
HS017695, R01 HS018721, K12 HS019461).
Background: Medication use is a potentially reversible cause of
urinary incontinence (UI). This cohort study evaluated whether the
use of specific antihypertensive classes is associated with self-reported
incident UI in community-dwelling older women.
Methods: The sample consisted of 959 black and white women
aged 72 to 81 years without baseline (Year 1) UI from the Health,
Aging and Body Composition study. Use of any antihypertensive
from 10 drug classes (i.e., alpha blockers [central], alpha blockers [peripheral],
angiotensin-converting enzyme inhibitors, angiotensin-II
receptor blockers, beta blockers, calcium channel blockers, diuretics
[loop], diuretics [potassium-sparing], diuretics [thiazide], or vasodilators)
was determined during Year 3 in-person interviews. Self-reported
UI, operationally defined as leaking urine at least weekly during
the previous 12 months, was assessed at Year 4 visits.
Results: Overall, 197 women (20.5%) reported incident UI. Use
of specific antihypertensive drug classes ranged from a high of 32.4%
for diuretics (specifically, 8.1% for loop, 9.8% for potassium-sparing,
and 24.3% for thiazide) to a low of 5.6% for peripheral alpha blockers.
Use of nine of the 10 antihypertensive classes was not associated
with incident UI (all p>0.05). Only peripheral alpha blocker use (i.e.,
prazosin, doxazosin, terazosin) increased the risk of UI (adjusted
odds ratio [AOR] 4.47; 95% confidence interval [CI] 1.79-11.21).
There was an even greater increased risk of UI with peripheral alpha
blockers when taken in combination with loop diuretics (AOR 8.81;
95% CI 1.78-43.53).
Conclusions: In elderly community-dwelling women, peripheral
alpha blocker use was associated with incident UI, and this risk nearly
doubled when used in combination with loop diuretics.
B82
Increased Rhythmic Gait Variability May Contribute to Falls Risk in
Older Knee Osteoarthritis Patients.
J. E. DeCaria, 1 R. J. Petrella, 1,2 M. Montero-Odasso. 2,3 1. Aging,
Rehabilitation & Geriatric Care, Lawson Health Research Institute,
London, ON, Canada; 2. Schulich Faculty of Medicine and Dentistry,
The University of Western Ontario, London, ON, Canada; 3. Gait and
Brain Lab, Parkwood Hospital, London, ON, Canada.
BACKGROUND: Reduced joint motion and flexibility in knee
osteoarthritis (OA) patients may impair gait consistency. Increased
gait variability is associated with instability, and is a valid and strong
predictor of falls. However, the role of gait variability as a contributor
to falls in knee OA is unknown. Our objective was to determine if
rhythmic and postural gait variability is elevated in a sample of older
knee OA patients compared to healthy older adults.
METHODS: Community-dwelling older adults without cognitive
or neurological impairment were included. The gait characteristics
of 30 older knee OA patients (Kellgren-Lawrence II-III) were
compared to those of 23 healthy older adults. Gait characteristics
during self-selected gait velocity were determined with a 10 metre
electronic walkway (GAITRite). Rhythmic and postural gait variability
was calculated as the coefficient of variation (CoV) for stride
time (StrTM) and double-support time (DSTM) respectively. Significant
differences between groups (p

P OSTER
A BSTRACTS
Conclusion: In this analysis of palliative care inpatients, we
found that escalating ARS increases the odds of delirium. In an effort
to minimize delirium, anticholinergic medications should be added
with caution in this vulnerable cohort. Further prospective studies are
needed to establish a directly causal relationship.
B84
Screening for osteoporosis in elderly patients admitted to post-acute
rehabilitation.
K. Major, 1 S. Monod, 1 C. Bula, 1 S. Rochat, 1 O. Lamy, 2 D. Hans, 2
A. Laszlo, 3 M. Krieg. 2 1. Service of Geriatrics medicine and geriatric
rehabilitation, University of Lausanne Medical center, Lausanne,
Switzerland; 2. Center of Bone Diseases, Lausanne University
Hospital, Lausanne, Switzerland; 3. Service of Geriatric medicine,
Hospital of Fribourg, Fribourg, Switzerland.
Background: Screening for osteoporosis is important in older
patients admitted to post-acute rehabilitation. However, DXA measurement
is sometimes difficult to perform because of difficulties in
positioning the patient and artefacts (osteoarthritis, prosthesis). The
objectives were to determine the prevalence of unknown clinical osteoporosis
in rehab patients and to determine new strategies for identifying
clinical osteoporosis in this population.
Method: Over a 9-months period, patients consecutively admitted
to post-acute rehabilitation were included in th stdy. Patients with
osteoporosis diagnosis, and those with terminal illness or severe physical
limitations were excluded. Patients underwent Bone Mineral
Density (BMD) by DXA and Vertebral Fracture Assessment (VFA).
Clinical osteoporosis was defined as BMD ≤-2.5 SD at any site (lumbar
spine, femoral neck, total hip or distal radius), ≥1 vertebral fracture,
≥1 hip fracture, or another fragility fracture and BMD ≤-2 SD.
Results: Overall, 102 (17.0%) of the 600 patients admitted to
rehab refused to participate in the study or were unable to consent.
Among the 498 remaining patients, 99 (19.9%) were excluded because
of already known diagnosis of osteoporosis, 101 (20.3%) were
excluded because of terminal illness, severe physical limitations, and
45 (9.0%) because of inability to perform DXA during the stay
(death, hospital transfer). Overall, 253 patients were assessed with
DXA and VFA (166 women, mean age 83±7 years, mean BMI 27±6
kg/m2, and 87 men, mean age 82±6 yrs, mean BMI 27±5 kg/m2). Of
these, 70% had history of fall during the last 6 months and 9.1% had
hip fracture history. Prevalence of osteoporotic vertebral fracture was
36% in women and 32% in men. Overall, 152 (60.1%) patients had
clinical osteoporosis (women: 67%; men: 46%) according to above
criteria. Hip fracture history and vertebral fracture assessment identified
correctly 105 (69.1%) of these 152 patients.
Conclusion: A high prevalence of osteoporosis was observed in
this population of rehab patients. Osteoporosis status should be systematically
assessed in these patients at high fall risk, at least with
careful history of hip fracture and an assessment for vertebral fractures
with spine X-ray.
B85
Reasons for not prescribing guideline-recommended medications to
veterans with heart failure.
L. Dimaano, 1 C. Peterson, 2 M.A. Steinman. 2 1. University of California,
San Francisco, CA; 2.VA Medical Center, San Francisco, CA.
Supported By: MSTAR Program Grant 2 T35 AG026736-06
Department of Veteran Affairs Grant 06-080-02
Background:
ACE inhibitors and beta blockers reduce mortality among patients
with heart failure, yet some patients are not prescribed these
medications. While general barriers to prescribing have been previously
described, little is known about the reasons for foregoing treatment
in individual patients, and whether this represents appropriate
or inappropriate care. In this study, we described the distribution of
reasons for not prescribing guideline-recommended drugs to older
adults with heart failure.
Methods:
We conducted a chart review of patients from 4 VA health care
systems who had systolic heart failure but were not prescribed ACE
inhibitors (or ARBs) or beta blockers. For each patient, we used a
standardized chart abstraction tool to identify the clinician’s reasons
for not prescribing these drugs. Because chart review may not fully
capture reasons for non-prescribing, we interviewed 61 clinicians who
cared for patients in our cohort and compared the reasons they cited
in the interview with reasons found in chart review.
Results:
Among 2846 patients screened, 301 were included in the study.
Mean age of subjects was 75 +/- 10 years and 98% were male. 70%
were not prescribed ACE inhibitors or ARBs, 18% were not prescribed
beta blockers, and 11% were not prescribed both drugs. Using
chart review, we identified reasons for non-prescribing in 65% of patients.
The most common reason was clinical contraindications (58%).
We identified at least one non-biomedical reason in 18% of patients,
including patient attitude, adherence, and misuse of drugs (10%), and
co-management with another clinician (6%). Interviews with clinicians
yielded substantially more reasons than chart review (1.6 vs 0.9
reasons per patient, P < .001). While clinical contraindications remained
the most common reason for non-prescribing (70%), clinicians
described other reasons in 66% of patients. These included patient attitude,
adherence and misuse; co-management with other clinicians;
and believing that the drug was not indicated (21-27% each).
Conclusion:
Clinical contraindications are the most common reason for not
prescribing guideline-recommended drugs to heart failure patients.
While chart review indicates that clinical contraindication eclipses all
other reasons in importance, clinician interviews suggest that nonbiomedical
factors figure equally in the decision not to prescribe
these medicines.
B86
Tai Chi training increases the complexity of standing postural
control in frail older adults.
M. Lough, 1 B. Manor, 2 M. Gagnon, 1 I. Iloputaife, 1 P. Wayne, 3
L. Lipsitz. 1,2 1. Institute for Aging Research, Boston, MA; 2. Beth
Israel Deaconess Medical Center, Harvard Medical School, Boston,
MA; 3. Osher Center for Integrative Medicine, Boston, MA.
Background: The development of frailty in old age is accompanied
by a loss in the dynamic “complexity” of standing postural control.
In this case, complexity refers to the multi-scale structure contained
within postural sway fluctuations, which is believed to arise
from the numerous processes that regulate the body’s movements
over time. Tai Chi is a mind-body exercise with goals of targeting multiple
physiological processes and integrating their dynamics. We
therefore hypothesized that Tai Chi training would increase postural
sway complexity in frail older adults.
Methods: Subjects were recruited from supportive housing facilities
and randomized into a Tai Chi group (11 women and 3 men;
age=83±6yrs) or educational control group (12 women and 3 men;
age=84±8yrs). Tai Chi and education interventions consisted of two,
60min instructor-led group sessions per week for 12 weeks. To assess
postural sway, center-of-pressure dynamics were recorded during
standing with eyes-open and eyes-closed. Postural sway complexity
was estimated by multi-scale entropy analysis. Average sway speed
and area were also computed. Cognition (i.e., Trail Making Test,
TMT) and physical function (i.e., gait speed, timed up-and-go, TUG)
were evaluated.
S102
AGS 2012 ANNUAL MEETING

P OSTER
A BSTRACTS
Results: Groups were similar in age, height, body mass, and
baseline metrics of postural sway, cognition and physical function.
Following the intervention, the Tai Chi group increased postural sway
complexity when standing with eyes open (p = 0.001) and eyes closed
(p = 0.05) as compared to controls. No changes were observed in the
traditional metrics of sway speed or area. As compared to controls,
the Tai Chi group also exhibited improved performance in the TMT
(Part A, p = 0.04), 4-meter walk time (p = 0.04) and TUG (p = 0.04).
The percent increase in eyes-open postural sway complexity after Tai
Chi training related to percent increases in 4-meter walk (r 2 =0.34,
p=0.02) and TUG (r 2 =0.29, p=0.05) performance.
Conclusion: Tai Chi training effectively increased postural sway
complexity in a cohort of older frail adults. As 1) no changes were observed
in average sway speed or area, and 2) increased complexity
was associated with improved physical function, we contend that Tai
Chi may combat frailty by targeting the complex dynamics of the
human postural control system.
B87
Polypharmacy and Prescribing Quality in Older HIV-Infected
Adults.
M. Greene, M. Steinman, K. Nicolas, V. Valcour. University of
California San Francisco, San Francisco, CA.
Supported By: NIH [K23-AG032872(VV), P50-AG023501(BM)],
UL1 RR024131(UCSF GCRC), P30-AI027763(UCSF CFAR)] and
the UCSF AIDS Research Institute
Background: Advances in antiretroviral therapy have led to an
aging HIV-infected population, with many individuals suffering from
multiple chronic diseases. The burden of HIV and non-HIV disease
puts patients at high risk for polypharmacy and medication-related
complications, yet little is known about the characteristics and burden
of prescribing problems in this population. Our aim was to describe
the frequency of polypharmacy and prescribing quality issues in an
older HIV-infected population.
Methods: We performed a retrospective chart review of subjects
enrolled in a cohort study of HIV infected adults age 60 and older in
San Francisco. Total number of medications, frequencies of inappropriate
medications as defined by the modified Beers criteria, anticholinergic
drug burden as defined by the Anticholinergic Risk Scale,
and potential drug-drug interactions were examined. The Lexicomp
drug interactions database was used to analyze drug-drug interactions
with a focus on severity scores D (consider therapy modification)
and X (contraindicated). Findings were compared to age and
gender matched HIV-negative controls.
Results: 89 HIV-infected subjects’ medications were reviewed.
Most subjects were Caucasian (91%) and male (94%) with a mean
age of 64 (range 60-82). Common co-morbidities included hyperlipidemia,
hypertension, peripheral neuropathy, and depression. A total
of 1,198 medications were prescribed, with a mean of 13 medications
per subject (range 2-38). At least one inappropriate medication was
prescribed in 34 subjects (38%), most commonly zolpidem, alprazolam,
and fluoxetine. A majority of subjects had at least one potential
drug-drug interaction, with 65 (73%) having a category D interaction
and 7 (8%) having a category X interaction. 15 subjects (17%) had an
anticholinergic risk scale score of ≥3. In contrast, HIV-negative controls
had a mean of 6 medications per subject, 18% had at least one
inappropriate medication, and 4% had an anticholinergic risk scale
score of 3 (p-value

P OSTER
A BSTRACTS
BMI=28.4, mean PSQI=8.7 and mean PHQ-9=4.6. Previously unrecognized
SA was common, with a mean AHI=19.5; 49.3% of participants
had AHI ≥15 (suggesting moderate-severe SA). 14.2% of all
participants were prescribed BzRAs, and 11.5% reported using the
BzRA during the study period. Among participants with moderatesevere
SA, 9.6% were prescribed BzRAs and 8.2% actually used the
medication. There were no significant differences between participants
with or without moderate-severe SA in BzRA prescription
(Chi-square=2.504, p=.157) or BzRA use (Chi-square=1.513, p=.303).
CONCLUSIONS: We found that half of community-dwelling
older Veterans meeting diagnostic criteria for insomnia had objective
evidence of unrecognized moderate-severe SA. Nearly 10% of these
individuals were prescribed BzRAs, some of which may worsen SA
and increase risk for adverse health outcomes. Further research is
needed to address the recognition and management of coexisting insomnia
and SA in older adults.
B90
Pyridostigmine Improves Orthostatic Tolerance and Symptoms in
Patients with Orthostatic Hypotension and Supine Hypertension:
The Faint and Fall Clinic Experience.
N. Sanders, 1 T. Jetter, 2 S. Wasmund, 2 C. Pacchia, 2 M. Hamdan. 2 1.
Geriatrics Division, University of Utah, Salt Lake City, UT; 2.
Cardiology Division, University of Utah, Salt Lake City, UT.
Background: Orthostatic Hypotension (OH) is a common problem
in the elderly. While midodrine helps OH, its use is often limited
by the presence of supine hypertension (HTN). Pyridostigmine is an
acetylcholinesterase inhibitor that increases sympathetic tone by improving
cholinergic neurotransmission. Its efficacy in patients with
OH remains uncertain.
Methods: All patients with symptomatic OH and supine HTN
were included. Supine, 1-min and 3-min orthostatic BP measurements
were obtained at baseline and following 30 days of pyridostigmine at
60 mg PO TID. The decreases in SBP and DBP at 1 and 3 minutes
were assessed at baseline and compared to the 30-day follow-up values.
Clinical symptoms were also assessed and categorized as worsening,
no change or improving.
Results: A total of 10 patients were enrolled with 2 patients not
tolerating the drug (Mean age=75). At baseline, the supine BP and
HR were 139/82 mmHg and 74 bpm. The mean decrease in SBP/DBP
at 1 minute and 3 minutes were 28/12 mmHg and 31/10 mmHg respectively.
After 30 days of drug therapy, the baseline supine BP and
HR were 132/78 and 73 bpm. The mean decrease in SBP/DBP at 1
minute and 3 minutes were 16/7 mmHg (p=0.055 for SBP; p=NS for
DBP when compared to baseline) and 13/9 mmHg (p=0.05 for SBP;
p=NS for DBP when compared to baseline) respectively (see Figure).
All patients reported improvement in their symptoms.
Conclusion: Pyridostigmine improves orthostatic tolerance and
symptoms in patients with OH and supine HTN at 30 days. Its longterm
efficacy awaits additional studies.
B91
Cancer, Functional Decline, and the Vulnerable Elders Survey
(VES-13) in Older Medicare Beneficiaries.
P. Wroe, 1 A. Naeim, 2 W. Dale, 1 L. Fan, 3 S. Mohile. 3 1. University of
Chicago, Chicago, IL; 2. University of California, Los Angeles, Los
Angeles, CA; 3. University of Rochester, Rochester, NY.
Supported By: The Medical Student Training in Aging Research
Program, the National Institute on Aging (T35AG026736), the John
A. Hartford Foundation, the MetLife Foundation, and the Lillian R.
Gleitsman Foundation.
University of Rochester John Hartford Foundation Center of
Excellence Grant (to Mohile).
Background: The US population is aging rapidly, cancer is more
prevalent among older adults, and older adults account for a large
and growing percentage of cancer cases and deaths. The longitudinal
association between a cancer history and functional decline has not
been determined, nor has the use of the Vulnerable Elders Survey
(VES-13) as a screening tool for predicting decline or death in older
cancer survivors.
Methods: Using data from the 2003 and 2004 Medicare Current
Beneficiary Survey, we compared older adults with and without a cancer
history on functional status (Activities and Instrumental Activities
of Daily Living, I/ADLs), geriatric syndromes, and vulnerability
(VES-13 score 3 or higher) with chi-squared tests of proportion. We
used receiver operating characteristic (ROC) curves to assess the
ability of the VES-13 survey instrument (VES-13 score 3 or higher) to
predict functional decline or death one year after baseline.We defined
functional decline as one of the following: a one-year increase of 2 or
more functional deficits, one or more functional deficits after one year
if zero functional deficits at baseline, or a nursing home admission.
Results: Older Medicare beneficiaries with a cancer history
(n=1,210) were significantly more likely than those without a cancer
history (n=5,278) to have functional limitations (56.2% vs. 49.3%,
p

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who reported an MD diagnosis of arthritis were asked to identify the
location of their arthritis as well as the presence of pain and stiffness
in their joints. Life-space (LS) was measured by distance, frequency
and independence of movement within four weeks of the interview
(range 0-120; higher scores represent greater mobility). Linear regression
was used to examine the association of arthritis with LS adjusting
for age, race, gender, rural residence, comorbidity, BMI, depression
and cognitive impairment. LS among participants reporting
a diagnosis of arthritis was examined using ANOVA according to location,
number of joint types involved and the presence of joint pain
and/or stiffness.
Results: Of 1000 participants (50% male; 50% African American;
51% rural; mean age (SD)=75.3 (6.7)), 662 reported an MD diagnosis
of arthritis. Elders with arthritis had a significantly lower mean
(SD) LS than those without arthritis (60.8±24.9 vs. 70.6±23.7 respectively;
p

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Each subject’s score was calculated as a sum of the points for the diseases
and conditions they had.
RESULTS: The variables retained in the model were congestive
heart failure (2 pts), peptic ulcer (1 pt), dementia (1 pt), cerebrovascular
disease (1 pt) and history of tumor (1 pt). Using these, we created
a score more parsimonious and more predictive than the Charlson
score. Scores given by our tool and Charlson scores were used as
predictors in a Cox model, revealing our score’s statistically significant
predictive value (p

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sess caregiver burden, the surviving spouse reported whether assistance
was provided with 6 ADLs and 4 IADLs in the last 3 months of
life. To assess change in depressive symptoms and health, we compared
CES-D (≥2 symptoms from the 8-item version) and self-rated
health (good or better) reported by the surviving spouse in the interview
waves before and after death.
Results: A total of 555 caregivers were women (mean age=70.6;
mean age of their deceased husbands=70.9) and 190 caregivers were
men (mean age=73.1; mean age of their deceased wives =75.1). Overall
the sample was 85% white, 12% African American, and 5% Hispanic.
For decedents, cancer was the leading reported cause of death
(41%). A majority (55%) of caregiver spouses provided help with
bathing, 53% with dressing, 43% with transferring, 38% with walking
37% with toileting, and 29% with eating. Assistance with IADLs was
also common: 54% helped with medications; 39% helped with meals;
29% helped with shopping; and 23% helped with phone calls. Men
and women did not differ in terms of the ADL tasks they performed,
but gender differences were observed with IADL assistance. Men
provided more help with meals (57% vs. 33%, p

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There is growing evidence that the broader process of advance care
planning (ACP) benefits patients at the end of life (EOL). Most clinicians
receive little training in ACP and medical institutions often lack
effective documentation tools.
Purpose: 1) To assess whether an educational intervention for
health care providers improves the quality of ACP discussion documentation;
and 2) to describe the preferences for EOL care of older
veterans.
Methods: Interventions included 1) a new template for ACP discussion
documentation introduced in electronic medical record in
February 2009; 2), educational trainings by 2 staff geriatricians (lectures
and small group discussions) emphasizing importance of ACP
documentation. Continuous 100 ACP discussion notes were selected
for review from pre-education period (PRE) and post-education period
(POST) respectively. Designation of desired surrogate decision
maker, use of quotes from patients or family, description of
goal/value, limitation of medical care, and EOL setting were compared
between PRE and POST.
Results: PRE was 2/09-6/09 with 97 patients and POST was 4/11-
8/11 with 93 patients. Patients in POST were younger (79.2 ± 9.5 vs
75.1 ± 12.3, p=0.012), and more patients in POST have 1 or more comorbidities
(66% vs 80%, p=0.036), and lacked decision-making capacity
(9.3% vs 20.4%, p=0.040). Descriptions of desired medical care
did not differ significantly (75% vs 80%, p=0.40), and among those
notes with descriptions, 91% expressed desires for certain limitations.
Among those who had decision-making capacity, there was no difference
of designation of desired surrogate decision maker (92 % vs 87
%, p=0.44). Description of goals/values (36% vs 52%, p=0.02) and
EOL setting (8% vs 18%, p=0.04) increased significantly in POST.
Among those notes without descriptions of desired medical care, specific
reasons were documented in significantly more notes (36% vs
70%, p=0.02).
Conclusion: The vast majority of older veterans expressed desired
limitations of medical care at EOL. Educational sessions to
health care providers led to improved quality of ACP documentation.
B102
Rehospitalization of Older Adults Discharged to Hospice Care.
A. M. Goldenheim, 1 D. Oates, 1 V. Parker, 2 M. Russell, 1 M. Winter, 2
R. Silliman. 1,2 1. Boston University School of Medicine, Boston, MA;
2. Boston University School of Public Health, Boston, MA.
Supported By: American Federation for Aging Research
T 35AG038027-01 (MSTAR)
Background: Hospital readmission of older adults receiving hospice
care can be traumatic, costly, and often preventable; acute care is
generally not aligned with the goals of hospice. We identified factors
associated with 30-day readmission of older adults newly discharged
to hospice from Boston Medical Center.
Methods: A structured medical record review of 59 patients, 19
readmitted within 30 days and 40 randomly selected controls who
were not readmitted, from 206 subjects newly discharged to hospice
between February 1, 2005 and January 31, 2010. We collected information
about disease characteristics, hospital course, end-of-life planning
and decision-making, and post-hospitalization follow-up. We calculated
bivariate associations and used a Cox Proportional Hazards
model to examine the relation between index admission characteristics
and readmission.
Results: Subjects had a mean age of 79.7 ± 8.4; 74.6% were female.
Among those readmitted, 25% received a palliative care consultation,
compared to 47.1% of those not readmitted (p = 0.06). Patients
who did not have a surrogate involved in their hospice decision
had 3.5 times the risk of readmission with 30 days, compared to patients
who had a surrogate involved in the hospice decision (HR 3.53,
CI 0.97, 12.82). Patients who had one or more telephone contacts with
their primary care physician (PCP) during the first week after discharge
had 2.4 times the risk of readmission with 30 days, compared
to patients who had no telephone contacts with PCPs during this period
(HR 2.35, CI 0.9, 6.1).
Conclusions: Readmission within 30 days of initial discharge to
hospice appears to be associated with a lack of education and communication
about the goals and course of hospice care. There is a
need for greater support for the patient and family during the transition
from hospital to hospice.
B103
Analysis of patient and clinician complaints related to care
transitions in a large, urban teaching hospital.
A. Levenson, 1 O. Hasan. 2 1. Mount Sinai School of Medicine, New
York, NY; 2. Center for Clinical Excellence, Brigham and Women’s
Hospital, Boston, MA.
Supported By: This research is supported by the Medical Student
Training in Aging Research program (MSTAR).
Many patients experience problems during transitions from one
care setting to another. Although patient concerns regarding care
transitions have been investigated in small, focused studies, a systematic
review of hospital-wide patient and clinician complaints has not
been published to date. To fill this gap, we aggregated and analyzed
all patient and clinician complaints related to care transitions filed at
an 800-bed urban, teaching hospital from January through June 2011.
We reviewed all relevant free-text complaints from three hospital reporting
databases: clinician-filed Patient Safety Reports tagged “Coordination
of Care” (n=208), Press-Ganey patient survey comments
in the “Discharge” section of the survey (n=698), and Patient & Family
Relations complaints tagged “Continuity of Care” and “Discharge”
(n=138). Reports unrelated to transitions into or out of the
hospital and complimentary comments were excluded from further
analysis. Of 1044 reports initially reviewed, 468 were found to be relevant
and were coded and examined in further detail. On the Press-
Ganey patient survey (n=347), 92 (26.5%) of complaints were about
delays in discharge, 46 (18.4%) were about unclear discharge instructions,
and 49 (14.1%) were about patient unreadiness for discharge.
Of the patient-generated Patient & Family Relations complaints
(n=84), 24 (28.6%) concerned patient confusion or discomfort with
the plan of care, 21 (25%) were about patient unreadiness for discharge,
and 14 (16.7%) were about insufficient care coordination. Of
the clinician-filed Patient Safety Reports (n=37), 18 (48.6%) were
about poor communication between providers, 4 (10.8%) concerned
unclear discharge instructions, and 3 (8.1%) were about insufficient
care coordination. Gaps in communication emerged as a dominant
theme in this analysis. Patients were most concerned about insufficient
communication of the discharge plan, while both patients and
clinicians felt that there was insufficient communication between clinicians
during transitions in care.
B104
Improving Documentation of Advance Care Planning in an
Electronic Medical Record.
B. Chauhan, C. Chang, A. Kelley. Department of Geriatrics and
Palliative Care, Mount Sinai School of Medicine, New York, NY.
Background: Advance care planning (ACP) is important to promote
patient dignity and autonomy in the setting of serious illness.
Electronic medical records (EMR) may help improve communication
among providers about ACP. Since 2005, the Geriatrics Practice
at Mount Sinai Hospital, a patient centered medical home, has used
an EMR for all aspects of patient care. While providers may discuss
ACP regularly, monthly quality measures of ACP documentation are
low (27%, July 2011). Thus, we aimed to understand how providers
document and retrieve ACP discussions in the EMR.
Methods: Using mixed methods, we first surveyed providers regarding
their current pattern of documenting ACP and areas they felt
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need improvement. We then conducted and audio-recorded semistructured
interviews with providers to better understand practice
patterns and challenges in documenting and retrieving ACP.
Results: Of 42 providers, 33 (79%) responded to the survey. Despite
low observed rates of ACP documentation (27%), 42.5% report
discussing ACP with patients yearly and 30% state they have documented
a Health Care Proxy for >50% of their patients. Yet 46% did
not know how to document DNR orders; 79% had never received
training on documenting ACP in the EMR; and 97% stated they
would benefit from such training. Of 28 providers (14 fellows & 14 attendings)
completing qualitative interviews, 24 (85%) said the primary
place they document ACP discussions is the progress note for
that visit, while 4 (14 %) primarily document the discussion in a permanent
section of the chart (e.g., demographic notes). When asked
about locating ACP information on another provider’s patient, interviewees
commented, “People are having the conversations but documenting
it all over the place”; “When you can’t find the discussions, it
can significantly impact the trust of patients. It is a big problem.” On a
likert scale of 1-5 (5= absolutely certain), providers averaged 1.8 on
certainty of finding ACP documentation: “I do not know where to
start”.
Conclusions: Despite a well established EMR, ACP documentation
varies widely among providers thus making this important information
difficult to find. A standardized ACP template in a labeled
section of the EMR and training providers to document ACP uniformly
may enhance high-quality patient centered care.
B105
Self-rated Health and Memory Impairment. A Connection?
D. Peng, 1 K. Connor, 1 S. Vassar, 1 M. Lee, 1 B. Vickrey, 1,2 J. Chodosh. 1,2
1. VA GLAHS / UCLA, Los Angeles, CA; 2. RAND Health, Santa
Monica, CA.
Supported By: SCAN Health Plan
Veterans Administration
Background: Dementia has high personal and societal costs. Diagnoses
are often substantially delayed, yet those with dementia are
at greater risk for functional decline than non-demented patients.
Cognitive screening applied to all older patients may be too stigmatizing
and burdensome due to false positives. Thus, screening those atrisk
for dementia through self-reported general health ratings - a
known predictor of functional decline –may be desirable.
Methods: Randomly selected seniors ≥ 75 years enrolled in a
Southern California “Medicare Advantage” HMO and seen in a primary
care practice between 2003 and 2006 to yield an analytic sample
of ~300 was drawn from administrative data; those with an ICD code
for dementia or prescription for anti-dementia medication were excluded.
For consented subjects, cognitive impairment was assessed
using the Memory Impairment Screen for Telephone (MIS-T), a 4-
item cue-recall test. Self-reported health was measured using a 5-
point scale (excellent, very good, good, fair, or poor). Cut-points predictive
of dementia (MIS-T of ≤ 4) provided prevalence estimates
and were used to assess specificity of self-rated health for memory
impairment. Association between MIS-T scores and self-rated health
were assessed using multivariable regression, controlling for age, gender,
ethnicity, and education.
Results: Of 458 potential subjects, 60% (N=275) were interviewed,
of which 30% were male; mean age was 82.1 years; 83% were
Caucasian; and 89% had at least a high school education. Fifteen percent
(N=40) had MIS-T scores predictive of dementia. Overall, 29%
(N=81) rated their health as “fair” (N=57) or “poor (N=24),” including
55% (22 of 40) of those with memory impairment versus 25% (59
of 235) of those without impairment (p-value75 years old, 658 (61%)
failed a screen for > 1 condition (mean 1.6 conditions) and triggered a
mean 7.1 QIs. Charts were reviewed for a randomly selected 485 of
these. Approximately half (237 (49%) were seen by a NP for co-management.
Overall 53% of QIs were passed. Quality scores for those
seen by a NP were higher for all conditions except depression
(Table).
In multivariate analyses, adjusting for gender, age of patient,
number of conditions, site, and a NP estimate of physician management
style, team care remained significant (p

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variation in utilization of screening mammography in women with
limited life expectancy at the level of the usual care provider (UCP)
and associated physician characteristics.
Methods: We used 100% Texas Medicare claims data to select a
cohort of Texas female Medicare beneficiaries aged 67-90 years, with
a life expectancy based on age and comorbidity of less than 7 years,
and with an identifiable UCP. The sample contains 103,385 women
and 11,554 UCPs. Data were linked to the American Medical Association
masterfile to obtain UCP characteristics. Each woman was followed
up for two years to measure her screening mammography utilization.
Descriptive statistics and multilevel modeling were used for
the analyses.
Results: 28.4% of women with

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life care. Application of this benefit to NH residents has come under
increasing scrutiny due to dramatic expansion in recent years and increasing
costs. We used a unique merged dataset to describe trends
over time in NH patients who used hospice.
Methods:Between 1999-2009, data was collected on 33,387 people
over age 65 who had contact with a large, urban public hospital
which serves a population that is largely poor, about 60% women and
35% black. Clinical data from the local comprehensive electronic
medical record was merged with Medicare claims, Indiana Medicaid
claims, Minimum Data Set, and Outcome and Assessment Information
Set. Patients with a hospice claim and the sub-group of hospice
patients in NHs were identified. We present trends over time with descriptive
statistics.
Results: 4361 patients used hospice in the 10 year period; about
1/3 of overall decedents enrolled in hospice. About 1/3 of the overall
cohort had a nursing home stay. There were 1260 patients who used
hospice and lived in NHs. In this NH-hospice cohort 62% of patients
were female; 61% were white and 38% were black. Average age at
hospice enrollment was 81 years and did not change appreciably over
time. A trend of increased enrollment over time was evident. The proportion
of NH-hospice patients with non-cancer diagnoses increased
over time from 35% in 1999 to 79% in 2009. In 1999, the median
length of stay on hospice was 93 days (mean 195 days) and remained
high throughout the study period. The overall median for the 10 year
period was 85 days (mean 161). For hospice patients not in NHs, the
median length of stay was 16 days (mean 58).
Conclusions: Consistent with national data, the use of hospice
by nursing home patients and proportion with non-cancer diagnoses
has risen over time. A striking difference from other studies is the
much longer length of stay of NH-hospice patients throughout the 10
year study period. In contrast to our results, NH-hospice patients
were found to have a median length of stay of 46 days in 1999 and a
steady increase over time in a national sample. Additional analyses
will use this rich dataset to probe factors affecting length of stay and
use of hospice in this population of vulnerable older adults.
B111
Can primary care providers estimate remaining life expectancy in
older adults with chronic kidney disease and other comorbidities?
K. H. Campbell, 1 S. G. Smith, 2 C. Fox, 3 J. W. Mold, 4 J. W. Shega, 1
W. Dale. 1 1. Section of Geriatrics and Palliative Medicine, University
of Chicago, Chicago, IL; 2. Pritzker School of Medicine, University of
Chicago, Chicago, IL; 3. UNYNET, University at Buffalo, Buffalo,
NY; 4. OKPRN, University of Oklahoma, Oklahoma City, OK.
Supported By: Supported by the John A. Hartford Foundation
Center of Excellence in Geriatrics at the University of Chicago Pilot
Research Award.
Background: Estimating remaining life expectancy (RLE) is
considered preferable to using age to guide medical decision-making
for older adults. We evaluated whether primary care providers
(PCPs) were able to estimate RLE in older patients with chronic kidney
disease (CKD) and various comorbidities with known RLE associations.
Methods: Using a cross-sectional survey of PCPs in 2 practicebased
regional networks designed to evaluate referral decisions for
older adults with chronic kidney disease, we developed clinical vignettes
of older adults. Vignettes randomly varied 6 factors dichotomously
(age, race, gender, presence of stage III congestive heart failure
(CHF), ability to ambulate, and presence of moderate dementia)
in a block factorial design. PCPs were asked to estimate RLE of vignette
patients. We categorized vignettes as: 1) no comorbidities; 2)
presence of CHF; 3) presence of dementia; and 4) presence of both
CHF and dementia. Each category was assigned an “expected” RLE
using life tables, placing each group into upper, middle, and lower
quartiles by age and gender. We compared the mean RLE estimated
by the PCPs with the expected RLE from life tables using t-test.
Results: Eighty-two PCPs answered RLE questions about 8 randomly-assigned
vignettes. Providers significantly underestimated
RLE of patients assigned to the “no comorbidities”: women age 67
RLE estimate 12.4 years versus life table expected RLE 21.3 years;
p

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complex elders should consider extra clinic visits and resources (e.g.,
pharmacy to review additional medication burden).
B113
Defining Fever in Nursing Home Patients.
P. D. Sloane, 1,2 C. Kistler, 2 C. Mitchell, 1 A. S. Beeber, 4 R. Bertrand, 5
S. Zimmerman. 1,3 1. Sheps Ctr for Health Services Research, Univ. of
North Carolina at Chapel Hill, Chapel Hill, NC; 2. Department of
Family Medicine, Univ. of North Carolina at Chapel Hill, Chapel Hill,
NC; 3. School of Social Work, Univ. of North Carolina at Chapel Hill,
Chapel Hill, NC; 4. School of Nursing, Univ. of North Carolina at
Chapel Hill, Chapel Hill, NC; 5. Abt Associates, Inc., Cambridge, MA.
Supported By: Agency for Healthcare Research and Quality
Background: Existence of fever is often identified as a criterion
for determining the “appropriate” use of systemic antibiotics; however,
several different criteria exist for determining what temperature
in a nursing home patient constitutes a fever.Among the more popular
fever guidelines are those of Loeb et al., who defined fever as either
37.9°C [100°F] or 1.5°C [2.4°F] above average routine temperature.
Methods: To develop a more empirical basis for definition of
fever, we evaluated 257 residents of six North Carolina nursing
homes who had been treated with antibiotics for a presumed infection
during a two month observation period. Data collected included
the temperature recorded on the day the treatment was started, and
three prior routine temperatures recorded when the residents were
not ill. We then proposed to redefine fever based on the temperature
distribution in the sample, and used that standard to evaluate
whether or not fever was present at the time of a suspected infection
for each of the 257 residents using both the standard Loeb fever criteria
and this new definition.
Results: The mean routine temperature was 97.8°F, with a standard
deviation of 0.59°F. Based on these routine temperatures, we derived
two empirical definitions of fever in nursing home patients: (1)
a temperature of 99.0° F or higher (i.e., above the 95th percentile for
the sample); or (2) 1.2° F (i.e., two standard deviations) above the average
temperature for an individual patient. Applying these criteria
to the 257 episodes of antibiotic prescribing, we found that 21% of
urinary tract infections, 22% of respiratory infections, and 15% of
skin infections treated with systemic antibiotics were accompanied by
a fever. In contrast, 13% of urinary infections, 14% of respiratory infections,
and 6% of skin infections met the Loeb fever criteria.
Conclusions: The presence or absence of fever should be assessed
using different criteria in nursing home patients from that used
with the general adult populations. Whether, when, and how often a
fever should be present for antibiotic prescribing to be considered
“appropriate” remains debatable.
B114
Reducing Potentially Inappropriate Antibiotic Prescribing in
Nursing Homes.
S. Zimmerman, 2,4 P. D. Sloane, 1,2 A. S. Beeber, 3 C. Kistler, 1
R. Bertrand, 5 L. Haddon, 5 C. Mitchell. 2 1. Dept. of Family Medicine,
Univ. of North Carolina, Chapel Hill, NC; 2. Sheps Ctr for Health
Services Research, Univ. of North Carolina, Chapel Hill, NC; 3.
School of Nursing, Univ. of North Carolina, Chapel Hill, NC; 4.
School of Social Work, Univ. of North Carolina, Chapel Hill, NC; 5.
Abt Associates Inc., Cambridge, MA.
Supported By: Agency for Healthcare Research and Quality
Background: As concern regarding antibiotic-resistant organisms
has reached global proportions, attention has become focused
on populations in which prescribing is high and may be inappropriate.
Nursing home residents are one such population.
Methods: To examine the extent of potentially inappropriate antibiotic
prescribing and the ability of educational efforts to reduce
such prescribing, we conducted and evaluated a quality improvement
program in six North Carolina nursing homes. The program had four
components: 1) training physicians in antibiotic prescribing criteria,
especially criteria prescribed by Loeb and colleagues; 2) training
nursing home (NH) nurses in the use of a Medical Care Referral
Form (MCRF) to report the signs and symptoms of the Loeb criteria
to physicians; 3) providing information to residents, their family
members, and other NH staff about antibiotic prescribing; and 4)
maintaining contact with physicians and NH staff during a six-month
quality improvement program, providing information about prescribing
rates, concurrence with the Loeb criteria, and use of the MCRF.
Results: At baseline, the number of monthly antibiotic prescriptions
(unadjusted) ranged from 26-52 across the six NHs. Within three
months of initiating the program, five of the six settings evidenced reduced
prescribing ranging from 19-41%. Adherence to the Loeb criteria
for prescribing increased for urinary tract infections (8% at
baseline to 12% at follow-up), respiratory infections (2% at baseline
to 8% at follow-up) and especially for skin infections (41% at baseline
to 82% at follow-up). The MCRF was used to report information
for only a minority of treated infections (from 0 to 17%).
Conclusions: Antibiotic prescribing may be reduced in nursing
homes through concerted efforts including prescriber training, more
detailed and focused staff-prescriber communication, and patient and
family education. While not all treated infections should meet published
criteria for appropriateness, some further reduction in prescribing
that does not meet criteria would likely constitute optimal care.
The MCRF may be a mechanism to improve prescribing practices.
B115
Where Heroes Meet Angels:the Medical Foster Home.
T. Edes, 3 C. Levy, 4 D. Goedken, 3 B. kinosian. 2,1 1. Univ of PA,
Philadelphia, PA; 2. CHERP, Philadelphia VAMC, Philadelphia, PA;
3. Dept. Veterans Affairs, Washington DC, DC; 4. Denver VAMC,
Denver, CO.
Background: Medical Foster Home (MFH) merges care in a personal
home with an interdisciplinary home care team (IDT), such as
VA Home Based Primary Care (HBPC). MFH is for veterans who
cannot live independently because of complex chronic medical, psychological
and functional impairments and lack of adequate family
support. The Department of Veterans Affairs (VA) has rapidly expanded
the availability of MFHs, growing from 3 programs in 2008 to
over 56, with 358 foster homes caring for 484 veterans. Over 1,245 veterans
have been served since program inception. All Veterans in
MFH meet nursing home level of care. MFH is intended to be the Veteran’s
home often until the end of life. HBPC provides comprehensive
care in the home, as well as caregiver training and support.Veterans
pay the MFH caregiver, approximately $1800 to $2500 per month.
Methods: All 56 MFH programs for FY 2011 were analyzed in
terms of their expenses (administration, coordination, HBPC-IDT
management of complex care needs) and their revenue, creating an
internal, virtual firm. We operationalized revenue as the lowest-cost
nursing facility care VA could provide to veterans who were eligible
to have VA covered nursing home care (veterans in Priority Group
1A), crediting monthly NH payments each month a P1A veteran was
in MFH. In FY2011, the community NH rate VA paid was
$7076/month, while HBPC and MFH administration cost
$1520/month. We also examined savings if VA were to cover the
MFH housing cost of $2400/mo for P1A veterans.
Results: During FY 2011, census grew from 297 total and80 P1A
to 454 total and 132 P1As at year end. Discharges averaged
6%/month (240 for FY2011), with 13% to an assisted living facility,
9% to a nursing home, 18% to their own or family’s home, and 49%
due to death. With a total of 4459 MFH months/1217 months for
P1As, expenses would be $6.372M with revenues of $8.61 M, or a net
margin of $2.24M (35% ROI). Serving 27% P1A veterans, the program
would still be slightly in the black ($6.4M in net revenue, or a
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net margin of $48,980), if it covered the housing payment now made
by the veteran.
Conclusion: Medical Foster Home is a cost-saving alternative to
nursing home care. When organized as a virtual “firm”, a MFH program
can generate savings for further non-institutional care investment,
improving the re-balancing of long term living dollars.
B116
Improving Care for Frail Elders: A Home-Visiting Provider
Program for Medicare Advantage Members.
J. M. McBride, 1 R. D. Laird, 2 L. C. Hanson. 1 1. Division of Geriatric
Medicine and Center for Aging and Health, University of North
Carolina at Chapel Hill, Chapel Hill, NC; 2. Health First Aging
Institute, Melbourne, FL.
Supported By: Health First Health Plan, Melbourne, Florida;
INSPIRIS, Inc., Brentwood, Tennessee;
Center for Aging and Health, University of North Carolina at
Chapel Hill
Background: A Medicare Advantage plan in Florida desired to
improve the hospital readmission rate of members with repeated hospitalizations
and multiple medical co-morbidities, many of whom had
barriers to access. The plan partnered with a physician house call
company in 2004 to implement a home visit program, and evaluated
its effect on hospitalization rates.
Program Description: Patients were eligible for the program if
they had > 1 hospitalization in the previous 12 months and multiple
chronic illnesses; participation was voluntary with no additional cost
to the patient. Home visits were provided by physicians and nurse
practitioners who were employed full-time by the program; participants
maintained relationships with their primary care physicians.
Home visits were provided as needed, but no less than monthly. A
provider was always on call, making home visits on nights and weekends
as necessary. Telephonic nurse case managers were an integral
component of the program, coordinating and facilitating care.
Results: The program served 997 patients during 2010. 59%
were female, the mean age was 80.4 years, and the mean number of
major chronic disease diagnoses (included in the Medicare Hierarchical
Condition Categories model) was 2.96 per patient. The hospitalization
rate in 2010 for program participants was 1,047 per thousand
person- years, compared to an expected hospitalization rate of 2,611
using actuarially adjusted baseline data. For the entire 23,000 member
plan, the 30-day hospital readmission rate in 2010 was 15.2%,
compared to a baseline readmission rate of 18.2%. The decrease in
the 30-day readmission rate for the plan closely corresponded to the
decrease in hospitalizations among the program participants.
Conclusions:Implementation of a physician and nurse practitioner
home visit program is associated with a reduced hospitalization rate for
high risk geriatric patients. Clarification of the role of the home-visiting
provider as a“house call specialist”co-managing the member collaboratively
with the primary care physician was important in gaining acceptance
from members as well as community physicians.Community physicians
now see the program as an important resource for their most
vulnerable patients, and regular referrals to the program continue.
B117
Patients Surviving 6 Months in Hospice Care: Who are they?
L. Rothenberg, 1,5 G. Cordts, 2 L. Simon, 3 J. Gryczynski, 4
D. Doberman. 3 1. Stony Brook School of Medicine, Port Jefferson,
NY; 2. Geriatric Medicine and Gerontology, Johns Hopkins Bayview
Center, Baltimore, MD; 3. Gilchrist Hospice Care, Hunt Valley, MD; 4.
Friends Research Institute, Baltimore, MD; 5. Medical Student
Training in Aging Research (MSTAR) Program, Johns Hopkins
School of Medicine, Baltimore, MD.
BACKGROUND: In 2011, CMS regulation required U.S. hospices
to conduct a “face-to-face” (F2F) assessment of ongoing hospice
eligibility for all patients entering their 3rd certification period.
Using a cohort of patients enrolled in hospice we sought to characterize
those requiring F2F assessment.
METHODS: Retrospective program records were obtained for
hospice patients enrolled 6 months prior to January 1, 2011 (N=375).
Patients who remained in hospice on January 1, 2011 and received a
F2F (n=140) were compared to patients who were no longer in hospice
(n=235) on demographics, terminal condition, presence of comorbidity,
length of stay, and hospice outcome using bivariate statistics.
Predictors of F2F assessment were examined using a multivariable logistic
regression model controlling for demographics, setting of care
prior to admission, comorbidity, and primary terminal diagnosis.
RESULTS: Patients with a F2F were older (p64 years of age and reside within 35 miles
of the Durham, NC VA. Comprehensive in-home needs assessments
are performed by the COACH RN and social worker, with subsequent
case review by the full COACH team (geriatrician, geriatric
psychiatrist, geriatric pharmacist, RN, geriatric social worker) and
recommendations are made to PCP. Individualized follow-up plans
are developed and monitored.
Data from the 92 p-cd enrolled during the first 12 months of the
program’s existence were analyzed. Rates of NHP were tracked and
compared with historical controls. Health delivery was evaluated using
percentage of caregivers receiving education on available resources,
identification of patients with behavioral disturbance, and number of
geriatric psychiatry referrals. Caregiver burden was measured at baseline
and over time with the Caregiver Strain Index (CSI). Quality of life
was evaluated by caregiver satisfaction survey. Costs, cost avoidance
and savings were estimated and compared with accepted averages for
similar community populations to determine cost-effectiveness.
RESULTS
Three COACH patients were placed in nursing homes as compared
with the estimated average annual risk of NHP for COACH
patients of 13%, or 6 patients (50% reduction). Average CSI score
was reduced by one point, from 7 to 6. 90% of caregivers reported
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satisfaction with the program. COACH is estimated to have saved the
health care system $223,000 in a year by delaying NHP.
CONCLUSIONS
The COACH program reduced NHP in its first year of existence,
while also improving dementia care delivery, caregiver burden
and quality of life. These outcomes were achieved cost-effectively.
The COACH program represents an innovative collaborative care
model for patients with dementia.
B119
Knowledge-To-Action for Delirium Prevention: Diffusion of the
Hospital Elder Life Program (HELP).
T. T. Hshieh, 1 P. Chen, 1 S. Dowal, 2 S. K. Inouye. 1,2 1. Internal
Medicine, Beth Israel Deaconess Medical Center, Boston, MA; 2.
Hebrew SeniorLife, Harvard Medical School, Boston, MA.
Background: Delirium is a common, increasingly prevalent condition
among older hospitalized patients with significant morbidity
and mortality. HELP has been a successful evidence-based model of
care to prevent delirium and functional decline in hospitalized elders,
which has been disseminated widely. Knowledge translation and diffusion
in healthcare is important but often challenging, and theoretical
frameworks to do so effectively are underutilized.
Aim: To evaluate the effectiveness and scope of the HELP diffusion
process (2000-2011), we applied the Knowledge-To-Action
framework (Straus 2009) to determine adherence of HELP diffusion
to best practices in translation and diffusion.
Methods: The Knowledge-To-Action framework consists of 10
phases (3 knowledge creation, 7 action phases), incorporating knowledge
translation into a collaborative, multi-level, systems-based approach.
The 3 knowledge creation phases are: inquiry, synthesis, products/tools.
The 7 action phases are: identify problem/knowledge,
adapt to local context, assess barriers, implement intervention, monitor
use, evaluate outcomes, sustain use.
Results: HELP adheres to all 10 phases of the Knowledge-To-
Action framework (See Table). Many HELP diffusion steps were assignable
to more than one feature.
Conclusions: The HELP diffusion process followed best practices
in translation of knowledge. The steps to evaluate efficacy, costeffectiveness,
adaptations, barriers, and ongoing outcomes may have
helped contribute to its success. We hope this case example may assist
others in developing their own effective knowledge translation programs
for innovations in geriatrics.
HELP Diffusion Adheres To Knowledge-To-Action Framework
B120
Factors associated with Survival after Stroke among Elderly Women
in the WHI.
C. L. Bell, 1 A. LaCroix, 2 S. Smoller, 3 K. Masaki, 1 J. Curb, 1
E. M. Hade, 4 T. Manini, 5 W. Mysiw. 6 1. Geriatric Medicine, University
of Hawaii John A Burns School of Medicine, Honolulu, HI; 2. Fred
Hutchinson Cancer Research Center, Seattle, WA; 3. Epidemiology &
Social Medicine, Albert Einstein College of Medicine, Bronx, NY; 4.
Center for Biostatistics, Ohio State University, Columbus, OH; 5.
Aging and Geriatric Research, University of Florida, Gainesville, FL;
6. Physical Medicine & Rehabilitation, Ohio State University,
Columbus, OH.
Supported By: National Heart, Lung and Blood Institute
Background: Data are limited on factors affecting long-term
post-stroke survival in older women.
Methods: Women’s Health Initiative (clinical trials and observational
study) data on women aged 50-79 and stroke-free at baseline,
with incident stroke prior to 2005, were analyzed for survival through
2010. Prestroke physical function used Rand-36 subscale scores
(range 0-100, higher=better).
Results: Of 3,173 women, 2,062 (65%) survived through 2010;
1,111 (35%) died. On multivariable Cox models, prestroke factors associated
with post-stroke mortality included: older age at stroke
(HR=1.07, 95%CI= 1.05-1.08, p

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trolling for resident demographics, acuity, and facility characteristics,
there was a 2.8% (Standard Error 0.01; p=0.004) increase in death at
30 days and a 3.9% (Standard Error 0.01; p=0.008) increase in death
at 90 days for residents with severe dementia who evacuated for Hurricane
Gustav.
Conclusions: Nationwide, of the approximately 1.6 million
adults who live in nursing homes, an estimated 50% to 70% carry a
diagnosis of Alzheimer’s disease or a related dementia. This research
reveals the deleterious effects of evacuation on residents
with severe dementia. Interventions need to be developed and
tested to determine the best methods for protecting this at-risk
population when there are no other options than to evacuate the
facility.
B122
Proteinuria in Mid-Life and Cognitive Function in Late-Life: The
Honolulu-Asia Aging Study.
M. Higuchi, 1 R. Chen, 2 C. Bell, 1 L. Wongvarcharoen, 1 W. Ross, 3,1
H. Petrovitch, 1,2 L. Launer, 4 R. Abbott, 1 K. Masaki. 1,2 1. Geriatric
Medicine, University of Hawaii, Honolulu, HI; 2. Kuakini Medical
Center, Honolulu, HI; 3. VA Pacific Islands Healthcare System,
Honolulu, HI; 4. National Institute on Aging, Bethesda, MD.
Supported By: The National Heart, Lung, and Blood Institute; the
National Institute on Aging; Veterans Affairs Pacific Islands
Healthcare Systems; John A. Hartford Foundation Center of
Excellence in Geriatrics, University of Hawaii.
Background: Impairment of renal function has been linked to
cognitive impairment. There are few longitudinal studies of proteinuria
and cognitive function. We assessed mid-life proteinuria and
cognitive decline or incident dementia in an elderly Asian male population.
Methods: The Honolulu Heart Program (HHP) is a prospective
study that began in 1965 with 8,006 Japanese-American men ages 45-
68 years. Mid-life proteinuria was detected by urine dipstick at exam
3 (1971-74). Subjects were classified into 3 groups: no proteinuria,
trace, and positive. The Honolulu-Asia Aging Study of dementia
began 20 years later with HHP exam 4 (1991-93) with 3,734 men ages
71-93 years. Global cognitive function was assessed by the Cognitive
Abilities Screening Instrument (CASI) (score range 0-100). Cognitive
decline was defined as drop in CASI score of >=1 SD (>=10
points at 3 years, >=14 at 6 years, >=14 at 8 years). Standard criteria
were used to classify 8-year incident dementia (DSM-IIIR),
Alzheimer’s Disease (NINDS-ADRDA), and Vascular Dementia
(California ADDTC).
Results: No proteinuria was found in 97.2% of subjects, trace in
1.7% and positive proteinuria in 1.1%. Age-adjusted incident dementia
rates increased significantly from 13.8, to 22.8, to 39.7 per 1,000
person years follow-up, among those with no, trace and positive proteinuria
respectively, p=0.004. Using multiple logistic regression adjusting
for age, education, apoE4, prevalent stroke, hypertension, diabetes,
and baseline CASI, those with positive proteinuria were more
likely to have cognitive decline (3-year decline OR=2.89, 95%
CI=1.28-6.55, p=0.011; 6-year decline OR=3.46, 95% CI=1.15-10.4,
p=0.027; 8-year decline OR=3.74, 95% CI=1.15-12.1, p=0.028), using
no proteinuria as reference. Multivariate Cox regression found a significant
association between positive proteinuria and all-cause incident
dementia (RR=2.71, 95% CI=1.20-6.09, p=0.016) and incident
Vascular Dementia (RR= 6.38, 95%CI=1.98-20.5, p=0.002), using no
proteinuria as reference.
Conclusion: Proteinuria in mid-life was an independent predictor
for late-life incident dementia and cognitive decline over 8
years. This association needs to be confirmed in other ethnic groups
and women.
B123
Effect of rapamycin in a mouse model of synucleinopathy.
M. Hughes, 1 M. Wey, 2 X. Bai, 2 A. Martinez, 2 E. Fernandez, 2,3
R. Strong. 2,3 1. School of Medicine, UTHSCSA, San Antonio, TX; 2.
Pharmacology, Barshop Institute for Longevity and Aging Studies,
San Antonio, TX; 3. Geriatric Research, Education and Clinical
Center, South Texas Veterans Health Care Network, San Antonio, TX.
Supported By: MH was supported by the MSTAR program, the
American Federation for Aging Research and the NIA. Support for
this project also included PHS grants AG022307, AG036613 and
AG13319 and by a grant from the Department of Veterans Affairs
Medical Research Program (RS).
Background: Synucleinopathies, including Parkinson’s disease
(PD), multiple system atrophy and the Lewy body variant of
Alzheimer’s disease (AD), are age-related neurodegenerative disorders
characterized by expression of pathological intracellular inclusions
containing α-synuclein. Mice transgenic for α-synuclein containing
the human A53T mutation, expressed specifically in neurons,
exhibit severe motor symptoms. Rapamycin has been shown to be
neuroprotective in mouse models of several neurodegenerative disorders,
including AD, Huntington’s disease and PD. However, it was
unknown whether rapamycin would be effective in an animal model
of synucleinopathy. The aim of this study was to determine whether
rapamycin reduces accumulation of α-synuclein and attenuates
motor deficits in A53T transgenic mice.
Methods: Mouse diet containing microencapsulated rapamycin
(14 ppm in diet; 2.25 mg/kg body weight/day) was fed to age-matched
wild type and A53T transgenic mice from 13 to 41 weeks of age. The
control diet contained the microencapsulation material. The mice
were assessed on several tests of motor performance including the
pole test, forepaw stepping adjustment test, accelerating rotarod, grip
strength test, gait performance and the challenging beam traversal
test. Expression of α-synuclein in midbrain, striatum, cerebellum, and
spinal cord was tested by Western analysis.
Results: Rapamycin significantly improved performance on the
forepaw stepping adjustment test, the rotarod and the pole test in
both genders of transgenic mice. Rapamycin significantly reduced
error steps on the challenging beam traversal test in male, but not female,
transgenic mice. Feeding rapamycin had no effect on grip
strength or stride length or any effect in wild-type mice. Rapamycin
significantly reduced expression of human α-synuclein in midbrain
and spinal cord, but not in striatum or cerebellum.
Conclusions: Rapamycin significantly attenuated motor deficits
in the A53T mice by reducing human α-synuclein expression in midbrain
and spinal cord. Further experiments will determine whether
the effect of rapamycin is through enhancement of autophagy and
whether rapamycin prevents neurodegeneration.
B124
Does Slow Reaction Time Predict Incident Parkinson’s Disease?:
The Honolulu-Asia Aging Study.
M. Inaba, 1 M. Kamal, 1,2 R. D. Abbott, 1 K. Fong, 2 C. Bell, 1
H. Petrovitch, 1,2 C. Tanner, 4 W. G. Ross. 3,1 1. Geriatric Medicine,
University of Hawaii, Honolulu, HI; 2. Kuakini Medical Center,
Honolulu, HI; 3. Veterans Affairs Pacific Islands Healthcare System,
Honolulu, HI; 4. The Parkinson’s Institute, Sunnyvale, CA.
Supported By: National Parkinson Foundation; the National
Institute on Aging; Veterans Affairs Pacific Islands Healthcare
Systems; John A. Hartford Foundation Center of Excellence in
Geriatrics, University of Hawaii.
Introduction: Many studies have shown a deficit in reaction time
(RT) in Parkinson’s disease (PD) patients. To date, there have been
no longitudinal population-based studies of RT and incident PD. We
studied whether RT may identify individuals at risk for PD among
elderly Japanese-American men.
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Methods: The Honolulu-Asia Aging Study (HAAS) is a longitudinal
cohort study of aging, cognition and movement disorders in
Japanese-American men in Hawaii, which began in 1991 among survivors
of the Honolulu Heart Program cohort, followed since 1965.
The fifth examination cycle was held in 1994-96, when 2,705 men ages
74 to 95 years were examined. Subjects were administered simple RT
(SRT) and choice RT (CRT) tests performed with a laptop computer.
Subjects were divided into quartiles based on reaction time. Diagnosis
of PD was based on consensus from at least 2 neurologists according
to published criteria. Incident PD data were available for 7 years
of follow-up, and those with prevalent PD were excluded. Separate
analyses were performed for SRT and CRT, using the lowest quartile
of each as reference.
Results: There were 25 cases of incident PD during follow-up,
and incidence rates increased by quartiles of SRT, from 5.7, to 20.0, to
19.1, to 25.0 per 10,000 person-years follow up, p for trend=0.03.
Using multivariate Cox regression, adjusting for age, education, baseline
cognitive test score, prevalent stroke, handedness, handgrip
strength, percent SRT error rate and amount of caffeine intake, men
in the highest (slowest) quartile of SRT were significantly more likely
to develop incident PD (RR=5.32, 95% CI=1.05-26.9, p=0.04). Analyses
were repeated on men who were cognitively intact at baseline and
without prevalent stroke, and those in the highest quartile of SRT still
had higher incidence of PD (RR=5.03, 95% CI=0.96-26.2, p=0.055).
We found no significant associations between CRT and incident PD.
Conclusions: Men in the slowest quartile of SRT were significantly
more likely to develop incident PD compared to those in the fastest
quartile. Measurement of RT is a low-cost method that may help to
identify those at risk for PD who may benefit from early intervention.
B125
Neuropsychological and Functional Performance in Adult
Protective Services Clients.
M. T. Le, D. J. Goldstein, J. E. Schillerstrom. University of Texas
Health Science Center at San Antonio, San Antonio, TX.
Supported By: The research reported on this abstract was supported
by Hartford/AFAR Medical Student Training in Aging Research
(MSTAR) Program.
Background: In fiscal year of 2010, Texas Adult Protective
Services (APS) validated 56,053 cases of neglect, abuse, or exploitation.
The UTHSCSA Department of Psychiatry performs decisionalcapacity
assessments across Region 8 which encompasses 29 Texas
counties. In Texas, the legal definition of decisional capacity is heavily
dependent on the functional status of the client. The purpose of this
study was to determine which cognitive domains contribute independent
variance to instrumental activities of daily living (IADL) in
elderly APS referrals. Methods: We performed a retrospective
medical record review of referrals (n=157 of which n=75 subjects
completed all measures), calculated Spearman correlation coefficients
between cognitive and functional scores, and regressed neuropsychological
measures onto IADL to search for independent contributions.
Results: There was no correlation between IADL and
the Geriatric Depression Scale. IADL correlated significantly with
the Executive Interview (r=0.68, p

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RESULTS: Participants had a mean age of 77.6 (SD=5.8, range
69-98), 42% were African American, 50% were female, and 29% and
20% had eGFR levels 45-59 and

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B130
Early Discontinuation of Adjuvant Chemotherapy among Veterans
with Colon Cancer.
H. Riggs, 1,4 K. Lane, 1 S. Rawl, 3,4 P. Loehrer, 1,4 S. Hui, 1 M. Weiner. 1,2 1.
Indiana University School of Medicine, Indpls, IN; 2. Center of
Excellence on Implementing Evidence-Based Practice, VHA HSR&D
HFP 04-148 at Richard L. Roudebush VA Medical Center, Indpls, IN;
3. Indiana University School of Nursing, Indpls, IN; 4. Indiana
University Melvin and Bren Simon Cancer Center, Indpls, IN.
Supported By: John A. Hartford Foundation
BACKGROUND: Standard therapy for patients (pts) with
colon cancer and high-risk features or lymph node involvement is 6
months (mos) of adjuvant chemotherapy (C) after surgical resection.
Receipt of 5 mos or less of C may be a marker for inferior outcomes.
Whether advanced age, regimen-specific or other clinical and demographic
factors are associated with delivery of C is uncertain. We evaluated
the association of baseline characteristics and planned C regimen
with C delivery in pts with resected colon cancer.
METHODS: We identified stage II or III colon cancer pts from
our local VA tumor registry and assembled a cohort who initiated C
at our VA between 2004 and 2010. C delivery was measured as the
percentage of planned cumulative dose (PCD) of C that was actually
delivered. Baseline characteristics were pts’ demographics, disease
stage, travel distance to the treatment site, Adult Comorbidity Evaluation-27
score (ACE), and lab results. We classified C as oral
capecitabine- or intravenous 5-fluorouracil-based and as oxaliplatinor
non-oxaliplatin-containing. Linear regression tested each association
with PCD. Toxicities, hospitalization, and other reasons for modifying
or discontinuing C were recorded.
RESULTS: Fifty pts (98% male) initiated C for stage II (n=6)
and III (n=44) disease. Median age was 63 years (range 41-82); median
baseline estimated glomerular filtration rate (GFR) was 83
mL/min/1.76 m 2 (range 26-171); 76% were white; 28% were married;
52% had moderate or severe comorbidity; 74% received oxaliplatin;
and 24% received oral capecitabine. The median travel distance was
40 miles. The median PCD was 75%; median treatment duration was
5 mos. Lower PCD was associated with older age (P=0.05), lower
GFR (P=0.05), higher travel distance (P=0.02), and receipt of
capecitabine (P

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ther studies should target the evaluation of connective tissue markers
and pathological mechanisms linking low BMD and pelvic floor
symptoms.
B133
Biomarkers of Joint Metabolism and the Severity of Radiographic
Hand Osteoarthritis.
I. Perjar, 1 A. Shi, 1 Y. Golightly, 1 J. Renner, 1 A. Nelson, 1 V. Kraus, 2
J. Jordan. 1 1. Thurston Arthritis Research Center, UNC School of
Medicine, Chapel Hill, NC; 2. Duke University School of Medicine,
Durham, NC.
Supported By: American Federation for Aging Research, American
College of Rheumatology
Background: Osteoarthritis (OA) is a joint disorder traditionally
diagnosed using physical examination and radiographic imaging.
Focus has turned to the possibility of using biomarkers of joint metabolism
to assess the extent of joint damage and understand the biological
processes involved in OA. Most studies to date have examined
biomarkers in relation to knee OA, but few have investigated biomarker
patterns in hand OA (hOA) in diverse populations. We examine
the association of two biomarkers with hOA in a bi-racial population-based
study.
Methods: The sample consisted of 667 African American (AA)
and Caucasian adults (37% AA, 49% men, mean age 64 years, mean
BMI 30 kg/m 2 ) with available hOA and biomarker data from the
Johnston County Osteoarthritis Project, a prospective cohort of OA
in a rural county in North Carolina. Radiographs were obtained for
the DIP (distal interphalangeal), PIP (proximal interphalangeal),
MCP (metacarpophalangeal), and CMC (carpometacarpal) joints, as
well as the knees and hips. Radiographic OA in a joint was defined as
a Kellgren-Lawrence score of ≥2. We examined urine C-terminal
crosslinked telopeptide of type II collagen (CTX-II), a marker of collagen
breakdown, and serum hyaluronic acid (HA), a component of
cartilage and synovium, in relation to hOA defined by hand joint
group affected and total number of hand joints affected. Separate
multiple regression models were used to estimate the association between
each hOA outcome and biomarker, adjusting for race, gender,
age, BMI, and knee and hip OA status.
Results: The prevalence of radiographic OA in the sample was
26% for hand, 27% for hip, and 36% for knee. Looking at individual
joint groups, CTX-II was associated with OA at the DIPs (p

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IgE antibodies in serum. Additional work is needed to test large numbers
of samples for clinical application.
B136
Does this Patient have Benign Prostatic Hypertrophy with Bladder
Outlet Obstruction?
K. A. D’Silva , 1 P. Dahm, 2 C. L. Wong. 1 1. Geriatric Medicine,
University of Toronto, Toronto, ON, Canada; 2. Urology, University of
Florida, Gainesville, FL.
Background: Although benign prostatic hyperplasia (BPH) is
very common in older men, not all men with histologic BPH will develop
the non-specific symptoms known as lower urinary tract symptoms
(LUTS). Likewise, not all men with LUTS have histologic BPH.
Bladder outlet obstruction (BOO) refers to the pressure gradient at
the bladder neck/prostatic urethra which can be measured by invasive
urodynamics. Accurate diagnosis of BOO is important because it
can cause not only immediate symptoms including severe pain and
urinary retention but also lead to complications, e.g.incontinence and
renal insufficiency.
Objective: To systematically review the evidence on the diagnostic
accuracy of office-based tests for BPH with BOO in males
with LUTS.
Methods: Search of MEDLINE and EMBASE (from 1950 to
August 12, 2010), Cochrane Central Register of Controlled Trials via
Ovid, and references of retrieved articles, to identify diagnostic studies
of patients with LUTS due to BPH with BOO.
Data selection: Prospective studies comparing at least one diagnostic
test, feasible in a clinical setting and readily available to a nonspecialist
clinician, to the gold standard reference test, invasive urodynamic
studies. Studies were excluded if they used pediatric patients
or if participants had confounding medical conditions.
There were 6692 unique citations identified with 9 prospectively
conducted studies (N=1217 patients) meeting inclusion criteria and
describing use of 2 symptom questionnaires as well as individual
symptom(s). All tests were administered and scored based on international
guidelines. The best constellation of symptoms that suggested
BPH with BOO was ‘poor stream and frequency and/or nocturia’
(positive LR, 1.76; 95% CI, 1.17- 2.64). The most useful
symptom in which the absence made a diagnosis of BPH with BOO
less likely, was nocturia (negative LR, 0.19, 95% CI, CI 0.05-0.79). The
best symptom questionnaire to support or rule out a diagnosis of
BPH with BOO was the International Prostatic Symptom Score (I-
PSS) at a cut-off of 8 (summary positive LR, 1.34; 95% CI, 1.06-1.70;
summary negative LR, 0.28, 95% CI, CI 0.12-0.70).
Conclusions: Although urodynamic investigations are the gold
standard for diagnosis of BPH with BOO, symptoms obtained
through history may be useful for diagnosis. The best evidence supports
asking the patient about nocuturia, stream and frequency.
B137
Predicting Mortality Following Clostridium difficile Infection.
L. Archbald-Pannone, 1,2 R. Pinkerton, 1,3 R. Guerrant. 1,3 1. Internal
Medicine, University of Virginia, Charlottesville, VA; 2. Division of
General Medicine, Geriatrics, and Palliative Care, University of
Virginia, Charlottesville, VA; 3. Division of Infectious Diseases and
International Health, University of Virginia, Charlottesville, VA.
Supported By: NIH/ NIAID 5K23AI074681-04
Background: With increasing incidence & severity of Clostridium
difficile (C. difficile) infection (CDI), there are no objective factors
at diagnosis that have been proven to predict poor outcome. We
evaluated demographics, co-morbidities, medications, & laboratory
tests in a cohort of hospitalized patients to determine factors that
could predict death following CDI diagnosis. Methods: After obtaining
consent, adult inpatients with CDI diagnosed in our hospital
(September 2008-May 2010, UVA HSR-IRB 13630) were followed 12
months after C. difficile diagnosis to determine short-term mortality
(STM, 1 month) & long-term (LTM, 12 months). Age & Charlson comorbidities
score were calculated on day of CDI diagnosis. White
blood cell count (WBC) & renal function (BUN, GFR, & Creatinine)
were recorded on day of diagnosis; serum albumin recorded within 7
days of diagnosis (mean, if multiple); & medications prior to diagnosis
were recorded. Binary logistic regression (SPSS 19) determined a
model to best predict mortality, using univariate predictors of mortality
(student’s t-tests, chi-squared) & backward regression to eliminate
non-significant factors. Significance set p ≤ 0.05. Results: 85 subjects;
age 63.4 years (sd 16.9); Charlson score 5.8 (sd 4.0); time to death 2.4
months (sd 3.6); STM rate 32.9% (n=28); LTM rate 52.9% (n=45).
Factors associated with STM & LTM, respectively: age (both
p

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Table 1. Multivariable Odds Ratios (95% Confidence Intervals) for
Malignancy by Serum Ferritin Level
B139
IL-6 inhibits erythroid maturation in human TF-1
erythroleukemia cells.
N. M. Cruz, 1 B. J. McCranor, 1 F. Peña-Cruz, 1 A. E. Berger, 2
C. Cheadle, 2 C. I. Civin, 3 C. N. Roy. 1,4 1. Division of Geriatric
Medicine, Johns Hopkins University School of Medicine, Baltimore,
MD; 2. Lowe Family Genomics Core, Johns Hopkins University
School of Medicine, Baltimore, MD; 3. Center for Stem Cell Biology
& Regenerative Medicine and Departments of Pediatrics and
Physiology, University of Maryland School of Medicine, Baltimore,
MD; 4. Division of Hematology, Johns Hopkins University School of
Medicine, Baltimore, MD.
Supported By: MSTAR/AFAR 5T35AG026758-07; American
Society for Hematology Scholars Award (CNR); R01 DK082722
Background: Approximately 10% percent of adults over 65
years of age are anemic. One-third of cases can be attributed to anemia
of inflammation (AI). Aging, even in the absence of disease, can
be considered a chronic pro-inflammatory state. Interleukin-6 (IL-6)
increases with age and is elevated in the serum of patients with AI.
We tested the hypothesis that IL-6 inhibits erythroid precursor maturation.
To provide rationale for future studies in human volunteers,
we used TF-1 human erythroleukemia cells as an in vitro model of
human erythroid maturation and AI.
Methods: We incubated TF-1 cells overnight in basal medium,
and then treated the cells for 3-4 days with erythropoietin (Epo) to
induce erythroid maturation in the presence or absence of 100 ng/mL
of human IL-6. Erythroid maturation was assessed by staining with
CD44 and glycophorin A (GYPA) monoclonal antibodies and flow
cytometry. We performed quantitative RT-PCR to measure fold
changes in expression of aminolevulinic acid synthase 2 (ALAS2)
and band 3 (SLC4A1), which are markers of heme biosynthesis and
erythroid maturation.
Results: We found that Epo-treated TF-1 cells became phenotypically
more mature, as measured by CD44 and GYPA. The mature
population was 45 ± 11% of total cells, but this population was
reduced to 33 ± 9% of total cells with IL-6 treatment. ALAS2 expression
increased in Epo-treated cells to 10 times that of untreated
cells (p

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contribution by heightened immune activation to age-associated accelerated
HIV disease progression has not been delineated.
Methods: Prospective, age-differentiated, multicenter cohort
study of older (≥45 years) and younger (18-30 years) subjects who received
192 weeks of a uniform ART regimen. Age-group differences
in the time course of a diverse array of immunologic indices were assessed
with adjustment for other correlates of T cell restoration in
mixed-effects models.
Results: 90 subjects enrolled in this cohort, including 45 younger
(median age 26, range 18-30 yrs) and 45 older (median age 50, range
45-79 yrs) subjects. The increases of naive, memory and total CD4
cells, and naïve CD8 cells per week with ART did not differ significantly
between the age-groups, but older subjects maintained significantly
fewer circulating naive ( P

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ing decisions when patients develop dementia. The purpose of this
study was to describe the perspectives of family caregivers toward
forgoing or continuing cancer screening.
We audio-taped and transcribed focus group sessions with a
convenience sample of caregivers of patients with dementia attending
4 local Alzheimer’s Association support groups. Session topics included
recent experiences with screening decisions and preferences
for patient-clinician communication. The interviews were coded independently
by all investigators to identify key themes using methods
of grounded theory.
We conducted 4 focus group sessions with 32 caregivers of patients
with dementia. Mean age was 65.5 (range 49-85), 25 were
women, 7 were African American, 24 white, and 1 African American/Indian.
Caregivers were 14 daughters, 13 were spouse, and 5
other. The most important factor in making decisions about screening
tests preserving the patient’s Quality of Life. One said, “I was concerned
about her quality of life and making sure that she was very,
very comfortable, and I think that means more than putting people
through a lot of unnecessary, uncomfortable…procedures.” The second
theme involved the Increasing Burdens and Decreasing Benefits
of continued screening as dementia worsened. Specifically, the inability
to understand procedures and patient agitation increased the test
burdens. Caregivers noted their own Pivotal Role in Decision Making,
often stepping in to stop invasive tests and deciding when to take
over decision making from the patient. Caregivers noted variable levels
of Physician Knowledge/Expertise, with some having limited
knowledge of the course or challenges of dementia.
Caregivers of patients with dementia consider cancer screening
tests in light of their impact on quality of life. Given their perceptions
of the changing balance of burdens and benefits as dementia worsens,
many caregivers choose to forgo screening. The perspective of caregivers
contrasts with prior research on patient perspectives, which
finds that many patients plan to continue screening for themselves
despite possible future declines in health.
B145
Older Adult Opinions of “Advanced Driving Directives”
M. E. Betz, 1 S. Lowenstein, 1 R. Schwartz. 2 1. Emergency Medicine,
University of Colorado School of Medicine, Aurora, CO; 2. Division
of Geriatrics, University of Colorado School of Medicine, Aurora, CO.
Supported By: Emergency Medicine Foundation and John A
Hartford University of Colorado Denver Center of Excellence.
BACKGROUND: Discussions and decisions about driving retirement
are difficult. “Advanced driving directives” [ADDs], similar
to advanced directives for end-of-life care, would allow drivers to designate
a person to help make decisions about driving cessation when
their driving skills decline. It is not known if older drivers support the
idea of ADDs; we sought to describe older adults’ experiences and
opinions about driving discussions and ADDs”.
METHODS: A convenience sample of English-speaking adults
(55+ years) at two independent living facilities and two community
centers were invited to complete an anonymous survey.
RESULTS: Of the 168 participants, 133 (80%) were female and
the median age was 76.5 (range: 56-93) years. Most reported driving a
motor vehicle at least occasionally (96%; 95%CI:92-98) and only
29% (95CI:22-37) found driving somewhat or very stressful. Seven
percent (95CI:4-12) reported a crash in the past year. Most participants
(73%; 95CI:66-80) supported mandatory age-based driver testing;
of these, half (50%; 95CI:40-59) though testing should begin at
age 80 or higher. More thought that the driver (71%; 95CI65-78),
family (61%; 95CI:53-68) or physician (59%; 95CI:51-66) should determine
license revocation for an unsafe driver rather than the department
of motor vehicles (32%; 95CI:25-39). A minority had spoken
with someone about driving safety (5%; 95CI:2-10) or wishes
when driving skills decline (21%; 95CI:15-28); of these, 83%
(95CI:67-94) had spoken with a family member but only 17%
(95CI:6-33) with a healthcare provider. However, older adults were
open to discussions (table) and 54% (95CI:46-62) said they would
complete an ADD if recommended. Of these, 79% (95CI:69-87) said
it was likely or very likely they would follow the ADD in the future.
CONCLUSION: Older drivers are open to driving discussions
with physicians, supporting the important physician role in counseling
and coordinating conversations about driving. Advanced planning
with ADDs may facilitate future decisions about driving retirement.
B146
Walking Ability is Associated with Pain, Depression, and
Overweight among Community Dwelling Older Adults.
N. Satchidanand , 1 C. Fox, 1 K. Brunton, 2 G. S. Cherr . 2 1. Family
Medicine, State University of New York at Buffalo, Buffalo, NY; 2.
Surgery, State University of New York at Buffalo, Buffalo, NY.
Supported By: American Geriatrics Society: Dennis W. Jahnigen
Career Development Scholars Awards Program.
BACKGROUND: Maintenance of mobility is an important goal
for the elderly. Impaired physical function limits the ability of older
adults to live independently and is strongly associated with declining
health. The association between physical comorbidities and disability
is well studied. However, less is known about the influence of modifiable
factors on physical function. The study purpose was to examine
the influence that select treatable factors have on walking ability
among older adults.
METHODS: A total of 200 subjects, age ≥65 were included
(62.5% female). Depressive symptoms, psycho-social stress and
chronic pain were assessed using literature validated questionnaires.
Body mass index (BMI) was calculated. Physical function was assessed
using the Six Minute Walk Test. Pre-existing medical conditions
which may impact walking ability (i.e. PAD, COPD, CHF) were
also assessed. Path analysis was performed to characterize the contribution
of each predictor variable (depression, stress, chronic pain,
BMI) on distance walked and to derive path coefficients, R 2 -values
and probability values.
RESULTS: The predictor variables demonstrated low to moderate
correlations with one another, (0.27 to 0.54). Depressive symptoms,
pain and BMI (but not psychosocial stress) were significant predictors
of distance walked.The overall causal model accounted for about 30%
of the variance in distance walked among all patients. After adjusting
for pre-existing medical conditions, the proposed model still accounted
for about 30% of the variance in distance walked.The strongest association
with distance walked was with chronic pain for both the overall
model (β = -.296, p < .01) and adjusted model (β = -.250, p < .01).
CONCLUSIONS: Among community dwelling older adults,
three treatable factors were significantly associated with impaired
walking ability. These associations remained after adjusting for medical
conditions that are also associated with impaired physical function.
Further research is needed to determine the most efficacious interventions
to treat depression, ameliorate chronic pain, and prevent weight
gain in aging in order to preserve physical function and quality of life.
B147
“SERIOUSLY ILL OCTOGENARIANS &
NONAGENARIANS”– ROLE OF PALLIATIVE CARE
CONSULTS IN INITIATING “DO NOT ESCALATE CARE”
PATHWAY AND DISCHARGE TO HOSPICE IN SERIOUSLY
ILL OLDEST OLD PATIENTS ADMITTED TO A TERTIARY
ACADEMIC MEDICAL CENTER.
F. Kawai, V. Periyakoil. Stanford University School of Medicine,
Stanford, CA.
Supported By: Stanford University School of Medicine
Background:
AGS 2012 ANNUAL MEETING
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The oldest old (age>85yo) are the fastest growing segment of
the US population
About 27% of Medicare’s annual $426 billion budget goes to
care for patients in their final year of life, with acute hospitalizations
being a major cost.
Evidence supports improved clinical and utilization outcomes
with palliative care consults for seriously ill patients and increased
patient and family satisfaction.
The goal of this study was to assess the role of palliative care
consults(PCC)in preventing futile escalation of care in a cohort of seriously
ill oldest old inpatients.
Methods:
A retrospective chart review of palliative care consults in a tertiary
academic medical center between August 2008 and June 2011
yielded 314 patients >85 yo. Charts were reviewed to extract patient
demographics,admitting diagnosis, inpatient mortality and disposition
post PCC including initiation of “Do Not Escalate Care” pathway
and facilitation of Hospice discharge.
Results:
-Of the 314 patients identified, there were 148 males (47%) and
166 females (53%).153 patients (49%) were nonagenarians.
-Admission diagnosis included Cancer: 25% (77), Stroke:15%
(48), Cardiac:15% (47), Dementia: 12% (36), Pulmonary: 6% (8), and
Other (including infection, falls, failure to thrive, Hepatic & Renal
disease): 27% (86)
-36% (113 patients) died during the course of hospitalization.
-PCC resulted in the initiation of the “Do Not Escalate Care”
pathway in 73% (229 patients) during the hospitalization.
-Of the 201 patients who did not die during the hospitalization,hospice
was initiated in 60% (113 patients): 32% home hospice,
22% long term care facility with hospice, 6% inpatient hospice. Non
hospice discharges: 17% SNF and 18% home. No discharge data
available: 5%.
Conclusions:
-Oldest old inpatients had a high (36%) in hospital mortality.
Most deaths were expected and due to serious illnesses including
Cancer, Stroke, end stage cardiac, lung and renal disease.
-PCC resulted in initiation of the “Do Not Escalate Care” pathway
in 73% of the patients, thereby preventing ineffective interventions
(such as CPR, invasive procedures, ICU care) in this seriously ill
population of older adults;
-PCC facilitated discharge to hospice in 60% of the survivors,
thereby promoting comfort and quality of life while avoiding prolonged
hospitalizations.
B148
Predicting Mortality in End Stage Dementia: A Retrospective
comparison of Medicare Guidelines and Mitchell Criteria for
Hospice Referral.
J. Almeida, M. C. Galicia-Castillo. Internal Medicine/Geriatrics,
Eastern Virginia Medical School, Norfolk, VA.
Background: Dementia is the sixth-leading cause of death posing
a significant cost of $183 billion annually(1). The progression of
the disease is variable, with the end stage lasting as long as three
years(2). Current guidelines for predicting six-month mortality have
been under scrutiny; they are not evidenced-based and were never
studied prior to implementation as hospice criteria(3,4). Mitchell et al
derived a mortality risk index for six-month mortality using items
from the minimum data set. The objective of this study was to compare
the Mitchell risk index to Medicare guidelines in predicting sixmonth
mortality in end-stage dementia(3).
Methods: A retrospective chart review of patients who died
from dementia in a nursing home facility from January 2004 through
December of 2009 was performed. Data points from three, six and
twelve months prior to death were collected from the minimum data
set. At each point subjects were coded as eligible or ineligible for hospice
according to Mitchell risk index and Medicare guidelines.
Results: At six months prior to death, out of 24 subjects, the
Mitchell risk index score identified 13 (54%) as eligible for hospice
and Medicare guidelines identified six(25%; p =0.16). Three months
prior to death, out of 24 subjects Mitchell risk index identified 19
(79%); using Medicare guidelines identified nine(37.5%, p=0.118)
Conclusion: Current guidelines for predicting six-month mortality
for appropriate hospice referral for end-stage dementia are inaccurate.
The Mitchell risk index may be a better tool to help clinicians
better prognosticate six-month mortality and employ hospice services
earlier.
References
1 Herbert, LE; Scherr, PA; Bienias, JL; Bennet, DA. Alzheimer
Disease in the U.S. Population: Prevalence Estimates Using the 2000
Census. Archives of Neurology August 2003:60(8)1119-1122.
2 Shuster, J. Palliative Care for Advanced Dementia. Clinics in
Geriatric Medicine 2000: 16(2).
3 Mitchell, SL; Kiely, DK; Hamel, MB; Park, PS; Morriss, JN;
Fries, BE. Estimating Prognosis for Nursing Home Residents with
Advanced Dementia. JAMA2004:291 (22) 2734-2740.
4 Schonwetter RS, Han B, Small BJ, Martin B, Tope K, Haley
WE. Predictors of six-month survival among patients with dementia.
American Journal of Hospice and Palliative Care 2003:(20):105-113.
B149 Encore Presentation
Pain is good for you? Non-cancer pain predicts improved 5-year
survival.
J. Shega, 1 M. Andrew, 2 D. Lau, 3 K. Herr, 4 M. Ersek, 5 D. Weiner, 6
W. Dale. 1 1. Medicine, University of Chicago, Chicago, IL; 2.
Medicine, Dalhousie University, Halifax, NS, Canada; 3. Pharmacy,
University of Illinois, Chicago, IL; 4. Nursing, University of Iowa, Des
Moines, IA; 5. Nursing, University of Pennsylvania, Philidelphia, PA;
6. Medicine, University of Pittsburgh, Pittsburgh, PA.
Supported By: NIA
Background: Non-cancer pain is known to result in significant
morbidity, but little is known about its impact on mortality. We assessed
the relationship of self-reported non-cancer pain at baseline
and subsequent 5-year mortality among community-dwelling older
adults.
Methods: We analyzed data from a large prospective cohort
study, the 1996 wave of the Canadian Study of Health and Aging.
Non-cancer pain was assessed using the 5-point verbal descriptor
scale, dichotomized into “no/very mild” versus “moderate” or greater
pain. Frailty was measured as the sum of self-reported health (1
item), social support (1 item), co-morbidity (17 items), and functional
abilities (14 items) with each item scored from 0 to 1, ranging from 0-
33, with higher scores indicating greater frailty. Cognitive status was
measured using the Modified Mini-Mental Status Exam, ranging
from 0-100, with a score 11
indicating depression. Multivariable logistic regression was used to
analyze the relationship between pain and mortality, controlling for
other factors.
Results: Of the 5,703 participants, 4,694 (82.3%) had complete
data for analysis. Of these, 35.4% reported moderate or greater pain
and 28.6% had died at 5-year follow-up. The 5-year mortality odds
increased by 1.12 (CI: 1.10, 1.13); p

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older adults are needed to better understand its trajectory, associated
factors, and outcomes.
B150
Factors associated with enrollment in a randomized controlled trial
of oxycodone vs acetaminophen for moderate or greater noncancer
pain.
J. Shega, C. Ogbevire, W. Dale. Medicine, University of Chicago,
Chicago, IL.
Supported By: NIA
Background: Studies document the under-identification and
treatment of non-cancer pain among older persons. In addition optimal
pharmacologic management remains unclear.
An obstacle of analgesic use in this setting is lack of high-quality
comparative effectiveness data comparing acetaminophen to opioids
in community-based populations, particularly African Americans
(AA). We sought to identify factors associated with the likelihood of
older adults enrolling in a randomized control trial (RCT) of these
therapies.
Methods: A face-to-face screening questionnaire was completed
for all referred older adults who were eligible for an analgesic intervention
conducted in a predominantly AA, community-based geriatrics
clinic. Information elicited from the screening questionnaire included
basic demographics, pain intensity (verbal descriptor scale: 0
[no pain] to 5 [excruciating pain], frequency of pain in the past week,
number of painful sites, mobility difficulty, and presence of adequate
social support.
Results: Among the first 50 participants (46/50, 96%, AA) referred,
15 (30%) elected to enroll in the RCT. The most commonly
cited reasons for not enrolling were: 1) infrequency of pain (6%) and
2) fear of opioid-related side effects (8%). Age was not associated
with likelihood of enrollment, 82.2 ( SD=6.78) years versus 82.0
(SD=6.72) years, p=0.94. Gender (female) 31% vs 69%, p=0.55, pain
severity 2.87 ( SD=1.1) versus 3.18 ( SD=1.2), p=0.40, number of
painful sites 2.6 (SD=1.6) versus 2.1 (SD=1.4), p=.53, mobility difficulty
60% versus 40%, p=0.31, and availability of social support 93%
versus 97%, p=1.00 were also not associated with study enrollment.
Those who reported pain everyday, compared with those reporting
pain 1-3 times per week were more likely to enroll, 100% versus
31%., p=0.065.
Conclusion: In this preliminary analysis, the number of older,
primarily AA adults in a community setting enrolled in a RCT that
included an opioid mirrored the rates from cancer clinical trials.
Common stated reasons for not enrolling were concern for side effects
and pain considered insufficient for treatment. The experience
of pain everyday was positively associated with enrollment, while age,
gender, pain intensity, number of pain sites, mobility difficulty, and social
support were not associated with study enrollment. This is unique
information on AA enrollment in RCT for pain management.
B151
Experiences of informal caregivers of older adults discharged from
nursing homes to the community through the Money Follows the
Person Demonstration Program.
L. Kristof, C. Butler, J. Robison, R. Fortinsky. Center on Aging,
University of Connecticut, Farmington, CT.
Background: The multi-state Money Follows the Person (MFP)
Demonstration Program enables Medicaid recipients residing in
nursing homes to move back to their communities. Little is known
about how family and other informal caregivers are affected by older
adults returning to the community after what was considered longterm
nursing home residence. We examined caregiver burden and the
positive aspects of caregiving in caregivers of older adults (age >65)
enrolled in Connecticut’s MFP who were discharged to the community
after a nursing home stay of more than 3 months. Secondary outcomes
evaluated were depressive symptoms and anxiety in caregivers.
Methods: In this cross-sectional study, caregivers completed a
self-administered questionnaire 6 months after their family members
returned to the community. We asked caregivers about stress levels
compared to previous time points. Caregiver burden was measured
using the Modified Zarit Burden Interview. Positive aspects of caregiving
were evaluated using the COPE index. We evaluated for symptoms
of depression using the 2 question PRIME-MD screen. Statistical
analysis was done using SPSS.
Results: Preliminary results from 21 caregivers were analyzed
(M age = 57, range 30-77; 81% female; 48% live with the MFP participant;
32% work full time, 53% do not work). The mean Burden
Index score was 5.38 (M=5.38, Range 0-12); mean score for the
COPE index was 8.85 (M=8.85, Range 0-10). Compared to the time
when the older adults resided in nursing homes, 75% of caregivers
felt less stressed, 10% felt the same stress, and 15 % felt more
stressed. Compared to the period before nursing home admission,
61.1% of the caregivers felt less stress, 27.8% felt the same stress, 11.1
% felt more stressed. Burden scores and COPE index scores were not
significantly different whether caregiver lived with the MPF participant
or not (Burden M=4.2 vs. M=6.45, p=0.081; COPE M=9.6 vs. M=
8.18, p=0.234).
Conclusions: Preliminary results suggest a decrease in caregiver
stress and, compared to other studies of community-based caregivers,
lower levels of caregiver burden and higher levels of positive aspects
of caregiving for caregivers of older MFP participants in CT.
B152
FUNCTIONAL OUTCOMES AND HEALTH RELATED
QUALITY OF LIFE AFTER TRANSCATHETER AORTIC
VALVE IMPLANTATION IN ELDERLY PATIENTS WITH
SEVERE AORTIC STENOSIS.
M. G. Mendieta F., 1 N. F. Pereyra, 1 E. Sánchez G., 1 E. Gutierrez, 2
F. Fernández Aviles, 2 H. Bueno, 2 M. Vidán A.. 1 1. Geriatry, Gregorio
Marañón Hospital, Madrid, Madrid, Spain; 2. Cardiology Service,
Gregorio Marañon Hospital, Madrid, Madrid, Spain.
Background: Transcatheter aortic valve implantation (TAVI)
improves survival in patients with aortic stenosis unelegible for surgery.
The changes in patients functional performance and quality of
life (QoL) after TAVI are not well known.
Methods: The change in health related quality of life (SF-12
questionnaire), autonomy for activities of daily living (ADL), mobility
and social help was prospectively evaluated in a cohort of consecutive
patients one month after TAVI. Demographic and clinical characteristics,
in-hospital complications and clinical evolution were also
evaluated.
Results: Between January 2009 and November 2011, 57 patients
were enrolled in the Cardiology Department, with a mean age of 82.2
± 5.7 years. Thirty-day mortality was 12,2%. Among survivors, 58%
improved cardiac symptoms, 26% improved mobility, and 15% improved
autonomy for ADL but 30% increased dependency for ADL.
In addition, 41% needed new social or private help for daily living.
Baseline SF-12 physical summary was 36.3± 10 and baseline mental
summary was 43±9.2. Both scores showed modest improvements
after one month: 2.9±9.6 (p=0.04) and 2.7±11.6 (p=0.02), for physical
and mental scores, respectively. The proportion of patients with relevant
improvement (>2points) in physical health was 47.7%, and
59.1% in mental health. No significant association between cardiac
symptoms improvement and changes in quality of life was found.
Conclusions: Most inoperable patients with severe aortic stenosis
show improvements in symptoms and quality of life one month
after TAVI but the changes are modest in absolute terms and not always
associated with functional improvement. Longer-term follow-up
is ongoing.
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B153 Encore Presentation
Too Many Finger Sticks for Nothing? A Study of Sliding Scale
Insulin Use Among Elderly Nursing Home Residents With Type 2
Diabetes.
N. Pandya, 1 W. Wei, 2 B. S. Kilpatrick, 3 J. L. Meyers, 4 K. L. Davis. 4 1.
Nova Southeastern University, Ft. Lauderdale, FL; 2. sanofi-aventis,
Bridgewater, NJ; 3. AnalytiCare, LLC, Glenview, IL; 4. RTI Health
Solutions, Research Triangle Park, NC.
Supported By: This study was funded by sanofi-aventis U.S. The authors
received editorial support in the preparation of the abstract,
funded by sanofi-aventis U.S.
Background: Type 2 diabetes mellitus (T2DM) patients in longterm
care (LTC) often receive sliding scale insulin (SSI) therapy;
however, this provides suboptimal glycemic control.
Methods: This retrospective study assessed the burden associated
with SSI use in older T2DM patients treated with insulin at US
nursing homes, using merged medical chart data and the Minimum
Data Set (MDS). Patients who were not comatose or receiving hospice
care, residing in LTC facilities for ≥3 months were included if
they had ≥1 full MDS assessment and ≥2 records of insulin dispensing
with no insulin pump use.
Results: A total of 2,096 patients (mean [SD] age = 74 [12.1]
years) were identified with a median of 56 days of medical administration
record sheet data available (range 6-424 days). Among these
patients, 35.1% had ≥1 glycated hemoglobin AIC (A1C) value
recorded (mean [SD] A1C = 7.2% [1.3]); 51.1% had A1C ≤7.0% and
mean (SD) fasting blood glucose was 146.4 (43.6) mg/dL. Seventyfour
percent of patients (n=1,550) were on SSI (either alone or as
supplemental therapy with another regimen) for the entire follow-up;
30.9% (n=648) were exclusively on SSI throughout follow-up. On average,
patients received 19.9 SSI-related finger sticks per week, with
12.5 (62.8%) of these showing blood glucose levels that did not necessitate
subsequent insulin administration.
Conclusions: Despite older T2DM patients maintaining relatively
good glycemic control, SSI use was widespread in the LTC facilities
examined and was associated with a high finger-stick burden.
These findings question the need of prolonged SSI therapy among
older T2DM patients in LTC.
B154
Attitudes of medical providers regarding the withdrawal of life
sustaining interventions during end-of-life care.
A. J. Shipley, 2 Q. Cao, 1 D. Cummings. 1 1. Family Medicine, East
Carolina University, Greenville, NC; 2. Brody Medical School, East
Carolina University, Greenville, NC.
Supported By: HRSA:K01 HP20471, Geriatric Academic Career
Award
Background: Taking care of patients near the end of life is a
daunting and delicate task. Interventions like pacemakers, implantable
cardioverter defibrillators (ICDs), hemodialysis, artificial
hydration and nutrition, and ventilator support all can prolong life,
often without improving quality of life. The distinction between terminating
a life sustaining treatment and physician assisted suicide
(PAS) has been questioned and the decisions about withdrawal are
challenging.
Objective: A statewide cross-sectional survey was developed to
assess the attitudes among medical providers in North Carolina related
to withdrawal of life sustaining interventions.
Methods: The survey was conducted online in November 2011.
Participants were asked if withdrawal of a specific intervention constituted
PAS and whether they would feel comfortable with the withdrawal
if patient preference was known. Demographic questions include
age, gender, race, the medical school, and the year of
graduation, the residency program, and the specialty/subspecialty.
Survey responses were based on a Likert scale and T-tests compared
differences between groups.
Results: n=888 medical providers participated in the survey; the
vast majority of respondents were white, with a mean age of 53 ± 14
years. The sample was 65% Male; 35% female. 64% of respondents
were specialists and 36% were primary care providers. Over 79% of
participants either strongly disagreed or disagreed that withdrawal of
a specific intervention constituted PAS and the majority of them felt
comfortable with the withdrawal of life-sustaining interventions.
There were small but statistically significant differences by age with
younger providers (< 48 yrs) expressing stronger disagreement with
intervention withdrawal being equated with PAS and more comfort
in withdrawing interventions (p

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B156
The Impact of Testing Protocol on Recorded Gait Speed.
A. Sustakoski, J. M. VanSwearingen, S. Perera, S. A. Studenski,
J. S. Brach. University of Pittsburgh, Pittsburgh, PA.
Supported By: T32 AG021885, K23 AG026766, P30 AG024827
Background: Gait speed predicts disability, cognitive decline,
hospitalization, nursing home admission and mortality. Although gait
speed is often measured in clinical practice and research, testing protocols
vary widely and its impact on recorded gait speed has yet to be
explored. Our purpose is to describe and compare gait speeds obtained
from different testing protocols in the same individuals.
Methods: Subjects were 104 community-dwelling older adults
who could ambulate household distances independently (mean
age=77.2±6.1). Gait speed was recorded over 4 meters using the protocols:
1) standing start, usual pace over ground, 2) walking start,
usual pace over ground, 3) walking start, usual pace on a computerized
walkway, and 4) walking start, fast pace on a computerized walkway.
Paired t-tests were performed to compare gait speeds within individuals
across different protocols. Linear regression was used to
derive an equation to convert standing start usual pace to walking
start usual pace gait speed.
Results: Mean±SD gait speed for each condition was: standing
start, usual pace over ground 0.97±0.23 m/s; walking start, usual pace
over ground 1.14±0.25 m/s; walking start, usual pace on walkway
1.01±0.26 m/s; and walking start, fast pace on walkway 1.31±0.34 m/s.
On average, the determined gait speed was 0.17 m/s faster during the
walking compared to the standing start (p=1 transition/year
(aHR=3.70, 95%CI=2.23-6.14, p

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B159
Accuracy of Formulas to Predict Resting Metabolic Rate in Elderly
Admitted to a Recuperative Care Unit.
D. H. Sullivan, 1,2 K. P. Padala, 1,2 K. K. Garner, 1,2 R. A. Dennis, 1,2
M. Bopp, 1,2 P. R. Padala. 1,2 1. Geriatric Research Education and
Clinical Center, VISN16/CAVHS, North Little Rock, AR; 2. Geriatrics,
University of Arkansas for Medical Sciences, Little Rock, AR.
Supported By: VA Health Services and Clinical Science Research
and Development programs (HSR&D IIR-04-298 and CSR&D)
and a University of Arkansas for Medical Sciences Tobacco
Settlement award
Background: There is a lack of validation studies of formulas for
estimating resting metabolic rate (RMR) in elderly patients in the recuperative
phase of illness. Given the importance of such formulas
for estimating the nutrient requirements of older medically complex
patients, this study was undertaken to explore this issue.
Methods: This prospective study included 156 males over 64
years of age admitted to a recuperative care and rehabilitation unit
located within a Veterans Affairs hospital Community Living Center.
RMR was measured (mRMR) within seven days after admission by
indirect calorimetry in the fasted state prior to the subjects’ arising in
the morning. Height and weight were measured at the same time.
Results: The subjects had a mean age of 79 + 8 years and 85%
were white. Although free of metastatic cancer and other terminal
conditions, all were deconditioned and most were undernourished
and frail. For all 10 published formulas evaluated, estimated RMR
(eRMR) was highly correlated with mRMR (r = 0.70 to 0.74,
p

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a different strategy than young adults to deal with a walking challenge
may potentially inform interventions to improve motor skill in
walking.
B162
Dual-Stiffness Flooring: Does it Reduce Fracture Rates Among
Older Fallers ?
F. Knoefel, 1 L. Patrick, 1 J. Taylor, 1 R. Goubran. 2,1 1. EBRI Research
Institute, Ottawa, ON, Canada; 2. Engineering and Design, Carleton
University, Ottawa, ON, Canada.
Supported By: Satech Inc., Chehalis, WA, USA
BACKGROUND: Fractures in older adults are associated with
significant morbidity and mortality. Falls in this population lead to
fractures approximately once every 20 falls. A number of bio-mechanical
studies suggest that dual-stiffness flooring (DSF) diminishes
the impact of contact with a floor, potentially reducing injuries associated
with falls. To our knowledge however, there has never been a
controlled study comparing fracture rates on regular flooring to that
on DSF. METHODS: Mountain View Manor is a Skilled Nursing Facility
in Prescott, Arizona where two resident bedrooms have DSF
flooring (SmartCells flooring). Falls and related injuries were tracked
during the period of July 1, 2008 to December 31, 2010. Injury rate
comparisons, based on Chi-Square analyses, and prediction of room
type allocation based on the number of injuries sustained, using Logistic
Regression, were conducted. RESULTS: A total of 167 falls
were reviewed. Fifty-five percent (55%) of falls resulted in an injury
and 26% in a significant injury, defined as abrasion, cut, fracture or
two or more injuries. There were 82 falls on the DSF and 85 falls on
the regular floor. Patients in the dual-stiffness flooring rooms were
significantly younger and took significantly fewer medications; these
factors were thus treated as covariates in the analyses. There was a
marked tendency for residents falling on DSF to have less bruising
and abrasions, while having more redness and cuts. There were two
fractures on regular flooring (2.4% fracture rate) and none on the
DSF flooring (0% fracture rate). DISCUSSION: A 2.4% fracture
rate (as noted on the regular floor) is consistent with numerous incidence
reports in the literature; whereas a 0% rate (as noted on Smart-
Cells DSF floor) is a clinically significant improvement over prior reported
results. Both clinical findings and preliminary statistical trends
analysis suggest a positive effect of dual-stiffness flooring. This suggests
that DSF may be a practical approach for institutions and consumers
to reduce fall-related injuries. In contrast to other solutions,
like hip protectors, DSF requires no active client participation. A
large scale study to achieve sufficient statistical power to statistically
confirm these preliminary findings is warranted.
B163
Subcortical Hyperintensities and Outcomes of Targeted Gait
Interventions for Mobility Impairment.
N. K. Nadkarni, S. Perera, J. Brach, H. Aizenstein, C. Rosano,
S. A. Studenski, J. M. Van Swearingen. University of Pittsburgh,
Pittsburgh, PA.
Supported By: Source of funding: Pittsburgh Claude D. Pepper
Older American’s Independence Center grant (P30 AG024827)
Background: Gait interventions that incorporate motor-skill acquisition
are superior to standard therapy in improving mobility impairment
in elderly. Subcortical hyperintensities (SH), commonly
seen on brain MRI of older adults, are associated with impairments in
gait and executive function.
Objective: We examined whether regional SH volumes influence
gait outcomes from two types of gait interventions.
Methods: We analyzed data from a 12 week randomized trial of
community-dwelling older adults with mobility impairment receiving
two interventions: progressive strength, balance and endurance training
(I) vs goal-directed motor learning, adaptive stepping, pattern
walking and dual-tasking (M). A linear model was used to study the
relationship between pre- to post-intervention change in outcomes
(gait speed, double-support time, step-time, stance time variability)
with baseline SH in regions associated with executive function (anterior
prefrontal cortex (APC), dorsolateral prefrontal cortex
(DLPFC), ventrolateral prefrontal cortex (VLPFC), anterior cingulate
(AC), basal ganglia and posterior parietal cortex).
Results: Significant interactions emerged between right APC
SH and intervention on changes in gait speed (p=0.04), step-time
(p=0.001) and double-support time (p=0.01). With respect to steptime
change, significant interactions emerged for SH in left APC
(p=0.02), right and left DLPFC (p=0.03 and 0.02), right VLPFC
(p=0.04) and right AC (p=0.02) with intervention. In the I-group,
greater right APC and right AC SH were associated with poorer
changes in gait speed (p=0.005 and 0.02), double support time
(p=0.002 and 0.001), step-time (p=0.002 and 0.001) and variability in
stance-time (p=0.004 and 0.01). In the M-group, there were no significant
associations between changes in outcomes and SH in any of the
above brain regions.
Conclusion: Gait interventions that incorporate motor-skill acquisition
and dual-tasking may benefit older adults irrespective of SH
severity in brain regions linked to executive function while benefits
from impairment-based interventions may depend on SH burden in
these regions.
B164
Mood and Neurocognitive Measures to Predict Intake and Function
in Elderly in a Recuperative Care Unit.
P. R. Padala, 1,3 P. Dubbert, 1,3 K. P. Padala, 1,2 K. Garner, 1,2
R. A. Dennis, 1,2 M. Bopp, 1,2 D. H. Sullivan. 1,2 1. Geriatric Research
Education and Clinical Center, VISN16/CAVHS, North Little Rock,
AR; 2. Geriatrics, University of Arkansas for Medical Sciences, Little
Rock, AR; 3. Psychiatry, University of Arkansas for Medical Sciences,
Little Rock, AR.
Supported By: VA Health Services and Clinical Science Research
and Development programs (HSR&D IIR-04-298 and CSR&D)
and a University of Arkansas for Medical Sciences Tobacco
Settlement award
Background: Among older patients hospitalized for recuperative
care and rehabilitation, persistent anorexia and poor functional
rehabilitation are associated with high levels of inflammatory markers
and other indicators of illness severity at admission. It is not
known whether cognitive dysfunction or depression also contribute
to the persistent anorexia and poor functional outcomes.
Methods: This prospective study included patients over 64 years
admitted to a recuperative care and rehabilitation unit in a VA hospital
Community Living Center. Each subject’s daily total nutrient intake
from all sources was measured using a standardized protocol.
Depression was measured by the Geriatric Depression Scale-15 items
(GDS), apathy was derived from 3 items on the GDS related to motivation
(GDS-apathy), and executive function was measured by verbal
fluency, digit span and Florida praxis battery. Correlation analyses
were performed between the dependent variables of energy and protein
intake with independent variables of mood and neurocognitive
measures followed by regression analyses. T-tests were performed on
the neurocognitive measures based on if the subjects were apathetic
or not.
Results: 416 veterans were enrolled. Mean scores at baseline
were 3.7 (± 2.7) for GDS, 1.5 (±0.9) for GDS-apathy, 5.9 (±3.7) for
Verbal Fluency-F, 7.4 (±2.5) for Digit Span Forward, 4.6 (±2.2) for
Digit Span Backwards, 14.6 (±1.4) for Florida Praxis Battery, 83.8
(±35.7) and 59.7 (±23.6)for Average Energy and Protein Intake respectively.
Baseline measures of apathy, depression, executive function
did not predict either energy or protein intake. However baseline
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GDS and GDS apathy were negatively correlated to change in walking
and walking endurance. The impact of depression and apathy on
changes in walking endurance persisted even after controlling for
change in inflammatory markers. Apathetic patients when compared
to those without apathy had lower scores on verbal fluency (p=0.01-
0.04), and increased intake (0.02).
Conclusions: Depression and apathy scores but not neurocognitive
scores were strong correlates of change in measures of physical
function.
B165
Three, Five or Seven Days: How Much is Enough When Measuring
Physical Activity with an ActiGraph Accelerometer in Older
Adults?
S. J. Francois, S. A. Studenski, J. S. Brach. University of Pittsburgh,
Pittsburgh, PA.
Supported By: Research/Grant Support: K23 AG026766, P30
AG024827, T32 AG021885
Background/Aims: Accelerometers provide valid and reliable
measures of physical activity but have primarily been studied in
healthy, young adults. Little is known about the reliability or wear
time of accelerometers for measuring physical activity in older adults.
Current protocols suggest 7 days to provide the best estimates of
daily activity. Therefore, our goal is to assess the test-retest reliability
of the ActiGraph accelerometer in community-dwelling older adults
and determine if the number of days worn (3, 5, or 7) impact the testretest
reliability of the measure.
Methods: Participants included 32 community-dwelling older
adults (mean age 78.0 ± 5.5 years) who ambulated independently
(mean gait speed 0.96 ± 0.28 m/s). Physical activity was measured using
an ActiGraph GT1M accelerometer (ActiGraph LLC, Pensacola, FL)
worn on the waist during waking hours for 7 days. Subjects recorded
wear times of the accelerometer in a daily journal. Subjects wore the
accelerometers for another 7 days approximately 1 week later. Physical
activity was summarized for each time period as the mean counts
per minute per day (cpm) averaged over all 7 days, the first 5 days, and
the first 3 days. Paired t-tests were used to compare physical activity
measures from time 1 and time 2 and intraclass correlation coefficients
(ICCs) were calculated to estimate the test-retest reliability.
Results: The mean physical activity was similar for time 1 and
time 2 for 7 days (135.4 and 135.3 cpm), 5 days (127.6 and 133.1 cpm)
and 3 days (121.1 and 133.7 cpm); all p>0.15. The ICCs (95% CI) for
7, 5, and 3 days of wear were 0.93 (0.86, 0.97), 0.92 (0.83, 0.96), and
0.87 (0.73, 0.94), respectively.
Conclusions: Compared to previous research in communitydwelling
older adults (70+), the older adults in this sample demonstrated
slightly lower levels of physical activity. Test-retest reliability
for the ActiGraph accelerometer indicates moderate (3 days) to high
(5 and 7 days) agreement in this older adult population. Taking into
consideration accuracy of measurement and participant burden, our
initial recommendation is at least 5 days of wear. The impact of weekend
versus weekdays on physical activity measurement needs to be
examined in future studies of older adults.
B166
How Do Falls, Fear and Cognition Influence the Association
between Physical Performance and Self-Reported Function in Older
Adults?
V. A. Hornyak, 1 J. VanSwearingen, 1 D. Wert, 1 S. Studenski, 2 J. Brach. 1
1. Physical Therapy, University of Pittsburgh, Pittsburgh, PA; 2.
Geriatric Medicine, University of Pittsburgh, Pittsburgh, PA.
Supported By: Support: Pittsburgh Older American’s Independence
Center, 1 P30AG024827; Geriatric Academic Career Award
K01HP20478; K23 AG026766.
Background: Fall history, fear of falling (FOF) and cognitive
function associate with reported physical functioning but how they
influence the relation between physical performance and self-reported
physical function is not known. We examined the relation of
fall history, fear and cognition to reported physical functioning, controlling
for performance in older adults.
Methods: Older adults, independent in ambulation (n=70, mean
age, 77± 5.3 years) completed physical performance and self-reported
measures of function and cognition. The Late Life Function and Disability
Instrument (LLFDI) overall functioning was used to determine
physical function in daily life. Gait speed a performance measure
of physical function was determined from self-paced walking over
an instrumented walkway. Fall history and FOF were determined
from the participant’s report. Cognitive function was determined
using the Digit Symbol Substitution Test (DSST) and Trail-Making
Test B (Trails B), measures of executive cognitive functioning. Pearson
bivariate correlations were used to determine the relation between
age, gait and cognitive functioning with physical functioning
and define the related variables to include in the regression model. A
linear regression model was used to determine the relative association
of falls, fear and cognition to physical functioning, controlling for
age, gender and gait speed.
Results: Self-reported functioning (LLFDI) was related to gait
speed (r=.56, p

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ent effect of cardiopulmonary comorbidities on VTE. Secondarily, we
analyzed functional status expressed in a summary physical component
score (PCS) in a subset of patients for whom it was available.
Results: There were 24,051 THR and TKR surgeries performed
at the VA during the study period. COPD predicted a 24% increase in
VTE (OR=1.24, 95% CI 1.06-1.45). Low values of PCS, which was
available for 3256 patients, demonstrated a trend of increased risk of
VTE (lowest quartile OR =1.65, 95% CI 0.96-2.85 compared with
highest quartile).
Conclusions: COPD predicted a small increase in VTE whereas
low functional status appeared to increase the odds of VTE substantially.
Our findings suggest that cardiopulmonary comorbidities
should not be factored into decisions about prophylaxis but that functional
status probably should be assessed. More definitive conclusions
about the role of these comorbidities and functional status are
limited by typical constraints of administrative data analysis.
B168
Psychoactive Medications as Predictors of Post-operative Delirium
in Hip Fracture Patients.
A. L. Gruber-Baldini, 1 E. R. Marcantonio, 2 D. Orwig, 1 E. Barr, 1
N. Ma, 1 M. Terrin, 1 J. Magaziner, 1 J. L. Carson. 3 1. Epidemiology &
Public Health, University of Maryland School of Medicine, Baltimore,
MD; 2. Division of General Medicine and Primary Care, Beth Israel
Deaconess Medical Center, Boston, MA; 3. . Division of General
Internal Medicine, UMDNJ-Robert Wood Johnson Medical School,
New Brunswick, NJ.
Supported By: Supported in part by grants from the National Heart,
Lung, & Blood Institute: R01 HL085706, U01 HL073958 and U01
HL074815, by a National Institute on Aging training grant: T32
AG00262, and by funds from the Claude D. Pepper Older
Americans Independence Center, National Institute on Aging, P30
AG028747.Dr. Marcantonio is a recipient of a Mid-Career
Investigator Award in Patient-Oriented Research (K24 AG035075)
from the National Institute on Aging.
Delirium is common after hip fracture and is associated with
poor short- and long-term outcomes. Previous research suggests that
psychoactive medications may increase risk of delirium, and it is hypothesized
that anticholinergic medications may also increase delirium.
In this paper we examine the association of psychoactive medications
on delirium severity in 131 patients from the Transfusion
Trigger Trial for Functional Outcomes in Cardiovascular Patients Undergoing
Surgical Hip Fracture Repair(FOCUS) Cognitive Ancillary
Study, a randomized clinical trial examining the impact of blood
transfusion strategy on delirium. Medication administration records
24 hours before initial post-surgery assessment were coded by drug
class, and also using 3 scales which summarize anticholinergic effects:
Anticholinergic Drug Scale (ADS), Anticholinergic Risk Scale
(ARS), and Anticholinergic Cognitive Burden Scale (ACBS). Delirium
severity was measured 1-5 days post-surgery (Mean=1.8, SD=0.8)
using the Memorial Delirium Assessment Scale (MDAS) and delirium
presence using Confusion Assessment Method Diagnostic Algorithm
(CAM). Average age was 81.8 (SD=9.0), 74.1% female, and
90.8% white. The average number of psychoactive medications administered
24-hours before initial post-operative assessment was 1.7
(SD=1.8, range 0-8). Mean MDAS 7.1 (SD=5.3) and 29.8% CAM
delirium. Percentage on medications by class: antipsychotics 2.3%,
antidepressants 13.7%, opiates 0.8%, antihistamines 6.1%, analgesics
62.6%, sedative-hypnotics 10.7%, anticholinergics 5.3%, ADS 57.3%,
ARS 22.1%, ACBS 58.0%. The simple count of anticholinergic drugs
was significantly associated with MDAS delirium severity (r=0.22,
p=0.01), but none of the more complicated anticholinergic scales (all
r0.10). Number of opiates, antihistamines, analgesics, antidepressants,
and sedative-hypnotics was not associated with delirium
severity or presence. Greater antipsychotic medication use was associated
with worse MDAS delirium severity (r=0.18, p=0.03). Simple
counts of antipsychotics and anticholinergics in prior 24 hours were
associated with delirium after hip fracture surgery.
B169
Complications Following Cochlear Implantation in Older Adults.
D. M. Clarrett, 1 L. Li, 2 F. R. Lin. 3 1. University of Cincinnati College
of Medicine, Cincinnati, OH; 2. The Johns Hopkins Center on Aging
and Health, Baltimore, MD; 3. Otolaryngology-Head and Neck
Surgery, Johns Hopkins Hospital, Baltimore, MD.
Supported By: Medical Student Training in Aging Research
(MSTAR) program at Johns Hopkins University
Background: Cochlear implantation (CI) is a hearing rehabilitative
option for individuals with severe-to-profound sensorineural
hearing loss. However, older adults with hearing loss are infrequently
referred for CI, in part due to concerns about surgical risks and the
potential for poor recovery among older adults. The objective of this
study was to analyze the postoperative complications associated with
CI surgery in a large, consecutive case series of older adults (≥60
years) undergoing CI. Methods:The Johns Hopkins Listening Center,
the largest provider of cochlear implants in North America, maintains
a prospective database of all patients receiving cochlear implants at
Johns Hopkins. We queried this database to ascertain all individuals
≥60 years who underwent a first CI from 1999-2011. We then performed
a retrospective chart review of the electronic patient record
system at Johns Hopkins to abstract data on post-operative follow-up
and complications. Abstracted data were coded and validated by randomly
sampling 15% of the sample for repeat data abstraction. Statistical
analyses comparing observed frequencies were performed
using goodness-of-fit Fisher exact tests. Results: From 1999-2011, 445
individuals ≥60 years received a first cochlear implant at Johns Hopkins.
The mean age at implantation was 72.7 years (range 60-94.9
years) and the median duration of follow-up was 4.8 years (range 0.1-
12.5 years). There were a total of 42 minor complications (surgical
site infection, balance problems, delayed transient facial weakness, facial
nerve stimulation) in 41 patients (9.2%) and 36 major complications
(device failure, skin flap dehiscence, surgical device removal) in
21 patients (4.7%). There were no cases of meningitis or postoperative
facial paralysis. Seventeen patients (3.8%) required surgical device
removal. Complication rates did not differ between individuals

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status, procedure complexity, and the presence or absence of major
complications.
Results: 100,831 patients were included for analysis. In general,
advanced age was associated with increased preoperative comorbidities
and postoperative complications. After adjustment for these associations,
however, advanced patient remained an independent predictor
of overall and diagnosis-specific mortality and for
failure-to-rescue (mortality after the development of a major complication;
see Table). Of the 32 variables included for risk adjustment,
the strongest predictor of postoperative mortality for those patients
aged ≥80 years was the development of a major postoperative complication
(adjusted odds ratio 5.69, 95% CI 4.88-6.59).
Conclusions: Advanced age is an indepedendent predictor of
mortality after emergency general surgery, even after adjustment for
other known perioperative predictors. Failure-to-rescue is identified
as a primary reason for this increase in mortality. Efforts to improve
the outcomes of elderly patients needing emergent surgery should
focus on prevention of major postoperative morbidity.
B171
Age and Preoperative Geriatric Assessments in Predicting Surgical
Outcomes in a Prospective Study of Patients Undergoing
Pancreaticoduodenectomy.
J. A. Hemmerich, 1 K. K. Roggin, 2 A. M. Kamm, 2 E. Melstrom, 1
S. Wilson, 1 W. Dale. 1 1. Medicine, The University of Chicago, Chicago,
IL; 2. Surgery, The University of Chicago, Chicago, IL.
Supported By: The Michael Rolfe Foundation, Rita Meltzer, The
John A. Hartford Foundation
Drs. Hemmerich and Roggin are co-first authors.
Objective: Older patients with pancreas cancer are often not
considered for pancreaticoduodenectomy (PD) due to anticipated
perioperative complications and prolonged recovery. Pre-operative
geriatric assessment (GA) of vulnerability might better predict major
complications, readmissions, discharge site, and hospital stays. We
conducted a prospective study of GA in older patients who were undergoing
PD.
Methods: PD-eligible patients were enrolled into a single-site
prospective observational study. Preoperative GA included components
of Fried’s Model of Frailty (weight loss/weakness/self-reported
exhaustion), the Vulnerable Elder Survey (VES-13), the short physical
performance battery (SPPB). Socio-demographics, body mass
index (BMI) clinical characteristics (including co-morbidities), and
American Society of Anesthesiologist (ASA) scores were also collected
at baseline. Outcomes included graded surgical complications
(Clavien classification), length of hospital stay, discharge location
(home vs rehab) and 30-day readmissions. Linear and logistic regressions
were used to control for the influence of patient age, body mass
BMI, preoperative ASA score, and co-morbid burden.
Results: A total of n=76 had a PD (median age 68 years; range
36-88). Significant preoperative vulnerability was identified in the
sample: VES-13 >3 in 15.0%; SPPB

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80% show signs of this condition. The goals of treatment are pain reduction
and preservation of functional status. Treatment is often multimodal
including surgery and medications, such as NSAIDs and opioids.
Many of these options pose a significant risk of adverse events.
Therefore assessing the efficacy of noninvasive and “alternative”
treatments, such as acupuncture, should be a primary focus of research.
Acupuncture is a low risk and likely effective treatment for a
number of chronic conditions. It is growing in popularity in the public
consciousness. Ralph Gardner addressed this topic when writing in
the Wall Street Journal (October 27, 2011) of his mother’s “willingness
to undergo (this) treatment” for her neck pain. Given the suitability
of the elderly as a target population for acupuncture, our objective
was to determine if geriatric populations are represented in
clinical studies on this subject.
Methods: A PubMed search of the combined MESH terms
“acupuncture and pain” and “acupuncture and osteoarthritis” for articles
published between 1999 and 2011 found 4017 articles. Studies
were excluded if they were not clinical trials or were in a language
other than English. The final number of publications was 40, 37 of
which were controlled trials. An analysis was carried out to determine
how well the older population was represented.
Results: Osteoarthritis was the primary indication for acupuncture
treatment in 38% of all 40 trials, with the remainder of the studies
evaluating other pain syndromes and insomnia. 78% of the studies
identified fewer than 20% adverse events. Only 20% analyzed subjects
who were 65 years of age or greater. No studies analyzed subjects
of age greater than 85. 32% of the controlled studies reported an
improvement in more than half the subjects
Conclusions: The use of acupuncture has many advantages for
the elderly because it is noninvasive, poses low risk of side effects, and
frequently appears to be efficacious. In spite of these advantages,
acupuncture is insufficiently studied in the elderly, the population for
which it is likely most indicated.
of paramount importance to consider CAA prior to thrombolysis for
acute stroke in elderly.
Multifocal hemorrhages
C3
Thrombolysis Related Intracerebral Hemorrhage due to Cerebral
Amyloid Angiopathy.
A. S. Danve, S. P. Kulkarni, M. Belal, S. Anand, S. Awasthi, E. Roffe.
Internal Medicine, Metropolitan Hospital New York, New York, NY.
INTRODUCTION-
Intracerebral hemorrhage (ICH)is most feared complication of
thrombolysis for acute stroke.Cerebral amyloid angiopathy (CAA) is
a known risk factor for thrombolysis related ICH especially in elderly.
CASE-
A 90 year old woman developed acute onset right sided weakness
45 minutes prior to arrival to ER. She had hypertension,
Alzheimer’s dementia and mitral valve replacement. Her medications
included Coumadin, Namenda and hydrochlorothiazide. On examination,
patient had global aphasia and right hemiparesis. INR was
1.12 with normal CBC and metabolic panel. CT Brain did not show
any new infarct. Thrombolytic therapy was administered after neuro
evaluation. One hour later, patient became unresponsive and developed
decerebrate posturing. NIH score worsened from 13 to 36. Repeat
CT Brain showed multifocal bilateral cerebral and cerebellar
hemorrhages mainly at gray-white junction. Patient died 3 days after
supportive care in ICU. Retrospectively, she was diagnosed to have
underlying probable CAA (based on Boston Criteria) leading to
thrombolysis related ICH.
DISCUSSION-
CAA is heterogeneous disorder characterized by deposition of
Aβ fibrils in the walls of medium sized arteries in brain. Sporadic
CAA is common in elderly, its incidence and severity increasing with
age. It affects about 50 % of people above 80 years. In elderly, CAA is
important risk factor for thrombolysis related ICH. It is typically multifocal,
lobar, at corticosubcortical areas and associated with dementia.
Currently, there is no specific therapy available for treatment. It is
C4
A Case Report Of Lung Cancer With Metastasis To Pancreas.
A. Iraqi, T. Hughes. Syracuse VA medical center, Syracuse, NY.
Introduction: Lung cancer is the leading cause of cancer deaths
in the United States of America. It is broadly classified in two major
histological entities, small cell lung (SCLC) and non-small cell lung
cancer (NSCLC).SCLC is distinguished from NSCLC by its rapid
doubling time and early development of widespread metastases with
a propensity to spread to liver, adrenals, bone, bone marrow, and
brain. However, it is rare for lung cancer including SCLC to metastasize
to the pancreas. The usual histology of pancreatic cancer is adenocarcinoma
and rare to have small cell.
We describe a case of lung cancer which has metastasis to the
pancreas.
Case Description: A 77 year old male was hospitalized with
painless jaundice. He had elevated bilirubin of 13.6 ( ref. 0.1 to
1mg/dl ) with direct bilirubin of 10.4 ( ref. 0.0 to 0.5mg/dl) and alkaline
phosphatase of 208 ( ref. 50-136 units/L ). His medical history included
prior CVA, Atrial fibrillation, chronic kidney disease. Abdominal
sonogram showed a 5.5cm mass in the region of pancreatic head
with intra and extrahepatic biliary ductal dilation, no gall bladder
wall thickening. Abdominal CT confirmed a 5 mm mass at pancreatic
head with no evidence of masses outside the pancreatic head. He underwent
ERCP with sphincterotomy, brushing with cytology and
common bile duct (CBD) stenting. CBD and pancreatic duct brushings
cytology were benign. Subsequently, he underwent endoscopic
ultrasound with fine needle aspiration of the mass in the pancreatic
head, and pathology showed small cell carcinoma, and special stains
suggested against the diagnosis of lymphoma and melanoma. Following
this, CT thorax showed a mediastinal mass, and CT brain negative
for metastasis. Over time his condition declined and was complicated
by pneumonia, GI bleed, infective endocarditis, worsening kidney
function and intracranial bleed with metastasis to brain. With declining
condition he opted for hospice care.
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In this case it was thought that mediastinal mass is due to SCLC
with metastasis to pancreas, and that he does not have a primary pancreatic
cancer with metastasis to mediastinum or that he did not have
two primary cancers.
Conclusion: This case is un-usual as it is rare for lung cancer to
have metastasis to pancreas and it is also rare for primary pancreatic
cancer to be small cell.
C5
An Unusual Approach to Aggressive Behavior in Dementia
Patients.
A. I. Akintan, 1 V. Nurpeisov, 1 B. Patel, 2 N. Holland. 2 1. Geriatric medicine,
Emory University, Atlanta, GA; 2. Geriatric medicine, VA
Medical Center, Decatur, GA.
We recently saw an 85 year old gentleman in the geriatric clinic
with a past medical history of hypertension, osteoarthritis and dementia.
He has had Alzheimer’s dementia for the past four years with
increasing episodes of agitation. He was on the following medications;
Aspirin, Metoprolol, Donepezil, Memantine, Allopurinol,
Cyanocobalamin, Lisinopril, Furosemide and Acetaminophen.
In an attempt to decrease his polypharmacy his Allopurinol was
weaned off as he had no history of gout for the past five years. His aggressive
behavior increased shortly after stopping the Allopurinol
and this was subsequently restarted at the family’s request. His aggressive
behavior stabilized after restarting Allopurinol.
A review of the literature looking at Allopurinol in the treatment
of aggression in dementia revealed two case reports.
Allopurinol, a xanthine oxidase inhibitor decreases production
of oxygen free radicals and promotes accumulation of purines and
thus increases circulating pools of adenosine that may ultimately
have antipsychotic and anxiolytics effects.
We present this case as we feel that the possible association of
using Allopurinol in treatment of aggressive behavior in patients with
dementia is not well known.
This may offer an alternative therapy for aggressive behavior in
dementia patients who also have recurring gouty arthritis and may
prove useful with more studies in other patients with dementia and
aggressive behavior.
C6
Infection Associated Parasthesia: Case of “parasthesias gone wrong”
A. Itticheria, B. Setters, R. Gopalraj. Family & Geriatric Medicine,
University of Louisville, Louisville, KY.
Introduction: Parasthesia is a main symptom of stroke, TIA’s,
and other neurological conditions. Other underlying etiologies including
the possibility of an infectious process should also be considered.
Symptoms such as generalized or unilateral weakness, numbness
and tingling of the extremities and sensory deficits have been
seen in patients with acute infections.
Case Report: A 64 yo female with history of a right middle cerebral
artery stroke presented with acute left handed weakness that was
gradually worsening. This was associated with asthenia and dysuria.
Review of systems found stumbling and falls. Physical exam revealed
mild left sided facial droop, decreased sensation of the left side, including
face, arm and leg. Strengths were 5/5 and reflexes were 2+ bilaterally.
She was dehydrated, with mild renal insufficiency and hypotension.
A CT of the head was negative for any acute changes and
brain MRI was unchanged showing a previous full occlusion of right
cervical and intracranial internal carotid artery. EEG was also negative.
A diagnosis of urosepsis was made and the patient was started on
IV antibiotics and aggressive IVF hydration. With appropriate treatment
in the next few days her symptoms fully resolved and the patient
was discharged home.
Three months later, she presented to the office with generalized
weakness, tingling sensation in the fingertips of the right hand with
numbness, blurred vision of the right eye, and sinusitis like symptoms.
Again, her vital signs and exam were unremarkable, but given her history
she was admitted to the hospital for further evaluation where
MRI/A of the head showed no changes. She was diagnosed with acute
sinusitis and treated with oral antibiotics. Her symptoms immediately
improved and had resolved by the next day when she was discharged
home at her baseline functional status. On both hospital visits the
neurology consultant was not able to link any symptoms to a neurologic
diagnosis.
Conclusion: This case illustrates that paresthesias may not always
be due to the typical neurological etiologies. As such other
causes including infection must be considered and a comprehensive
history and exam must be completed. Infectious processes may mimic
such symptoms due to associated sepsis, fever, or dehydration.
Recognition and treatment of potential infections might be the unusual
but simple answer to a startling presentation of new onset
paresthesias.
C7
Case Report of a Purple Rash and Gum Pain.
A. Lum. Geriatric Medicine, University of Pittsburgh Medical Center,
Pittsburgh, PA.
Case Report
Lum, Albert. University of Pittsburgh Medical Center Geriatric
Fellow. Pittsburgh, PA
A 68 years old Caucasian female with complaints of burning
pain to her oral mucosa and gums off and on for 4 months seen at
an outpatient clinic. She described the pain as burning type especially
after eating hot spicy foods and worsened in the morning
when she brushes her teeth. She also noticed purple pruritic rash to
her hands started approximately same time as her gums. She had no
previous history of similar symptoms. Her past medical history include
GERD and borderline hypertension. She denies smoking, illicit
drugs and alcohol use. She lives alone and is not sexually active.
She is currently taking omeprazole 20mg daily for GERD and
started on lisinopril 5mg daily approximately 5 months ago.On
physical exam her vital signs were normal. Oral exam her buccal
mucosa and gums had shallow, tender, erythematous small erosions

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C8
Blisters from my surgery: clinical history helped by internet pictures.
A. I. Garrido, A. Chakka, T. Iloabuchi, F. Perez, A. Nazir.
Geriatrics/Internal Medicine, Indiana University-Geriatrics fellowship,
Indianapolis, IN.
84 y/o WF admitted to a sub-acute rehab. to recover from complication
from a total knee arthroplasty. PMHx. consists of DM, HTN,
anemia, HLD, CAD, COPD, CKD, anxiety, and Hypothyroidism.
After two weeks of successful rehabilitation, she developed blisters
in her extremities and torso, with no other symptoms. When the
blisters burst, they express a clear fluid, then crust and new blisters
appear in other parts of her body.
The patient was started on Prednisone while in the hospital but
no documentation was found regarding the reason for it. With further
interrogation, she stated that she had the blisters before and that
steroids usually improved them. Until then, since no documentation
found about her blisters, COPD exacerbations were the presumable
cause for her steroid treatments.
After reviewing and taking in consideration that the patient is a
female older than 60, with previous episodes of non-complicated blistering,
also that those blisters have responded to steroids treatment,
and finally and foremost after comparing her lesions with the ones
posted online in multiple sites Our patient was diagnosed with Bullous
Pemphigoid and started on a long prednisone taper after which
she improved and was successfully discharged home.
Discussion:
Bullous Pemphigoid is a fairly uncommon disease, but when
present is usually in elderly females, it is one differential diagnosis we
should think of when blisters are present in the elderly, followed by
Pemphigus (similar but less common blistering disease). The difference
between the two is auto antibodies to intradermal epitopes in
the latter vs. sub dermal auto antibodies in the former. Both have
been linked with higher risk of death, and this is why primary care
geriatricians and anyone taking care of the elderly should be vigilant
to diagnose and treat Bullous Pemphigoid, the treatment is mainly
wound care (treat like a burn) and oral steroids. Recurrence is common
and even longer steroid tapers might be required. Etiology is
not well understood but an autoimmune response is known. The diagnosis
is clinical. An association with some medications use is
known (Furosemide, Penicillamine, and Captopril –among the most
prominent-).
References:
1. Beth G Goldstein, MD, Bullous pemphigoid and other pemphigoid
disorders. Topic review/Uptodate 2011
2. González Ramírez A, Romero de Ávila AD, Mazoteras
Muñoz V, Rev Esp Geriatr Gerontol. 2011 Nov 16.
C9
When Safe is Really Sad: Omeprazole Induced Depression with
Psychotic Features.
A. Tucker, B. Setters. Family and Geriatric Medicine, University of
Louisville, Louisville, KY.
Introduction: Omeprazole, a proton pump inhibitor, is used to
reduce acid production and relieve symptoms associated with gastric
reflux disease and is considered highly effective with relatively few
side effects. As a result, it is considered a safe medication even for
elderly patients and those sensitive to other medication classes.
Case Report: A 70 yo female presented to the hospital with
complaints of confusion. She had developed an acute change in her
mentation with audio- visual hallucinations, delusions about her family
and severe depression with vegetative type symptoms including
anhedonia, anorexia and self-neglect which was very atypical for this
active, fully independent woman. She had been recently diagnosed
with Sjogren’s syndrome and had been referred for an endoscopy
after persistent complaints of stomach discomfort. She was diagnosed
with lower esophageal sphincter dysfunction and was started on
omeprazole and fluconazole for oral thrush. Within the next two
weeks, the patient’s mental status changed and she declined into a
vegetative state. Examination found an unkempt, withdrawn, nonverbal
woman fixated upon the death of her family and everyone around
her. She was very bradykinesic and her mental status was equally
slowed and impaired with a 20/30 MMSE score and a 2/4 clock drawing
and she was hyponatremic (sodium 128). Her medications
(omeprazole and losartan) save fluconazole were stopped for a medication
washout. A complete work up ensured due to concern over
acute mental changes; including CT and MRI of the head, EEG, lumbar
puncture, cultures, toxicology and viral screens were all negative.
Neuropsychological testing for dementia was also negative. As a result,
she was started on olanzapine. Her symptoms persisted and she
eventually required electroconvulsive therapy to restore her function
and reverse her depression. She responded immediately to the ECT
therapy and was able to return home to her active, independent,
happy life.
Conclusion: While cognitive changes and other psychological
symptoms such as depression and hallucinations have been reported
with proton pump inhibitors, they are very rare and often overlooked.
This case illustrates the importance of considering unusual pharmacologic
side effects as an underlying cause of acute psychotic and depressive
symptoms, especially in the elderly patient. If overlooked,
this patient may not have recovered.
C10
Follow the polypharmacy leader: medication induced heart block in
a frail elderly female after failed cardio version.
A. Burke, 1 B. Setters. 2 1. Internal Medicine, University of Louisville,
Louisville, KY; 2. Family and Geriatric Medicine, University of
Louisville, Louisville, KY.
Introduction: Physicians continue to treat elderly patients with
the same goals and protocols used for less complicated, younger patients.
Slowed physiological responses, normal aging changes and
often times frailty mean many elderly patients do not have the ability
to appropriately respond to acute illness. Medical comorbidities and
polypharmacy complicate this already convoluted treatment picture
and lead to unexpected adverse events.
Case Report: Mrs. M, a 71 year old female with a history of oxygen
dependent COPD, diastolic dysfunction, paroxysmal atrial fibrillation
(Afib) treated with cardioversion, obesity and diabetes, present
to the emergency department with “trouble breathing” and palpations.
EKG revealed Afib with a heart rate in the 120’s. She was admitted
to the hospital for rate control, management of mild COPD
exacerbation, and acute renal insufficiency (Cr 2.99; clearance 16
ml/min). Mrs. M’s baseline rhythm on previous EKG was sinus bradycardia
with a first degree AV block. Cardiology was consulted due to
her complicated heart history and propafenone (225mg three times
daily) and digoxin (0.125mg daily) were continued at home dosages
with an increase dose of metoprolol (100mg twice daily from 75mg
twice daily). Mrs. M then developed two episodes of unresponsiveness
and subsequent code despite having a DNR code status. After
the second episode of unresponsiveness, the continuous telemetry
monitor revealed a wide irregular complex bradycardia without evidence
of a p wave. The digoxin was held, a dig level checked and her
beta blocker stopped as it was determined she was experiencing erratic
complete heart block. She then has a pacemaker placed to control
her bradycardia and heart block while the medications cleared
her system. After her pacemaker placement, she did not experience
any additional episodes of unresponsiveness and was discharged back
to her nursing facility the following week after her renal function recovered
and her medication effects wore off.
Conclusion: In the elderly, medication titration and goals need
to be adjusted from traditional protocols used in younger patients.
With slower medication titration, reduction of polypharmacy, or decrease
doses of home cardiac medications, Mrs. M may have avoided
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the episodes of unresponsiveness, subsequent code and pacemaker
placement.
C11
Unmasking PTSD in Dementia.
A. H. Chodos, A. Moreno. Geriatrics, UCSF, San Francisco, CA.
Introduction: A new presentation of posttraumatic stress disorder
(PTSD) in the setting of cognitive impairment is increasingly diagnosed
in patients with a history of prior trauma. The effect on caregivers
is not well understood.
Case: Mr. H is an 89-year-old male veteran with hypertension
and glaucoma. At a primary care visit, he had a Montreal Cognitive
Assessment score of 12/30 (normal ≥26) but reported no functional
impairments. A social work and APS evaluation found his home to be
safe and that he lived with his frail wife.
Two months later he was seen by psychiatry, who noted a previous
diagnosis of PTSD two years earlier and that he had since fallen
out of psychiatric care. They documented a history of trauma during
early childhood and WWII. Mr. H reported ongoing symptoms of
nightmares, intrusive thoughts, insomnia and frequently checking the
house at night. He refused any medication.
A neuropsychological battery revealed impaired memory, language
and attention,consistent with dementia.Laboratory tests showed
a B12 of 196, and he was started on B12 supplement. A head MRI
showed volume loss and subcortical white matter hyperintensities.
A month later he presented three times to the ER for nonspecific
symptoms and weight loss, and was admitted on the last visit. He
was discharged home after his symptoms resolved without intervention.
Several days later, he presented to his PMD endorsing severe
anxiety, paranoia about his wife and suicidality. He was admitted to
psychiatry. His suicidality resolved but he remained paranoid about
his family. His providers discovered that prior to his presentation to
his PMD, he had been alone for three days after exhibiting anxious
and paranoid behavior that prompted a stepdaughter to remove his
wife from the home. His family has refused to participate further in
his care, and he awaiting guardianship in the hospital.
Discussion: Mr. H was diagnosed late in life with PTSD in the
setting of cognitive decline. His symptoms worsened as his dementia
progressed and his social environment became strained. His case
demonstrates that protective cognitive strategies may be affected in
dementia, unmasking PTSD symptoms. Evidence also suggests traumatic
memories are better encoded than others and may be preferentially
recalled as dementia impairs recent memory. Older adults diagnosed
with dementia require early social and psychiatric assessment
to prevent harms of unaddressed psychiatric disease, caregiver stress
and social vulnerability.
C12
Foot recognition following amputation.
A. Gupta, 1,2 M. K. Bautista, 1,2 M. Izhar, 1,2 F. Aziz, 1,2 R. J. Beyth, 1,3
K. M. Heilman. 1,4 1. GRECC, NF/SGVHS, Gainesville, FL; 2.
Department of Aging and Geriatrics, University of Florida,
Gainesville, FL; 3. Department of Medicine, University of Florida,
Gainesville, FL; 4. Department of Neurology, University of Florida,
Gainesville, FL.
Background: Studies of body knowledge and imagery may help
us understand disorders of the body schema such as phantom limbs
and anosognosia. Following limb amputation there are alterations of
a limb’s cortical representation. This case report attempted to learn if
shortly after an above-knee amputation of the right leg this patient
had a normal or impaired ability to recognize pictures of the right
versus left foot taken from different angles.
Methods: A 56-year right handed man with history of diabetes,
peripheral vascular disease and remote history of right side stoke 10
years ago without residual neurological deficits, developed a diabetic
foot ulcer of the right lower leg and underwent an above-knee amputation
of the right leg. Two weeks after surgery, the right-left foot
recognition task was performed. The patient was shown, in a random
order, a total of 24 images of either right or left foot at 12 different angles
for each foot, and was asked to tell the examiner as rapidly, but as
accurately as possible, if this picture was either the right or left foot.
The subject made 44 errors recognizing the picture of the right foot
and 44 errors recognizing the left foot. The mean reaction time for the
right foot was 1.60±1.19 seconds, and the mean reaction time for the
left foot was 1.52±1.28 seconds. There was no statistical difference in
terms of the reaction time or accuracy in identifying images of the
right foot compared to the left foot.
Discussion: Previous studies using a limb recognition task with
people who had a unilateral hand amputation and unilateral leg pain
revealed increased reaction time and decreased accuracy in identifying
images of the affected limb compared to the unaffected limb.
Contrary to these prior reports this patient with right leg amputation
revealed no difference in identifying images of the right compared to
the left foot. Cortical reorganization occurs over a period of time and
this patient was tested only two weeks after amputation. Further
studies are needed to learn if patients such as this develop an alteration
of their amputated limbs representation and if this interferes
with recognition.
C13
Hip fractures in Elders Nearing End of Life: Is There a Role for
Palliative Surgery?
A. R. Atreya, S. Arora, M. J. Brennan. Medicine, Baystate Medical
Center/Tufts Univ. School of Medicine, Springfield, MA.
Background:
There are 350,000 hip fractures in the US annually, with over
90% of them in elders. Most patients benefit from rapid surgical repair
but decision making can be complex near the end of life. The authors
present a case of a frail dementia patient whose precarious situation
and limited reserves posed a conundrum regarding surgical
repair of his fracture.
Case Report:
An 88 year old retired pediatrician (Dr. R.) with advanced dementia
was found lying on the nursing home bathroom floor. His history
included CAD, a CABG and AVR, DM and HTN. He had lost
weight due to dysphagia; his BMI was 15.6. He had an advanced dementia
and was cachectic, incontinent of stool and urine; and he slept
most of the day. Dr. R. needed assistance with all his ADLs. He still
was able to speak a bit and could walk short distances unaided. An X-
Ray confirmed an intertrochanteric fracture.
In the ER, he was anemic, hypotensive, in rapid AF and had a
creatinine of 1.5; he was admitted to the ICU. The critical care, medical
consult and orthopedic teams were divided about whether to
proceed to an ORIF. All agreed that Dr. R was high risk but some
MDs felt he would have less pain after surgery and that the mortality
risk was justified. Geriatrics was consulted to render an opinion regarding
“palliative” surgery and to guide the family through this complex
decision. The family reported that Dr. R. had always valued
quality of life and function highly. He had chosen to have a CABG
and AVR at an advanced age (despite the risks) to decrease symptoms
and improve QOL. The family decided to proceed to surgery
but overnight Dr. R. became stuporous, had an MI, developed pneumonia
and worsening renal failure. Thoughts of surgery were abandoned,
comfort measures intensified and Dr. R. died peacefully 3
days after admission.
Discussion and Conclusion:
A search of the medical literature yields little data on the palliative
outcomes of fracture repair for frail elders like Dr. R. High risk
surgery is unjustified unless there is a real potential palliative benefit.
If patients have better pain control, are able to transfer to chairs and
have a lower requirement for opiates with fewer drug side effects,
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then the palliative benefits may outweigh the medical risks. This glaring
gap in the evidence calls for a multispecialty collaborative research
effort involving geriatricians, palliative care physicians, hospitalists
and orthopedists.
C14
End-of-life Care in Patients with Advanced Dementia or Severe
Mental Retardation.
B. D. Putnam, 2 Q. Cao, 1 D. Russo. 1 1. Family Medicine, East Carolina
University, Greenville, NC; 2. Brody Medical School, East Carolina
University, Greenville, NC.
Objective 1:
Understand that patients with dementia or mental retardation
may not be able to make end-of-life decisions.
Objective 2:
Recognize the importance of a Health Power of Attorney
(HPoA), and the role it plays in end-of-life decisions regarding a patient
with dementia or mental retardation not capable of acting on his
or her behalf.
Objective 3:
Discuss a particular case in which extraordinary measures were
undertaken to preserve the life of such a patient and the ethical conflicts
that present to health care and behavioral health providers in
these situations.
Abstract:
End-of-life decisions for individuals with dementia or/and mental
retardation may present more complications and uncertainties
than for other patients. Patients who are severely mentally retarded
or demented may have an inability to express themselves in spoken
word or physical movements. Some have never had the mental capacity
to understand what their options are as the end of life approaches.
These decisions are often left up to the individuals named in their
HPoA, often a family member or caregiver. In one particular case, a
woman with severe cerebral palsy and mental retardation had been
treated for eight of her last ten months of life in the hospital after a
large portion of her bowel was resected secondary to obstruction. She
required resuscitation in the medical intensive care unit multiple
times, was maintained via Total Parenteral Nutrition for nine months,
experiencing frequent complications which eventually led to septic
shock and death. The patient’s caregiver, who held the HPoA, insisted
all life-preserving measures be taken and refused hospice or palliative
care despite the patient’s failing physical condition. Added to this
was the concern of her health care providers secondary to the caregiver’s
refusal to consider narcotic pain management for the patient.
The health care team was faced with many moral and ethical issues
including what it meant to “do no harm” or how to address decisions
affecting the patient that they did not believe would improve her care
or prognosis. Models for development of collaboration with medical
and behavioral health team members and those with the HPoA need
to be further developed to answer these difficult dilemmas.
C15
Acute heart failure in an elder with multimorbidities: the “nonlinear
patient trap.”.
B. Gao, 2,1 S. H. Gottlieb. 2 1. Geriatrics, Northeast Ohio Medical
University, Rootstown, OH; 2. Medicine, Johns Hopkins University
School of Medicine, Baltimore, MD.
Introduction: Acute decompensated heart failure (HF) is one of
the most frequent reasons for hospitalization among the elderly.
Studies show that HF is often preceded by 2 weeks of worsening
symptoms. Elderly patients may not seek timely treatment for their
HF because they don’t sense or understand the import of premonitory
symptoms. However, elderly patients often suffer from many interacting
problems that cause symptoms to present in a nonlinear,
rapidly evolving course that is difficult to anticipate.
Case: A 73 year old woman with hypertension, hyperlipidemia,
large B cell lymphoma treated with CHOP, right-sided pleural effusions
with pleurodesis, and type 2 diabetes, stopped taking her medications,
olmesartan and hydrochlorothiazide, 6 months before admission
because she was exhausted taking care of her sister who had Lou
Gehrig’s disease and because she ran out of money. Her symptoms of
dyspnea and fatigue increased slowly until one week before admission
when they became progressively worse; on the day of admission
her symptoms became unbearable over 4 hours; when she thought
that she was dying, she called 911 and was taken to the emergency
room. On admission, her echocardiogram showed an ejection fraction
of 20% and NT-ProBNP was 5,288 pg/ml. Troponin I was

P OSTER
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paralysis is seen for 36-48 hours then medical therapy is fully acceptable.
In conclusion, the clinical presentation of epidural abscesses is
often non-specific and should be investigated in atypical scenarios.
C17
Case Report: A primary mucinous adenocarcinoma with multiple
recurrences and a 24 year survival.
C. M. Espinal, 1,2 N. K. Patel, 1,2 R. W. Parker. 1,2 1. Geriatrics, University
of Texas Health Science Center at SA, San Antonio, TX; 2. Geriatrics,
Christus Santa Rosa, San Antonio, TX.
INTRODUCTION: Advanced stage mucinous carcinoma of the
ovary is very rare and is associated with poor overall survival. We report
a case of a patient who has survived 24 years since her diagnosis
of mucinous adenocarcinoma.
CASE REPORT: A 70 year old (y/o) hispanic female with a 24
year history of ovarian mucinous adenocarcinoma diagnosed at 46
y/o in Mexico(1987). She underwent exploratory laparotomy due to
recurrent abdominal discomfort, was diagnosed with mucinous adenocarcinoma
of the left ovary. The patient was managed with
oophorectomy and chemotherapy. Latter in the course of her disease
she had about six laparotomies for removal of recurrent abdominal
mucinous collections. The last recurrence was at the left pleural cavity.
She has three fistulas on her left upper back draining serous fluid
since 2009. The patient presented to our clinic with a desire for surgical
evaluation for possible closure of fistulas, to regain her quality of
life. She is limited in her socialization because of the fistulas and
drainage. A CT of the chest demonstrated prior surgeries as well as
lesions that extend beyond the pleura into the overlying chest wall.
She was referred to a surgeon experienced with the geriatric population
for management of the fistulas and also to an oncologist.
DISCUSSION: Primary mucinous tumors are classified into benign,
borderline, or malignant categories depending on their
histopathology characteristics. For women with regional and distant
disease, 5 year survival rates are 73% and 28%, respectively. These tumors
usually develop in the third to fifth decades of life and typically
cause vague symptoms, such as increasing abdominal girth, abdomino-pelvic
pain, fatigue, constipation, and urinary incontinence.
The patient started experiencing abdominal symptoms in her late
40’s. Fortunately she had appropriate management with frequent interventions
of her abdominal recurrence and pain management. Her
wishes have always been to be able to live and enjoy her family.
CONCLUSION: The survival rates for women with ovarian
cancer and distant-recurrent disease is low, but considering the benefits
versus the risk of cancer management, one should consider not
only the comorbidities and life expectancy but quality of life. The patient
and the family’s preferences should be an important part of the
decision making for the plan of care.
C18
Thirteen courses of ECT over 4 years in an Alzheimer’s patient. Is it
helping?
C. D. Teodoro, M. Leiding, M. Gorbien, J. Olson, M. Bednarczyk.
Section of Geriatric Medicine and Palliative Care, Rush University
Medical Center, Chicago, IL.
Purpose:
To highlight the need for evidence-based practice guidelines in
the use of ECT in persons with dementia and depression.
Background:
Electroconvulsive therapy (ECT) is a widely accepted treatment
for older adults with medication refractory depression. Although
evidence is limited, ECT is presumed to be effective in treating
depression in older adults with dementia. Because patients with
advanced dementia are difficult to interview, surrogate markers for
depression must be used, such as function, oral intake, agitation or aggression.
We present an extreme case of a woman with Alzheimer’s
dementia, who has required repeated admissions for ECT to treat
symptoms presumed to represent depression.
Method: Case report
Case Report:
Mrs. G. is an 81 year-old female with Alzheimer’s dementia, who
has been admitted to the gero-psychiatry unit thirteen times since
Aug 2007 with symptoms of severe anxiety, insomnia and anorexia.
Despite multiple pharmacologic therapies and use of outpatient
maintenance ECT, her depression continues to relapse. She received
a mean of 9 treatments per admission, a minimum of 7 and maximum
of 15. Along with improved sleep and oral intake, one of the clearest
indications ECT is helping Mrs. G. has been the condition of her knitting.
A life-long knitter, she is always admitted with balls of yarn, her
needles, and a hopelessly, tangled, knitted scarf. By discharge, her new
scarf has few to no errors.
Discussion:
In the case of Mrs. G., ECT appears to relieve her depression, albeit
temporarily. However, due to her dementia, ECT’s effect on cognition
cannot be fully evaluated. In addition, observation of surrogate
makers for depression by caregivers is subjective and difficult to standardize.
A review of the literature reveals retrospective chart reviews
and case reports describing ECT efficacy and purport its safe use in
the treatment of depression with co-morbid dementia. However,
these are limited in number, and descriptive in nature. While we acknowledge
ECT’s therapeutic benefit in depressed patients, its use in
those with underlying dementia still necessitates careful consideration
and selection of the patients to be treated.
C19
Alzheimer’s Disease versus Hippocampal Sclerosis (HS): Is There a
Clinical Imperative to Diagnose HS?
D. M. Otero, K. Sharma. Division of Geriatrics, Albert Einstein
College of Medicine, Montefiore Medical Center, Bronx, NY.
Hippocampal sclerosis (HS) is a pathologic term used to describe
severe loss of neurons and reactive gliosis in the hippocampus.
HS is associated with hippocampal atrophy, severe amnesia, and
slowly progressive dementia without clinical seizure activity. HS is
found bilaterally in 50% of cases and 25% on the right or left side
only. HS is difficult to distinguish clinically from Alzheimer’s disease
(AD) and is often diagnosed postmortem. In autopsy series, HS is described
in 1-5% of cases as an isolated diagnosis. However, HS has
been described in up to 26% of cases when it occurs in combination
with other vascular and neurodegenerative disorders.
Case: A 78 year old woman was evaluated because the family
had noticed changes in her behavior for 6 months. She had no significant
PMH or toxic habits. The patient, a retired book-keeper with a
high-school education, was no longer paying her bills, her house was
disorganized and dirty and she could no longer use the computer.
General PE: Unremarkable. Neurological: No focal signs. Psychiatric:
No signs or symptoms of depression or personality change. Mental
Status Testing: Clock Drawing Test: 3 (3 or > cognitive deficit); Mini-
Mental State Examination: 21/30. Laboratory data revealed normal:
chemistry, CBC, TSH, B12 and folate levels. Given the atypical presentation
and rapid deterioration, the patient was referred for neuropsychological
(NP) testing. NP testing revealed preserved insight.
Memory was markedly impaired for both verbal and nonverbal material.
However, she displayed a high level of nonverbal reasoning
which was unexpected given her marked memory impairment. Verbal
intelligence was near superior. The patient’s profound memory impairment
in the context of well-preserved reasoning ability is an unusual
profile for AD and HS was considered. MRI showed nonspecific
vascular changes which is often seen in HS.
Discussion: HS is distinguished from AD by the findings of preserved
reasoning in the setting of profound memory loss early in the
disease. HS is currently a pathological diagnosis however new research
suggests that HS can be diagnosed with NS testing.This case il-
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lustrates how HS and AD could potentially be differentiated clinically
in the earliest stages with NP testing. The etiology and clinical significance
of HS and its associated dementia has to be further elucidated.
C20
Looking Past the Dementia: Anxiety & Tachycardia Induced Seizure
in a Patient with Dementia.
D. Neamtu, L. Grooms, B. Setters. Family & Geriatric Medicine,
University of Louisville, Louisville, KY.
Introduction: Twenty five percent of new onset seizures occur in
individuals over 65 years of age and approximately one fourth of all
persons with epilepsy are elderly. Most seizures in elderly patients are
partial onset, with or without secondary generalization, and are underdiagnosed
especially in patients with dementia. Given the high
quality of life burden seizures cause, it is important to diagnose and
appropriately treat them even among frail elders.
Case report: A 79 yo female with a history of advanced dementia,
hypercholesterolemia, gastro-esophageal reflux disease, urinary
incontinence and osteoarthritis, living in a long-term care facility, had
a witnessed tonic-clonic seizure with no loss of consciousness while
ambulating in the hallway. After the episode the patient had garbled
speech and worsening confusion. By the time she was evaluated in the
emergency department, the aphasia resolved and no neurological
deficits were noted. Diagnostic studies including CMP, CBC, TSH,
toxicology and head CT were normal; EEG showed normal activity
save movement artifact. Telemetry during hospitalization, however,
found the patient was experiencing episodes of sinus tachycardia to
150 beats per minute during restful awake periods. She was unaware
of these symptoms and additional cardiac evaluation including an
echocardiogram was unremarkable. Careful investigation and observation
suggested a relationship between the patient experiencing extreme
anxiety or heightened awareness and resultant sinus tachycardia
which were decreasing cerebral flow and resulting in seizure
activity. The patient returned to the nursing facility with recommendations
for anxiety treatment as a first measure.
Discussion: Patients with dementia are at increased risk of
seizures. Approximately 15% of patients with Alzheimer’s Dementia
will develop seizures, a rate that is ten times higher than expected for
age. No clear etiology was found for the tachycardia occurring during
wakeful periods; this may be secondary to anxiety as postulated, but
may also occur from uncontrolled pain or dementia associated psychosis.
No signs of the latter etiologies were noted in this patient.
Given the high burden of seizures on quality of life even among dementia
patients and those with high comorbid diseases proper diagnosis
and treatment is very important.
C21
Does Living in a Family Slow Cognitive Decline in Dementia?
D. Basu, M. Brennan. Baystate Medical Center/Tufts Univ. School of
Medicine, Springfield, MA.
INTRODUCTION: Cultural norms and family structures may
slow the progression of dementia or even delay its onset. The authors
report a case of a Latino senior with dementia who remained cognitively
stable longer than anticipated due in part to the devotion of his
family.
CASE: In 2008, a 85 year old man with CHF, atrial fibrillation,
CKD, DM, PVD, gait impairment and memory loss for a year was
seen by geriatrics and diagnosed with a moderate stage mixed
Alzheimer’s and vascular dementia. As the years passed, occasional
restlessness, insomnia and hallucinations occurred and he was treated
for depression; occasionally low dose antipsychotics were prescribed.
Overall, he has responded well to reorientation, cueing and cognitive/social
stimulation by his devoted family who never leave him unattended.
His dementia has progressed but he remains verbal, interactive,
recognizes family and enjoys life despite many admissions and
functional decline. He recently even made a trip back to Puerto Rico
to visit relatives.
DISCUSSION: Epidemiological data indicates the incidence
and rate of dementia are higher for socially isolated elders. Studies of
African and Italian patients indicate that social integration and networks
and cognitively challenging leisure activities protect against
dementia and some research suggests that occupational therapy approaches
may slow cognitive decline for dementia sufferers. Emotional
support maintains cognitive reserves and enhances recovery in
stroke patients. However, a search of the literature using standard engines
such as pubmed and google scholar, found no studies analyzing
whether preserved family life can prevent or slow dementia’s inexorable
course.
CONCLUSION: Living with loving families provides personalized
care for frail elders and will decrease the public costs of health
care; strategies to support family-based care in the community thus
may improve quality of life while decreasing the state’s financial burden.
Additionally, elders living with families who involve them in decision
making, problem solving and ongoing social interaction will be
stimulated cognitively and may maintain intellectual reserves longer.
There is a glaring gap in the literature; studies must be done to clarify
whether family life delays the onset or progression of dementia. The
role of families in slowing cognitive decline in dementia patients is
critically important for the field of ethnogeriatrics.
C22
A Request by a Septuagenarian to Stay Young.
D. Chen, 1,2 R. S. Tan. 2,1 1. Medicine/Geriatrics, Baylor College of
Medicine, Houston, TX; 2. Houston VA, Houston, TX.
A 77 yo female asked that her last years be of quality. She had
no falls, incontinence, mood instability or memory loss. She requested
hormones be checked due to fatigue, bruising and weakness. PMH:
hysterectomy 40 years ago. She lives by herself, drives and walks 30
minutes daily. She was using no meds.
She had a weight of 125 pounds, height 5 feet 6 inches,
BP:110/70, MMSE:30/30, senile purpura in forearms, mild kyphosis,
genu varus of left knee. Cardio-respiratory exam normal. Body fat by
impedance: 26%.
Labs (with normal ranges): estradiol: pg/mL (>27); testosterone:
11 ng/dL (2-40); undetectable progesterone; IGF-1: 56 ng/mL (34-245,
Z score -1.1). CBC, glucose, cholesterol and TSH were normal. Mammogram
was normal.
After a lengthy discussion of safety and that we have no longterm
data to guide us, and documenting informed consent for offlabel
use, the decision was made to initiate hormone therapy. Reproductive
hormone replacement was achieved through compounding of
estradiol 1mg, testosterone 2 mg and progesterone 40 mg in a topical
gel applied daily. Growth hormone replacement was administered
subcutaneously, initially with 0.3 mg 3 times weekly, and later increased
to 0.5 mg eod, after titrating IGF-1 levels. Therapy was to be
combined with a supervised exercise regimen in the gym.
The patient was followed up monthly. At month 4, she reported
significant changes to her quality of life. Her bruising had disappeared.
She was mentally sharper and felt physically stronger, and
able to ambulate faster and longer. There was no numbness in the
hands, hot flashes or virilism. Physical examination showed redistribution
of body fat to lean body mass as evidenced by constant weight,
but lowering of body fat from 26% to 25%. Her grip strength significantly
improved for both hands (see table). Labs confirm elevation of
estradiol to 32 pg/mL, testosterone to 58ng/dL and progesterone to
1.3 ng/mL. IGF-1 levels remained the same, which may be reflective
of the conservative dosing.
This case illustrates that while considered non-mainstream by
some, geriatricians can help selected septuagenarians improve quality
of life with careful replacement of hormones with aging. Cost and
ethical concerns must be considered.
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A BSTRACTS
grip strength change before and after treatment
*p

P OSTER
A BSTRACTS
ratory symptoms such as stridor and airway compromise due to RA.
The patient in this case presented with dysphagia and dysphonia
without any other respiratory symptoms. Also, this case illustrates a
unique presentation of RA in which dysphagia was not only caused
by laryngeal dysfunction but also oropharyngeal dysfunction possibly
related to striated muscle involvement, a phenomenon that has not
been very well described. Further studies are needed to investigate
pathophysiology and treatment of dysphagia and dysphonia in patients
with RA.
C26
Stuck Between a Rock and a Bare Metal Stent: Triple
Antithrombotic Therapy Resulting in a GI Bleed.
F. Longenecker, 2 B. Setters. 1 1. Family & Geriatric Medicine,
University of Louisville, Louisivlle, KY; 2. School of Medicine,
University of Louisville, Louisville, KY.
Introduction: Although the standard of care for PCI with stent
placement and DVT prophylaxis for hip arthroplasty are individually
well established, little evidence exists about what to do for patients
requiring both treatments simultaneously. In such a situation the risk
of bleeding vs. the risk of thrombosis must be used to determine the
individual patient’s treatment course.
Case Report: A 79 y/o WF was admitted with an L femoral neck
fracture after being found down for 48 hours. Preoperative clearance
determined she needed a cardiac catheterization which found a 90%
occlusion of her LAD requiring placement of a bare metal stent. She
was started on clopidogrel and aspirin therapy post stent for a minimum
of 30 days. Discussion ensued with orthopedics and cardiology
about the timing of the patient’s orthopedic procedure now that she
was on anticoagulation. Orthopedics felt that the surgery could be
safely performed on anticoagulants and performed the surgery 3 days
post-stent. She was then started on fondaparinux for DVT prophylaxis
post hip repair.
The patient was discharged to a rehabilitation center four days
post operatively with instructions to monitor for bleeding; Hemoglobin
at discharge was 10.3. Nine days later, she returned to the hospital
with dark, tarry stools worrisome for a GI bleed. Hemoglobin was 7.2
and two units of blood were transfused and pantoprazole was started.
Cardiology was consulted and it was decided the patient would remain
on aspirin but fondaparinux were discontinued to allow for an
upper endoscopic evaluation which was done the next day. She was
diagnosed with antral erosive gastritis without active bleeding. Follow
up Hemoglobin was 9.4 and without evidence of further bleeding,
clopidogrel was resumed. She remained stable and was discharged
back to her rehabilitation center with instructions for continued monitoring
and has done well.
Conclusion: Patients with indications for both DVT prophylaxis
and dual antiplatelet therapy pose a great challenge. In approaching
such cases, providers must assess each patient’s risk and benefit profile
to determine appropriate treatment and monitor for increased
risk of bleeding when combining multiple anticoagulants. Additional
recommendation for treatment and bleeding risks in patients with
bare metal stents who need DVT prophylaxis would be useful for
these cases.
C27
Gastrointestinal Bleeding as a Consequence of Bisphosphonate-
Induced Musculoskeletal Pain.
J. Seguin, 1 F. Chang, 1 K. Yeung. 2 1. School of Pharmacy, University of
Waterloo, Waterloo, ON, Canada; 2. Geriatric Medicine, North York
General Hospital, Toronto, ON, Canada.
Background:
Non-steroidal anti-inflammatory drugs (NSAIDs) are common
causes of gastrointestinal (GI) bleeds in older adults. Bisphosphonates
are first line treatment for osteoporosis, a chronic disease with
increased prevalence with aging. This case discusses how an uncommon
adverse effect associated with bisphosphonate use can be an underlying
cause to GI bleeds in older adults.
Pertinent Case History:
DA, a 79 year old community dwelling woman, was admitted
through the emergency department with acute leg and knee pain and
black stools. She was anemic with low hemoglobin (81 g/L or 8.1
g/dL), but did not require a blood transfusion. Endoscopy revealed 4
small gastric ulcers. Her pain started about 2.5 weeks prior to admission
and she was prescribed naproxen 375mg twice daily as management.
This was switched to diclofenac 75mg twice daily with rabeprazole
5 days prior to admission; however, she did not discontinue
naproxen. Upon investigation, the acute pain started with the initiation
of risedronate 35mg weekly for osteoporosis. The NSAIDs were
discontinued in hospital, and lansoprazole was initiated with acetaminophen,
as well as ferrous gluconate. She was discharged home 4
weeks later, followed by 3 months of outpatient physiotherapy.
Conclusions:
This case illustrates how missed identification of drug-related
adverse events can be harmful for the patient. Potential drug-related
causes should be investigated prior to symptomatic treatment for
pain. Practitioners should consider bisphosphonates in addition to osteoporotic
pain in their differential diagnosis for musculoskeletal
pain in the elderly. While the cause and risk factors for musculoskeletal
pain induced by bisphosphonates remain unclear, one study has
suggested that the effect may be mitigated by starting patients on
low-dose daily treatment before starting the once weekly dose. This
case also reinforces the 2009 recommendation by the American Geriatrics
Society to avoid the use of nonselective NSAIDs and COX-2
inhibitors in the elderly with persistent pain without a compelling
reason, and to exercise extreme caution if used. In addition, patient
education and reinforced understanding are pertinent to avoid therapeutic
duplications particularly with switching between agents in the
same high risk medication class.
C28
Terminal Suffering: the Complex Interplay of Pain and Delirium at
End of Life.
G. Sachdeva, 1 M. Brennan. 2 1. Internal Medicine, Baystate Medical
Center / Tufts University School of Medicine, Springfield, MA; 2.
Internal medicine/Geriatrics division, Baystate Medical Center/ Tufts
University School of Medicine, Springfield, MA.
A 70 year old man (Mr. F.) had a complex cardiopulmonary history,
anxiety, chronic pain, dysphagia, recurrent pneumonias and a
vascular dementia. Home medications included clonazepam (4 mg
over the day) a 350 mcg fentanyl patch and methadone (15 mg total
daily). He was admitted with lethargy, weakness and confusion and
proved to have a new aspiration pneumonia. His two daughters were
PAs and along with a wife and son were closely involved in decision
making. When he aspirated yet again, all agreed to strictly comfort
goals; family was deeply committed to relieving Mr. F.’s suffering. Despite
explanations that much of his restlessness and moaning was due
to a terminal delirium, the family worried he was in pain and often
declined antipsychotic doses and requested changes in the analgesic
regimen. House officers and covering hospitalists were uncomfortable
with the doses and drugs being used but certainly did not want
the patient to suffer. At times drugs (e.g. methadone) were inappropriately
discontinued but sometimes they were increased too quickly.
One day an escalation of morphine despite renal failure led to early
signs of opioid toxicity and occasional myoclonus. On another occasion,
opioids were switched because fentanyl “wasn’t working.” In
fact, the patient’s restlessness was due to urinary retention and resolved
with a catheter. With careful communication, education and
frequent reassessment, symptoms were controlled and the family
comforted. Mr. F. died calmly several days later.
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Discussion/Conclusion
Distress at the end of life may be from treatable factors such as
urinary retention but often results from a complex interplay of delirium,
pain and psychosocial factors. Effective palliation requires a
multimodal approach targeting all sources of suffering. Geriatricians
and palliative care experts have much to learn from each other and to
teach trainees and hospitalists. To ease patients’ final hours and relieve
the guilt of families, the American Academy of Hospice and Palliative
Medicine and the American Geriatrics Society should collaborate
on educational and clinical initiatives on end of life care
C29
Galantamine Induced Generalized Myoclonus.
G. Luna, 1 N. Sharma, 2 J. Makela. 3 1. Geriatric, UIC, Chicago, IL; 2.
Geriatric, UIC, Chicago, IL; 3. Geriatric, UIC, Chicago, IL.
Supported By: No financial support provided
Introduction: Myoclonus is a brief, involuntary twitching of a
muscle or a group of muscles characterized by spastic-ballistic disabling
jerking movements. It describes a medical sign and is not itself
a diagnosis. While respiratory myoclonus associated with galantamine
has been previously described, generalized myoclonus second to
galantamine use has not been described before in the published geriatric
literature.
Case: A 87-year-old male with vascular dementia was started on
galantamine for dementia. Four months later, at 16mg dosing, the
caregiver reported that the patient started to experience a fine right
hand tremor, but refused further work-up at the time. The patient
continued on galantamine 16 mg. Nine months after galantamine
therapy was started, the patient came to the clinic complaining of a
new disabling movement disorder. The movements first started three
months previous, as infrequent, short, brief jerks. These episodes did
not follow a day cycle pattern or involve loss of consciousness. On
clinical exam, high amplitude, frequent, multifocal myoclonus was observed.
These jerks involved the whole body; however they were
more prominent in the upper extremities. After discussion with a
movement disorder specialist, who assisted in the assessment, galantamine
was identified as a possible cause of myoclonus. Subsequent
laboratory work-up for other causes was negative. Two weeks after
stopping galantamine all movement symptoms had successfully disappeared,
confirming the suspicion.
Discussion:
In the geriatric practice we see a number of conditions that can
cause generalized myoclonus. Few of these conditions are reversible.
This case report suggest that when we see a patient present with generalized
myoclonus we should consider the possibility of galantamine
induced myoclous, as it is easily reversible. It is important to note that
the development of myoclonus was not abrupt, as might be expected
in a drug reaction. Rather, the myoclonus worsened over the course
of several months while on treatment. However, the rapid resolution
of symptoms after galantamine withdrawal implicated it as a cause.
The insidious onset and progression of myoclonus, as seen in this
case, may hinder recognition of galantamine as a cause. We would encourage
physicians treating generalized myoclonus to consider galantamine
as a possible reversible cause.
C30
Bilateral pulmonary emboli in a patient with renal angiomyolipoma.
G. Ratnarajah, D. Seminara, A. Szerszen . Geriatrics, Staten Island
University Hospital, Staten Island, NY.
Renal angiomyolipoma is a benign hamartoma that can rarely
extend into the renal vasculature and subsequently into the inferior
vena cava (IVC) . An even more rare occurrence is embolism of the
tumor from the IVC into the pulmonary circulation
A 72 year old lady with a history of hypertension was found to
have renal insufficiency on routine evaluation by her private medical
doctor. Her physical examination was unremarkable and workup of
the renal insufficiency revealed a mass in the left kidney by ultrasound.
Further inquiry of this renal mass was undertaken with abdominal
computerized tomography ( CT ) scan which revealed a left
sided renal mass with extension into the left renal vein; a preliminary
diagnosis of renal angiomyolipoma was made. The scan also showed
suspicion for a loculated effusion of the left lung. A chest CT scan was
then performed to investigate the pleural effusion which incidentally
revealed bilateral pulmonary emboli. In addition, the right sided embolus
was seen to contain macroscopic fat.
On admission to the hospital, the patient denied any chest pain,
shortness of breath, abdominal pain, or hematuria. Her physical examination
was unremarkable with no signs of tachycardia, fever, hypoxia,
or petechiae. Her labs were significant for a glomerular filtration
rate of 39 ml/min/1.73 m 2 . An echocardiogram was performed
which revealed no signs of right ventricular strain pattern. The patient
was started on intravenous heparin and the decision was made to
bridge her with Coumadin therapy upon discharge. An open radical
nephrectomy was planned on an outpatient basis.
In conclusion, we present an asymptomatic elderly patient with
bilateral pulmonary emboli from renal angiomyolipoma. The extension
of renal angiomyolipoma into the renal vasculature is an uncommon
entity. In these patients, clinicians should be aware of the complication
of embolization and consider further workup to rule out
pulmonary embolism.
C31
Cerebral Infarction: A Rare Presentation of Cryptococcal
Meningoencephalitis in an Immunocompetent Patient.
I. P. Resurreccion. Medicine, UAB Montgomery, Montgomery, AL.
Cerebral cryptococcosis is common fungal opportunistic infection
in immunocompromised, but a rare disease in immunocompetent
patients. We report an unusual case of CNS cryptococcosis as
cerebral infarction in an immunocompetent patient.
A 78-year-old Caucasian male with hypertension, hyperlipidemia
and osteoarthritis was admitted with confusion, left-sided
weakness, dizziness, falls, headache and anorexia. No head trauma nor
fever. On physical, he was disoriented to time and place and decreased
strength on the left side with preserved sensation. Brain CT
was negative. Brain MRI showed subacute infarct in anterior right
middle cerebral territory. Lumbar puncture had normal opening pressure,
showed 18 WBC with 100% mononuclears, high protein
82.5mg/dL, low glucose 18mg/dL, positive India ink and cryptococcal
antigen titer 1:1024. CSF culture grew Cryptococcus neoformans.
HIV screening was negative. Induction therapy initiated with liposomal
amphotericin and flucytosine. He continued to have altered mental
status and headache. He was planned for another lumbar puncture
every 2 weeks or earlier to relieve headaches. He continued to deteriorate
with multi-organ failure and died.
Cerebral infarction is an unusual presentation of CNS cryptococcosis.
Rarely, cryptococcus can cause cerebral infection in immunocompetent
patients. Manifestations include fever, headache, altered
mental status, personality changes and memory loss. Lumbar
puncture is useful for diagnostic and therapeutic. Opening pressure is
elevated and CSF has elevated protein, low glucose with positive
India ink stain, cryptococcal antigen titer and culture. Treatment includes
induction therapy with amphotericin B and flucytosine. Duration
in patients without neurological complications with a negative 2
week CSF culture is 4 weeks and in patients with neurological complications
is 6 weeks. Consolidation therapy with fluconazole is 8
weeks. Maintenance therapy is 6-12 months. The incidence of cerebral
infarction due to cryptococcal meningitis in HIV-negative patients is
4%. Mechanisms include antigen-antibody complexes with vasculitis
and direct toxic effects of viral antigen on vascular endothelium. Poor
prognostic factors are cerebral infarcts, high opening pressure, CSF
WBC

P OSTER
A BSTRACTS
antigen >1:32. Early diagnosis and appropriate management is crucial
to reduce the high morbidity and mortality with CNS cryptococcosis.
C32
WEIGHT LOSS ASSOCIATED WITH SWITCHING
CHOLINESTERASE INHIBITORS.
J. T. Stewart, 1,4 I. Sheyner, 2,5 L. V. George, 3 K. M. Mattox, 3
K. T. Stover. 2 1. Psychiatry, James A Haley VA Hospital, Tampa, FL; 2.
Geriatrics, James A Haley VA Hospital, Tampa, FL; 3. Pharmacy,
James A Haley VA Hospital, Tampa, FL; 4. Psychiatry, University of
South Florida College of Medicine, Tampa, FL; 5. Geriatric Medicine,
University of South Florida College of Medicine, Tampa, FL.
Supported By: There was no funding or other support for this work.
BACKGROUND: Weight loss is common in dementia, leading
to poor quality of life and increased mortality. Weight loss is reported
in up to 20% of patients receiving cholinesterase inhibitors. It is not
known which of these agents are more likely to cause weight loss, nor
whether patients who have lost weight on one agent can be treated
with another.
METHODS: Case report, literature review.
RESULTS: An 86 year old man with vascular dementia had
been treated with donepezil for six years; he had improved cognitively
and had never experienced any nausea, anorexia or weight loss.
Galantamine SR was substituted in 2010. Over the next 17 months he
and his daughter reported poor appetite and a loss of 48 pounds.
There was no nausea or vomiting. Ultimately donepezil was reinstated.
His appetite returned and he regained 30 pounds over the
next three months (Figure).
CONCLUSIONS: Cholinesterase inhibitors have modest benefits
in dementia but are not without risk. Weight loss in dementia can
have catastrophic effects on health and quality of life and a reasoned
risk-benefit analysis is essential in all prescribing. The literature does
not guide the clinician when a patient has clear benefit from a
cholinesterase inhibitor but also develops significant weight loss. This
case suggests that weight loss from one agent does not necessarily
predict weight loss from other agents in the class and that switching
to a different agent may be a reasonable strategy. It is not known
whether galantamine is more likely to cause weight loss than other
agents, nor whether its secondary effect of modulating nicotinic receptors
is salient; controlled studies will be necessary to examine
these questions.
C33
A PILOT RANDOMIZED TRIAL OF A BEHAVIORAL SLOW-
BREATHING INTERVENTION TO TREAT URGENCY
INCONTINENCE IN WOMEN.
A. Huang, D. Grady, A. Appa, S. Leslee. University of California, San
Francisco, CA.
Supported By: National Institutes of Health
Background: Urgency urinary incontinence affects up to a quarter
of middle-aged and older women and can have profound adverse
effects on functioning and quality of life. Existing anti-cholinergic
treatments for incontinence are associated with frequent side effects
and high rates of discontinuation in the community. Multiple studies
have indicated that urgency incontinence is associated with increased
levels of perceived stress as well as abnormalities in autonomic nervous
system activity, suggesting that behavioral relaxation interventions
that reduce stress and improve autonomic balance may be helpful
in alleviating this condition.
Methods: Pilot feasibility randomized trial in 20 ambulatory
women with ≥7 episodes of urgency incontinence per week and no
major urologic or neurologic co-morbidities. Women were randomized
to use a portable guided-breathing device (RESPeRATE) to
slow their breathing to

P OSTER
A BSTRACTS
Results: Of 1401 subjects screened at 109 sites, 562 (40%) were
eligible and enrolled. The most common reasons for exclusion were
not meeting VE criteria (226; 27%), low creatinine clearance (114;
14%), and/or too few UUI episodes (82; 10%). 446 subjects (79%)
completed the trial; 116 (21%) discontinued (Table 1). Drop-outs related
to study drug were 8%. Recruitment challenges included access
to fesoterodine without trial participation and subject concerns about
randomization to placebo.
Conclusions: Enrolling/retaining VE in an AM trial is feasible,
with a trial cost of ~$8M. Despite subject vulnerability, retention was
good and drug-related withdrawals were low. Future improvements
for VE trials include allowing assistance with questionnaire completion
and use of home and phone visits for safety assessments and follow-up,
making participation more convenient and less burdensome.
Table 1. Reasons for Subject Discontinuations.
C35 Encore Presentation
Central Nervous System (CNS) Penetration and Memory Effect:
Trospium Chloride vs Oxybutynin in Adults with Overactive
Bladder and Age-Associated Memory Impairment.
C. Tannenbaum, 1 D. Staskin, 2 G. Kay, 3 H. B. Goldman, 4 W. Tong, 5
R. K. Patel. 5 1. Department of Geriatric Medicine, Institut
Universitaire de Gériatrie de Montreal, Montreal, QC, Canada; 2.
Department of Urology, Caritas St. Elizabeth’s Medical Center,
Boston, MA; 3. Cognitive Research Corporation, St. Petersburg, FL; 4.
Glickman Institute, The Cleveland Clinic, Cleveland, OH; 5. Allergan,
Inc., Irvine, CA.
Supported By: Funding for this work was received from Allergan, Inc.
Background: Anticholinergic agents can affect memory due to
CNS penetration, which allows for muscarinic receptor binding in the
brain. Older adults with age-associated memory impairment may be
especially vulnerable. Antimuscarinic agents most likely to cross the
blood-brain barrier are lipophilic tertiary amines. Quaternary amines
are far less lipophilic. This double-blind, placebo-controlled trial
(SMART II) is the first to compare cerebrospinal fluid (CSF) permeation
and memory effects of a quaternary (trospium) and tertiary
(oxybutynin) amine in older adults with overactive bladder and ageassociated
memory impairment.
Methods: Adults ≥60 years were randomized to receive extended-release
(XR) trospium 60 mg QD for 10 days (n=6), or immediate-release
(IR) oxybutynin 5 mg TID for 2 days (n=10). Overactive
bladder was defined by ≥8 voids/day with ≥1 associated with urgency.
CSF was drawn at selected timepoints for bioanalysis. Memory was
measured at baseline and at post-dose plasma steady state using the
Hopkins Verbal Learning Test-Revised (HVLT-R) for total and delayed
recall.
Results: Oxybutynin was detected in the CSF in all oxybutynin
IR subjects (mean age: 68 years; range: 60-76 years). Mean CSF
AUC 0-tau
values were 0.204 ± 0.089 and 1.68 ± 1.06 ng*hr/mL, for oxybutynin
and desethyloxybutynin, respectively. CSF concentrations of
trospium were below the lower limit of quantification of 40 pg/mL at
all timepoints for all trospium XR subjects (mean age: 74 years;
range: 67-84 years). Increased memory impairment on the HVLT-R
delayed was seen with oxybutynin IR (mean baseline score, 9.4; mean
change from baseline, -1.3; p=0.03). Trospium XR had no deleterious
effect on memory (mean baseline score, 8.2; mean change from baseline,
-1.2; p=0.11).
Conclusions: In older adults with overactive bladder and age-associated
memory impairment, oxybutynin and desethyloxybutynin,
but not trospium, were detected in the CSF at steady state. Memory
worsened in adults receiving oxybutynin IR, but not trospium XR.
C36
Falls Assessment In Older Patients Treated With Duloxetine.
C. Nelson, 1 T. M. Oakes, 2 P. Liu, 2 J. Ahl, 2 M. E. Bangs, 2 J. Raskin, 3
D. G. Perahia, 4,5 M. J. Robinson. 2 1. University of California, San
Francisco, CA; 2. Eli Lilly and Company, Indianapolis, IN; 3. Eli Lilly
Canada, Scarborough, ON, Canada; 4. Lilly Research Center,
Windlesham, Surrey, United Kingdom; 5. The Gordon Hospital,
London, United Kingdom.
Supported By: Eli Lilly and Company and subsidiaries, Indianapolis,
IN, USA
Background: In an analysis of spontaneously reported treatment-emergent
adverse events in older patients (≥65 years) (N=3278)
from all placebo-controlled trials across indications, 1.1% of patients
treated with duloxetine had one or more falls compared with 0.4% of
patients treated with placebo. Methods: This was a secondary analysis
of falls data collected at each study visit using a specific soliciting
questionnaire during a 24-week, double-blind, randomized, placebocontrolled
trial of duloxetine for treatment of major depressive disorder
(MDD) in older patients. Patients were randomized to duloxetine
60 mg/day (N=249) or placebo (N=121) for the first 12 weeks (acute
phase), after which the duloxetine dose could be increased and
placebo patients could be switched to duloxetine if not responding.
The difference in frequency of falls with duloxetine treatment vs.
placebo was compared by Fisher’s exact test. The exposure adjusted
incidence rate (EAIR) of falls per patient-year was also estimated
based on the patient’s actual duration of exposure to drug or placebo.
Results: The percentage of patients with a fall in the acute phase was
17.3% with duloxetine 60 mg vs. 11.6% with placebo (p=.170). Over
24 weeks, the percentage of patients with a fall was significantly
higher with duloxetine 60/120 mg (25.3%) vs. placebo (15.7%,
p=.045), and the percentage of patients with a fall while taking duloxetine
60 mg during the 24-week study was 24.1% vs. placebo (15.7%,
p=.078). The EAIR of falls per patient-year during the acute phase
was 0.95 with duloxetine 60 mg and was 0.69 with placebo. Over 24
weeks, the EAIR was 0.79 with duloxetine 60 mg and was 0.54 with
placebo. Between-treatment differences in EAIRs over 12 weeks
(0.26; 95% confidence interval [CI]: -0.20 to 0.72) and over 24 weeks
(0.24; 95% CI: -0.07 to 0.56) were not significant. Conclusions: Although
the EAIR of falls per patient-year associated with duloxetine
treatment was not significantly different than with placebo in this
trial of elderly patients with MDD, the overall higher frequency of
falls during treatment with duloxetine suggests that the increase in
falls may be duloxetine-related.
C37 Encore Presentation
Factors Influencing Time to Resolution of Diarrhea in Patients with
Clostridium difficile Infection Treated with Fidaxomicin or
Vancomycin.
D. Gerding, 1 D. Crook, 2 M. Miller, 3 T. Louie, 4 O. Cornely, 5 T. Peto, 2
S. Gorbach. 6 1. VA Chicago Health Care System, Chicago, IL; 2.
University of Oxford, Oxford, United Kingdom; 3. McGill University,
Montreal, QC, Canada; 4. University of Calgary, Calgary, AB,
Canada; 5. University Hospital of Cologne, Cologne, Germany; 6.
Optimer Pharmaceuticals, Inc., San Diego, CA.
Supported By: This study was funded by Optimer
Pharmaceuticals, Inc.
Background: TTROD, an important endpoint for patients, varies
considerably among CDI patients even when treated with effective
antibiotics. We sought to identify factors that influenced TTROD in a
database of 1105 patients enrolled in two phase 3 studies and treated
with FDX or VAN.
Methods: Patients with CDI confirmed by positive stool toxin
test were randomized to receive oral FDX (200 mg twice daily) or
oral VAN (125 mg 4 times daily) for 10 days. TTROD was determined
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in hours from first dose of study drug to the time of last unformed
bowel movement. Survival functions were estimated by the Kaplan-
Meier product-limit method with log-rank and Wilcoxon tests to test
equality across strata for each parameter at α=0.05.
Results: Diarrhea resolved 24 h later in patients infected with
the REA type BI strain (median TTROD 78 h; [95% CI [61, 103])
than non-BI strains (54 h, 95% CI [51, 57]); Kaplan-Meier analysis
confirmed the difference (log-rank p24 h difference and
log-rank P

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Results: Regional anesthesia as compared to general anesthesia
did not carry excess mortality risk in elderly patients 90 and above (p
= 0.43). There was no association between the type of anesthesia used
and the rate of post-operative complications. The relationship of age
and the type of anesthesia used were also considered. Within this age
group, the choice of anesthesia did not seem to depend on a patient’s
age (p = 0.51).
Conclusion: The type of anesthesia, whether regional or general,
does not affect outcomes in elderly patients undergoing surgery for
hip fractures. Therefore, greater utilization of regional anesthesia in
this population may be a cost effective option, as it deters the need
for extensive preoperative evaluations.
C41
Translating Geriatric Assessment into Community Oncology Clinics:
Comparative Results.
G. R. Williams, 1 A. Deal, 2,3 T. Jolly, 4 S. Alston, 2 B. Gordon, 2 J. Pan, 2
A. Caprio, 1 S. Moore, 5 W. Taylor, 6 H. Muss. 2,4 1. Division of Geriatric
Medicine and Center for Aging and Health, University of North
Carolina at Chapel Hill, Chapel Hill, NC; 2. Lineberger
Comprehensive Cancer Center, University of North Carolina at
Chapel Hill, Chapel Hill, NC; 3. Biostatistics Core Faculty, University
of North Carolina at Chapel Hill, Chapel Hill, NC; 4. Division of
Hematology / Oncology, University of North Carolina at Chapel Hill,
Chapel Hill, NC; 5. Rex Hematology Oncology Associates, Raleigh,
NC; 6. New Bern Cancer Care, New Bern, NC.
Supported By: Supported by University Cancer Research Fund,
Lineberger Comprehensive Cancer Center, Chapel Hill, NC
Background: Emerging results support the value of geriatric assessment
(GA) in determining the risk and benefits of cancer treatment
in older adults. A brief GA tool consisting of valid and reliable
measures has been developed (Hurria et al, J Clin Oncol 29:1290,
2011), but little data exist on the GA of elderly patients in the community.
This study compares the differences between geriatric oncology
patients at academic versus community based oncology practices
in North Carolina.
Methods: From 2009 to 2011 a total of 386 patients were recruited.
283 (73%) were from a tertiary care referral cancer center
(UNC) and 103 (27%) were from community clinics. The two groups
were compared using Fisher’s Exact and Wilcoxon rank sum tests.
Results: Community clinics enrolled older patients (p= 0.004),
with 52% being ≥ 75 years of age, compared to only 33% at UNC. The
Karnofsky performance status as rated by medical staff was significantly
lower at community clinics (60% vs 25% with a score ≤ 90%;
p= 65 years of age hospitalized with pneumonia during fiscal
years 2002 to 2007 in Department of Veterans Affairs hospitals.
Our primary analyses were multilevel regression models that examined
the association between cardiovascular medication classes and
either 90-day mortality or cardiovascular events within 90-days after
adjusting for potential confounders.
Results: Our cohort included 50,064 patients with a mean age of
77.3 years, 98% were male, 23% died within 90 days of admission, and
38% had a cardiac event. Medications associated with decreased
mortality include beta-blockers (OR 0.92, 95% CI 0.87-0.97), statins
(OR 0.67, 95% CI 0.63-0.70), ACE inhibitors (OR 0.81, 95% CI 0.76-
0.86), and ARBs (OR 0.61, 95% CI 0.53-0.70), but an increased number
of cardiovascular events: beta-blockers (OR 1.15, 95% CI 1.10-
1.21), statins (OR 1.02, 95% CI 0.98-1.07), ACE inhibitors (OR 1.14,
95% CI 1.09-1.20), and ARBs (OR 1.20 95% CI 1.08-1.33).
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Discussion: While cardiovascular medications were associated
with decreased mortality, there was an association with increased
with increased number of cardiovascular events. These results indicate
that cardiovascular medications may have beneficial effects for
the outcomes of patients admitted with pneumonia however not due
only to cardioprotective effects.
C44 Encore Presentation
Lower diastolic blood pressure and increased heart rate are
independent predictors of mortality for 1 year in elderly outpatients:
Data from Frailty in elderly with cardiovascular disease.
A. R. Diniz, A. Frisoli, E. T. Pinto, J. D. Majeski, M. Erlichman,
A. C. Carvalho. UNIFESP- Escola Paulista de Medicina, São Paulo,
Brazil.
Introduction: Increased heart rate (HR) is risk factor for cardiovascular
mortality. Elevated values of diastolic (DBP) and systolic
blood pressure (SBP) have been associated with the same outcomes.
The predict outcomes of low values of DBP and SBP with increased
HF has been poor clarified in elderly.
The goal of this study was to evaluate the association of increased
HR, lower DBP and SBP with mortality for 1 year in elderly
outpatients.
Methods: cross sectional analysis of data from an observational
study of epidemiology of frailty in elderly outpatients with cardiovascular
diseases. DBS, SBP and HF were obtained with the median of
three measures at the first visit. Diagnoses of Heart failure were
made with ejection fraction higher (diastolic heart failure-DHF) or
lower than 50% (systolic heart failure-SHF) and the presence of signs
and symptoms of heart failure (NYHA). Mortality information was
obtained by phone call at 6, 12, 18 and 24 months after.
Results: On May, 2011, 103 patients reached 1 year or died.
74.5% had heart failure, which 48.4% DHF and 51.6% SHF. Female
was 60.2% (n=62) prevalent. The mean age of men was 76.05 (±5.0)
and women 77.71 (±5.5) years old. 60% were Caucasian. Mortality
rate was 8.7% (n=9), which 66.7% had heart failure and 50% DHF.
Among patients who died SBP (119 vs 141mmHg; 0.028) and DBS
(68 vs 88mmHg; 0.003) were significant lower, and HR (96 vs 69bpm;

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Conclusions: Conclusions: The results indicate that there may be
a single factor underlying the responses to OHIP-14 questions in
these older adults. The ohip-14 seems not to represent seven separate
dimensions of oral health as originally devised.
C47
Mexican-American Elder Post Hip Fracture Survival Study.
D. V. Espino, 1,2 R. C. Wood, 1,2 C. C. Moore. 2,1 1. Family and
Community Medicine, University of Texas Health Science Center at
San Antonio, San Antonio, TX; 2. School of Medicine, University of
Texas Health Science Center at San Antonio, San Antonio, TX.
Supported By: National Institute of Health (NIH)
American Federation for Aging Research (AFAR)
University of Texas Health Science Center at San Antonio
(UTHSCSA)
As the world’s population is shifting to an older age due to advances
in medical care, increased numbers of hospital visits, especially
for geriatric hip fractures, are being documented. Despite the
vast research conducted on hip fractures in general, little emphasis
has been made on the effects of hip fractures on Mexican-Americans.
The Hispanic Established Populations for the Epidemiologic
Study of the Elderly (H-EPESE) compiled data on risk factors for
morbidity and mortality in Mexican-Americans used to create a
community-based survival analysis of geriatric hip fractures. The H-
EPESE began in 1993 with a contingent of 3050 individuals and is
currently on the seventh wave of the study. Using a Cox Model Regression
Survival Analysis program, significance (p65), gender and presence or
absence of Type II Diabetes Mellitus creating a drastic influence on
mortality rates. Over a 7 year span after sustaining a hip fracture, a
patient meeting the appropriate risk factors noted above had an approximate
fifteen percent increased risk for mortality than a patient
not meeting the criteria. Factors influencing the comorbidities,such
as: osteoporosis in the elderly, post-menopausal hormone imbalances
in women and peripheral neuropathy associated with Type II
Diabetes Mellitus were investigated as contributors to the increased
mortality rates. While this study does not cover the entire spectrum
of comorbidities associated with increased geriatric hip fractures in
the Mexican-American population, it does attempt to bridge the literature
gap associated with the Mexican-American minority and
create interest for expanding the literature for this subset of the
population.
C48
Lifetime Manic Spectrum Syndromes and All-Cause Mortality: A
26-year Follow-Up of the US National Epidemiological Catchment
Area Study.
C. Ramsey, 1 A. P. Spira, 1 W. W. Eaton, 1 H. B. Lee. 2,1 1. Mental Health,
Johns Hopkins Bloomberg School of Public Health, Baltimore, MD;
2. Psychiatry, Yale University, New Haven, CT.
Background: Increasing evidence suggests a high prevalence of
bipolar spectrum disorders, associated morbidity and mortality.While
research supports the association between depression and mortality,
the role of mania has received less attention. This analysis evaluated
the association between manic spectrum syndromes and risk of mortality
in the community. Methods: Participants in the prospective US
National Epidemiological Catchment Area Study were classified into
mutually exclusive groups based on their responses to the Diagnostic
Interview Schedule items assessing mania in 1981. Those with manic
spectrum syndromes (n=133; mean age: 33.8 +/- 12.6; female: 29.2%)
met one of the following criteria: mania (met DSM-III criteria for a
manic episode; n=36), hypomania (met all DSM-III criteria for a
manic episode except the severity requirement of causing impairment
or help seeking; n=42) and subsyndromal mania (had a euphoric
or irritable mood for a week or more and at least one other
symptom, but did not meet criteria for mania or hypomania; n=55).
Participants without manic spectrum syndromes (n=13,784; mean
age: 48.6 +/- 20.2; female: 53.8%) comprised the control group. Vital
status through the end of follow-up in 2007 was ascertained by
matching individual identifying information with the National Death
Index. Manic spectrum and control groups were compared in terms
of demographics, depressive symptoms, and self-rated health in 1981
using independent samples t-tests and chi-squared tests. To account
for the age difference between groups, a propensity score was used.
Risk of mortality was assessed using a Cox-proportional hazards
model with age in 1981 as the time of entry and age at death or follow-up
as the time of exit. Results: Estimated lifetime prevalence of
manic spectrum syndromes was 0.98%. This group was older than the
controls, had more symptoms of depression, was more likely to be
married and to be Caucasian. After adjusting for these covariates in
the hazard model, manic spectrum syndromes were not a significant
risk factor for all-cause mortality (HR=1.3, p=0.270). Conclusions:
History of manic spectrum syndromes did not increase risk of allcause
mortality. Future studies should evaluate specific causes of
mortality.
C49
Asymptomatic Bacteriuria and Antibiotic Use in Nursing Homes.
D. R. Mehr, 1 C. D. Phillips, 2 L. Adepoju, 2 D. K. Moudouni, 2 N. Stone, 4
O. Nwaiwu, 2 E. Frentzel, 3 S. Garfinkel. 3 1. Family and Community
Medicine, University of Missouri, Columbia, MO; 2. Texas A&M
Health Sciences Center, College Station, TX; 3. American Institutes for
Research, Chapel Hill, NC; 4. Centers for Disease Control and
Prevention, Atlanta, GA.
Supported By: Supported by the Agency for Healthcare Research
and Quality
Background: Overuse of antibiotics is a longstanding concern in
nursing homes. As part of a project on antibiotic stewardship, we investigated
the use of antibiotics to treat asymptomatic bacteriuria
(ASB) among nursing home residents with a suspected urinary tract
infection (UTI).
Methods: In 4 central Texas nursing homes, episodes of treatment
for suspected UTI were identified from facility logs. Symptoms
and resident characteristics were abstracted from residents’ records.
Using a multi-level multivariate model, we evaluated resident and facility
characteristics associated with antibiotic use despite the absence
of symptoms and signs suggesting need to treat a UTI (criteria from
Loeb, et al. Infect Control Hosp Epidemiol 2001).
Results: Over 6 months, clinicians ordered antibiotics for suspected
UTI 227 times among 167 residents; 89% had urine studies.
Half (114) of the antibiotic prescriptions occurred in the absence of
any symptoms or signs. In multivariate analyses, resident characteristics
did not differentiate between treated residents with or without
symptoms or signs; however, in the same model, 2 of the 4 facilities
exhibited less treatment of asymptomatic residents (odd ratios and
95% confidence intervals, 0.28 [0.09,0.88] and 0.34 [0.15,0.74]).
Conclusions: This research confirms frequent use of antibiotics
for ASB in nursing homes. Antibiotic stewardship in nursing homes
must address treatment that seems to be based solely on urine findings.
Clinicians’ prescribing behavior was clearly associated with the
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nursing homes in which they practiced and may be related to, or may
create, the facility’s clinical culture.
C50
Hospital acquired pressure ulcers and markedly decreased survival
after a hip fracture.
E. I. Vidal, 1 D. C. Moreira, 6 R. S. Pinheiro, 2 F. B. Fukushima, 4
P. J. Villas Boas, 1 K. R. Camargo, 3 L. M. Almeida, 5 C. M. Coeli. 2 1.
Internal Medicine Department, UNESP, Botucatu, Brazil; 2. IESC,
UFJR, Rio de Janeiro, RJ, Brazil; 3. IMS, UERJ, Rio de Janeiro, RJ,
Brazil; 4. Anesthesiology Department, UNESP, Botucatu, SP, Brazil;
5. Epidemiology Division, INCA, Rio de Janeiro, RJ, Brazil; 6. Social
and Preventive Medicine Department, UNICAMP, Campinas, SP,
Brazil.
Supported By: This study was funded by the Brazilian National
Council for Scientific and Technological Development (CNPq).
Background: There are few data examining the association between
hospital acquired pressure ulcers and survival after a hip
fracture.
Methods: The medical records of all patients aged 60 years and
older admitted to a public university hospital in the city of Rio de
Janeiro with a primary diagnosis of hip fracture between 1995 and
2000 were reviewed. Stage II or higher hospital acquired pressure ulcers
were identified from medical records. Survival to hospital discharge
and at 1 year was examined.
Results: Among 343 patients included in the study, there were 18
(5.3%) in-hospital deaths, and 297 (86.6%) patients remained alive 1
year after surgery. A hospital acquired stage II or higher pressure
ulcer was recorded in 36 (10.5%) of patients. Incident pressure ulcers
were associated with markedly increased risk of reduced survival to
hospital discharge (hazard ratio [HR] 4.25, 95% CI 1.35–13.36,
p=0.013) and of reduced survival at 1 year after surgery (HR 4.15,
95% CI 2.14–8.06, p

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2.47–25.96), and cancer history (RR 3.73, 95% CI 1.28–10.88) at baseline
predicted disability in men only. Women with diabetes (RR 2.97,
95% CI 1.66–5.32), stroke history (RR 2.89, 95% CI 1.07–7.85), and
bodily pain (RR 1.95, 95% CI 1.11–3.41) had higher risk of incident
disability.
CONCLUSIONS: Older women and men with multimorbidity
had different risk factors for incident disability. Among them, several
factors were potentially modifiable. Early screening and targeted intervention
among multimorbid older adults may prevent or delay
disability.
C53
D as in Death - Dietary Vitamin D in Mid-Life and Total Mortality:
The Honolulu Heart Program.
G. Kojima, 1 F. Lui, 1 R. Chen, 2 C. Bell, 1 R. D. Abbott, 1 L. Launer, 4
G. W. Ross, 3,1 J. D. Curb, 1,2 K. H. Masaki. 1,2 1. The John A. Hartford
Foundation Center of Excellence in Geriatrics, Department of
Geriatric Medicine, University of Hawaii, Honolulu, HI; 2. Kuakini
Medical Center, Honolulu, HI; 3. Veterans Affairs Pacific Islands
Healthcare System, Honolulu, HI; 4. National Institute on Aging,
Bethesda, MD.
Supported By: The National Heart, Lung, and Blood Institute; the
National Institute on Aging; Veterans Affairs Pacific Islands
Healthcare Systems; John A. Hartford Foundation Center of
Excellence in Geriatrics, University of Hawaii.
Background:
Low serum vitamin D levels are associated with total mortality
in previous epidemiological studies. Little is known about effects of
dietary vitamin D intake on mortality. We examined the association
between mid-life dietary vitamin D intake and 45-year total mortality
in Japanese-American men.
Methods
The Honolulu Heart Program is a longitudinal cohort study of
8,006 Japanese-American men in Hawaii aged 45-68 at baseline in
1965-68. Mid-life dietary vitamin D intake was calculated from 24-
hour dietary recall using the Nutritionist IV v3 software. Subjects
were divided into quartiles of vitamin D intake. Data on total mortality
were available for up to 45 years, through December 2010. Cox
proportional hazards models were used, and analyses were also stratified
for hypertension (HTN) status.
Results
There were 6,972 deaths during the 45 years of follow-up. Ageadjusted
total mortality rates were higher in the lower 3 quartiles of
dietary vitamin D intake compared to the highest (p for trend=0.011).
In Cox regression models, there was a significant inverse association
between dietary vitamin D quartiles and mortality; quartile (Q) 1
hazard ratio (HR)=1.14, 95%CI=1.07-1.22, p30
days, 90 days after last MDS, death, or end of study).
Results: A total of 2144 VTE On Admission cases were identified,
accounting for 3.7% of all admissions (95% CI: 3.5–3.9%). A
total of 757 cases of VTE During Residence were identified (from an
est. 20,586 person–years [PY] at risk), yielding an incidence of 3.68
cases/100 PY During Residence (95% CI: 3.42–3.95). [See table for
full results] Conclusions: VTE incidence during admission and residence
was common in this population; the latter was higher than previously
reported in LTC studies. Furthermore, this rate was 6 times
higher than a similar-age community cohort.1 These incidence rates
merit further investigation as diagnostic improvements may be driving
greater recognition of VTE in LTC.
1. White RH. Circulation 2003;107(23 suppl 1):I4-8.
VTE Incidence by Age Group (95% CI)
C55
TITLE: Vitamin D Levels and Asssociation with Chronic Medical
Conditions in Home Based Primary Care (HBPC).
H. Moiduddin, 1,2 S. N. Imam, 1,2 A. Imran, 1,2 L. Medina Munoz, 1
T. Lee, 1 Q. Syed, 1 P. Karumanchi. 1 1. Geriatrics and Extended Care,
Edward Hines Veterans Hospital, Hines, IL; 2. Internal Medicine,
Loyola University Medical Center, Maywood, IL.
Background: Numerous studies suggest that Vitamin D deficiency
is commonplace in the United States and the world at large.
The homebound and frail elderly are at high risk for having Vitamin
D deficiency. Recent research confirms that Vitamin D deficiency
contributes to many common conditions other than the musculoskeletal
system disorders to include falls, chronic pain, diabetes
mellitus, hypertension, depression, cancer and increased overall mortality.
Several studies have shown reduced fall risk with Vitamin D
supplementation and also possible improvement in control of chronic
pain, hypertension, diabetes mellitus, and depression. Despite all this
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evidence there are currently no guidelines for screening for Vitamin
D deficiency and it remains a largely under diagnosed and under
treated problem. Treatment of Vitamin D deficiency has the potential
to improve the health and thus the quality of life of the elderly.
Purpose: To determine the prevalence of low Vitamin D levels in
Veterans enrolled in a single HBPC program and to mark any association
with depression, diabetes mellitus and cancer.
Methods: This is a retrospective observational cohort study of
Veterans enrolled in HBPC between January 2006 and December
2008. We reviewed medical records of Veterans with documented Vitamin
D levels during the specified time period to assess the following:
Serum 25-hydroxy Vitamin D level, Vitamin D therapy regimen,
length of time to repeat Vitamin D level, post-treatment Vitamin D
level, and correlation with depression, diabetes mellitus and cancer.
Results: Of 560 patients enrolled in HBPC during the study period,
218 (39%) had a Vitamin D level measured. Among these 135
patients (62%) had Vitamin D deficiency. In the Vitamin D deficient
group, the incidence of depression was higher 46% versus 35%, the
incidence of diabetes mellitus was also slightly higher 43% versus
37% and incidence of cancer was lower 30% versus 36%.
Conclusions: Vitamin D levels were measured infrequently in
Veterans enrolled in HBPC program. Vitamin D deficiency is very
common in this population and there is an association of depression
with Vitamin D deficiency.
C56
Is the Geriatric Population Represented to an Appropriate Degree
in Journals of Infectious Disease?
H. Chawla, 1,2 K. Steel, 2 M. Parulekar, 1,2 L. Tank, 1,2 A. Sarkar, 1,2
L. Mansour. 2 1. Geriatrics, UNDMJ, Newark, NJ; 2. Geriatrics,
HUMC, Hackensack, NJ.
Background: Although advances made in reducing complications
related to infections have been a significant factor in increasing
life expectancy, infections remain a major health care problem for
people in the older age group. Therefore we reviewed the clinical
studies in two infectious disease journals to determine how well the
geriatric population is represented in these trials.
Objective: To determine what percentage of clinical research articles
published in two journals, Clinical Infectious Disease and the
Journal of Infectious Diseases, report on a population with an age
equal to or greater than 65 years of age.
Method: We reviewed 100 consecutive clinical research articles
in the Journal of Infectious Disease published between January, 2011
and May, 2011 and 100 articles in a second journal, Clinical Infectious
Diseases published between January, 2011 and July, 2011.We defined
a geriatric population as individuals age 65 or older. If this information
was not available then the best estimate was made using the median
or mean age provided. A few studies did not provide information
about median or mean age and were therefore considered
“indeterminate”.
Results: In the 200 articles that were reviewed, the site of infection
under study was as follows: lung (25%), skin (11%), central nervous
system (8%) and gastrointestinal tract (7%). The most commonly
seen primary organism was HIV (20%) followed by influenza (17%).
38% of the studies were undertaken in a hospital setting and in 5 %
of studies the duration of stay in the hospital was more than 15 days.
Sepsis was observed in about 6 % of the studies reviewed.
Of the 200 articles published in these two journals during the
time period noted, only 14.5 % focused on an age group 65 years of
age or older. The percentage of death in the age group 65 and older
was provided in only 1 % of the studies.
Conclusion: The top 3 causes of death for the general population
are heart disease, cancer, and stroke. This also holds true for the elderly
population. But infectious diseases are the fourth leading cause
of death in the older population. The data from both the Journal of
Infectious
Diseases and Clinical Infectious Diseases suggest that the geriatric
population is strikingly underrepresented in clinical studies.
Only 14.5 percent of research articles had a study population with a
median age of 65 years or greater.
C57
Potential Barriers to Hospice Referral Among Internal Medicine
Residents and Physicians.
A. Marszalek-Litauska, 1 S. Pereira, 1 M. Kline, 2 A. Kozikowski, 1
R. Pekmezaris, 1 C. Nouryan, 1 G. Wolf-Klein. 1 1. NSLIJ Health
System, New Hyde Park, NY; 2. FIMR, Manhasset, NY.
INTRODUCTION: Only 30% of terminally ill patients are
under hospice care at time of death. We sought to identify physicians’
perceived barriers and approaches to hospice referral.
METHODS: Anonymous surveys were distributed in 5 hospitals
of a large health system in New York. Comparisons across gender and
training were performed using the chi-squared test or Fisher’s exact
test as appropriate. Spearman correlations were calculated to determine
if professional status and years in practice were correlated with
degree of comfort discussing end of life topics with terminal patients.
RESULTS: Of the 264 physicians who responded, 58.3% were
males, and 45% were between the ages of 21-30 years; PGY1 (23%),
PGY-2 (15.8%) and hospital attending /specialists (34%) accounted
for more than half of the respondents. A full 71.4% of respondents
had received palliative/hospice care training and of those, 90% asserted
they had referred the terminally ill to hospice care. However,
on questions that tap knowledge of hospice care, only 40% chose the
correct answer to all three questions. Though 91% of all respondents
stated that ascertaining patient preferences at end of life was important/very
important, over half (53%) believed that the ER attending
is actually responsible for “sorting out patient/family wishes”. Furthermore,
27.3% stated that the palliative care team generally initiates
hospice discussion. In addition, 45% of physicians incorrectly believed,
or were not sure, that patients must have six months prognosis
to be eligible for hospice. Most frequently identified barriers were
fear of patient/family reactions (34.3%), lack of familiarity (23.2%)
and time constraints (18.9%). Yet most physicians had never (21.1%)
or rarely (38.5%) actually experienced anger from their patients
when mentioning hospice. Physicians’ level of comfort discussing several
end of life topics (e.g., prognosis, advanced directives, pain management)
was significantly associated with increasing years of experience
and increasing professional status.
CONCLUSION: Despite palliative care training and experience,
physicians relinquish end-of-life care to emergency room physicians
and palliative care consultants. Exploring unfounded and preconceived
fear of patient and/or family anger in reaction to hospice
referral needs to be integrated into a palliative care curriculum.
C58
Advance Care Planning Documentation: from theory to practice at 2
VA Medical Centers.
E. Clark, 1,2 E. Lindenberger, 2,1 K. Blackstone, 3,4 R. Anderson-
Malico, 1 S. Pandey, 3,4 E. L. Cobbs. 3,4 1. JJ Peters VA Medical Center,
Bronx, NY; 2. Mt. Sinai School of Medicine, New York, NY; 3.
Washington DC VAMC, Washington, DC; 4. George Washington
University School of Medicine, Washington, DC.
Background: Advance Care Planning (ACP) benefits patients
with serious illness. Electronic medical records (EMR) offer promise
for sharing meaningful information about ACP, but clinicians may
lack familiarity with ACP methods or a standardized format for ACP
documentation.
Objective: Ongoing facility-wide implementation of EMR ACP
documentation
Setting: 2 urban VA Medical Centers
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Methods:
EMR ACP tool: VAMC 1 - 2000; VAMC 2 - 2009
ACP champions: VAMC 1 - 6 physicians, 9 nurse practitioners;
VAMC2 - 2 physicians, 1 advance practice nurse
Settings for ACP: VAMC 1 - NH, geriatrics clinic, home based
primary care, geriatrics & palliative care (PC)consults; VAMC 2 -
geriatrics & PC consults
Interventions: VAMC 1 - role modeling; monthly orientation for
housestaff; noon conferences for faculty & housestaff; training for fellows
& residents in geriatrics & PC; performance improvement initiatives.
VAMC 2 - large group lectures; small group provider detailing;
role modeling; noon conferences for housestaff; training of geriatrics
& PC fellows
Results: see table
Discussion: Both VAMCs have adopted standardized EMR
ACP documentation. At VAMC 1, where the EMR ACP tool was first
developed in 2000, ACP documentation has grown steadily over a
decade. At VAMC 2, the EMR ACP was introduced in 2009 and has
slowly expanded. Growth factors include a critical mass of committed
champions, ongoing recruitment of champions in other disciplines,
and regular multi-modal education of trainees. The NH may be an important
center of EMR ACP documentation since virtually all NH
residents are living with a serious illness. VAMC 1 has had 100%
EMR ACP documentation in its NH for the past 10 years. New initiatives
at VAMC 2 likely to increase EMR ACP documentation include
a required geriatrics rotation for medical interns; a needs assessment
program in key outpatient clinics and its NH to identify barriers to
ACP; and mentoring of individual providers.
Results: ACP notes completed
C59
Role of Advance Directives in Determining Care for Older Nursing
Home (NH) Residents.
E. Manu, 1,2 S. McNamara, 1,2 B. Lansing, 1,2 L. Mody, 1,2 C. A. Vitale. 1,2
1. Division of Geriatric & Palliative Medicine, Department of Internal
Medicine, University of Michigan Healthcare System, Ann Arbor, MI;
2. Geriatrics Research Education and Clinical Center, Veterans Affairs
Ann Arbor Healthcare System, Ann Arbor, MI.
Supported By: Funding source for the study was provided by NIA
K23 AG028943, ASP/AGS T. Franklin Williams Research
Scholarship, NIA R01AG032298 and The Claude D. Pepper Older
Americans Independence Center and Michigan Institute for Clinical
& Health Research, University of Michigan Pilot Grant Program.
Background:
We aimed to study the effect of advance directives on treatments
received including indwelling devices, hospital transfers, & antibiotics
in NHs.
Methods:
A subgroup analysis of a prospective cohort study of 178 residents
from 15 NHs in southeast MI. Demographic data, Charlson’s
Comorbidity Index (CCI), Functional Score (PSMS, scores 6-30) &
advance directives were obtained at enrollment. At 30 day intervals,
presence of indwelling device, infection rate, antibiotic use & hospitalization
were assessed. Advance directives were divided in 4 groups:
1-comfort measures only, no transfer to hospital; 2- comfort focused
care but may transfer to hospital & receive antibiotics, no CPR; 3-
transfer to acute care hospital for assessment & treatment, no CPR or
ICU admission, 4- full code. Poisson regression was used to calculate
the incidence rate ratios (IRR) of new infections, antibiotic use &
hospitalizations. Risk factors included in the analysis: PSMS, CCI, device
use & advance directive.
Result:
161 (91%) residents had advance directives. 38 (24%) were in
group 1 with comfort care only, 29 (18%) in Group 2, 43 (27%) in
Group 3 & 51 (32%) in Group 4 desiring full code. While Group 4
residents were younger (mean age 76.7 yrs., SD 11, p

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C61
New Non-Invasive Technique to Assess Arterial Stiffness.
F. M. Felice, A. K. Reddy, J. D. Taffet, C. J. Hartley, G. E. Taffet.
Baylor College of Medicine, Houston, TX.
Supported By: AFAR,NHLBI,Huffington Center on Aging
Large arteries stiffen with age increasing the risk of cardiovascular
disease. The stiffening causes increased systolic blood pressure,
decreased diastolic blood pressure, and increased pulse wave velocity(PWV).
Yet current techniques only measure PWV at diastolic
pressure when the pulse wave velocity is lowest because the artery is
not fully distended.
Methods: We developed a new technique to measure stiffness
looking at reversals in flow in the radial artery. Using 20 mHz
Doppler probes to assess blood flow velocity in the proximal and distal
radial arteries, sampling at both sites simultaneously to avoid beat
to beat variations. Probes were custom made and interfaced with a
multichannel Doppler Signal processing workstation (Indus Instrument).
Pulse wave velocity was calculated at the start of flow and
when forward flow started after each reversal.
Results: We attempted to assess radial artery flow non-invasively
in 8 subjects ranging in age from 18 to 64. We found that reversals
in blood flow happened in all our subjects, providing timing signals
for calculation. The quality of the signals needed to determine
the second wave PWV was very high so we could not get interpretable
data from 5 out of 8 subjects. We found within the range of
diastolic to systolic blood pressure, PWV increases by 40-80% as
blood pressure increased by 20 to 30 mmHg. Obtaining adequate signals
required significant attention to detail, however with good data,
it was then feasible to create a pressure versus PWV relationship.
Conclusion: With this strategy, the slope of the pressure PWV
relationship more directly defines stiffening and provides novel information
to assess arterial stiffening with aging and perhaps direct risk
reduction for cardiovascular disease for the elderly.
C62
Positive Effect of Restorative Sleep on IL6 and Fibrinogen in
Post-Midlife.
S. Song, 1 F. J. Prerost, 2 M. Sanders, 2 M. Barash, 2 A. Valone. 2 1.
Biomedical Sciences, Midwestern University, Downers Grove, IL; 2.
Family Medicine, Midwestern University, Downers Grove, IL.
BACKGROUND: Treatment of medical illnesses that emphasizes
hereditary and lifestyle etiological factors is often associated
with diverse health outcomes. The research identifying converging
bio-psychosocial pathways reflects this emphasis on disease risk. Proinflammatory
markers are understood as indicative of chronic conditions
including metabolic, autoimmune, and hematologic disorders.
The objective of the current study is to examine the positive effect of
restorative sleep on IL6 and fibrinogen as a protective factor that
might mitigate the onset of aging related decline.
METHODS/DESIGN: Longitudinal, secondary data
SETTING: Midlife in the United States (MIDUS) national sample
of independently dwelling middle-aged and older adults living in
the United States
PARTICIPANTS: Phase II of the MIDUS study comprised the
biomarkers project; a subsample (n = 398) of the original group of
participants between the ages of 35 and 84 underwent biological assessments
over a two-day period
MEASUREMENTS: Actiwatch sleep data collection and fasting
blood specimens of IL6 and fibrinogen biomarkers
RESULTS: Restorative sleep, measured as sleep efficiency, was
inversely related to serum IL6 (r = -.14, p < .001) and blood fibrinogen
(r = -.12, p = .01). Sleep efficiency was not significantly diminished
by the presence of diabetes (84% of participants did not have
diabetes) or physician diagnosed arthritis (F = .102, p >.05), blood
clots (F = .056, p > .05), or bleeding diseases (F = .031, p > .05).
CONCLUSIONS: Participants who exhibited higher amounts
of restorative sleep had lower levels of inflammation measured by
serum IL6 and blood fibrinogen. It was not the case that sleep efficiency
was adversely affected by pre-existing illnesses typically associated
with less healthy markers and subsequent disruptions to circadian
rhythm. Researchers have found that chronic and acute stressors
(i.e. childhood traumas, parental neglect, difficulties in adulthood,
etc.) have generated profiles similar to those of older and oldest
adults. Identifying possible mitigating factors of aged proinflammatory
markers will contribute to the literature and broaden treatment
options.
C63
Attitudes and Knowledge about Resuscitation Discussion in a
Community Hospital: A Survey of Physicians and Nurses.
C. X. Pan, 1 D. A. Acquista, 1 A. Bushan, 1 S. M. Constantine, 1
I. Kariolis, 1 S. Sunday. 2 1. New York Hospital Queens, Flushing, NY; 2.
North Shore- LIJ Health System, Manhasset, NY.
Background: For patients with a serious illness, discussions with
healthcare staff often include resuscitation preference or “code status”
including DNR/DNI (do not resuscitate/do not intubate). This
study assesses health care professionals’ attitudes and knowledge
about resuscitation discussions at a community hospital. The objective
is to examine if health care discipline and level of experience affect
attitudes and knowledge about discussion about resuscitation decisions.
Methods: A 34-question self administered survey was distributed
to attending physicians, nurses and internal medicine residents.
Questions included demographic information, religious beliefs, clinical
vignettes with management options, scales assessing
comfort/competency levels regarding treatment of symptoms in patients
who are full code vs DNR, knowledge of hospice appropriateness,
and perceived need for education about resuscitation discussions.
Results: There were 135 respondents: 30 attendings, 50 nurses
and 55 residents (M=37%; F=63%). Respondents were diverse in
ethnic/racial background. One respondent reported having a religious
reason that prevented discussing DNR/DNI. 83% of attendings,
49% of residents and 52% of nurses felt it was the attendings’
responsibility to discuss code status. When managing symptoms,
>85% of nurses, >75% of attendings and >63% of residents felt “very
comfortable,” while >89%, >63%, and >49% of nurses, attendings,
and residents felt “very competent,” respectively; (p-value for “comfort
level” NS; and “competence” p=0.0002). Attendings correctly
identified hospice appropriate patients in different case scenarios;
nurse and resident responses varied. Both nurses and residents
(>84%) felt they would benefit from more training about resuscitation
discussion. Conclusion: This study found differences in attitudes
and knowledge about resuscitation decisions among health care disciplines
with various levels of experience. Nurses felt more comfortable
and competent in managing symptoms compared to attendings
and residents; and only attendings consistently identified hospice appropriate
patients. Next steps may include: 1) residents and nurses receive
more education regarding resuscitation discussion and hospice
appropriateness, and 2) attendings and residents may benefit from
more training in symptom management.
C64
Weaving Aging Education Into The Surgery Clerkship: an
opportunity to increase future physician awareness of unique issues
in surgical care for the elderly.
A. Macnow, 1 R. Kelz, 1,3 A. Corcoran. 1,2 1. Perelman School of
Medicine, University of Pennsylvania, Philadelphia, PA; 2. Internal
Medicine, University of Pennsylvania, Philadelphia, PA; 3. Surgery,
University of Pennsylvania, Philadelphia, PA.
Supported By: Donald W. Reynolds Foundation
Background: Successful outcomes for geriatric surgical patients
are dependent on a team well versed in the unique issues of the aging
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patient population. We report the evaluation of a case-based educational
session for surgical clerks focused on the peri-operative management
of an elderly patient as part of an integrated aging theme
initiative. Methods: Utilizing a clinical scenario involving an elderly
patient with abdomen pain, a 55 minute case-based session was added
into the required lecture schedule. Students were divided into learning
teams and asked to provide group answers to open-ended questions
incorporated as the case unfolded. An anonymous audience response
system was employed to allow learners to assess their
successes in comparison to their peers to voluntary 5 multiple choice
knowledge questions and pre/post self-assessment survey using a
four-point Likert scale (1=very good,4=poor). Descriptive statistics
were performed comparing before and after the session using the
Wilcoxen rank sum test. Results: Thirty students participated in the
pilot. At the end of the case, students responded correctly 85% or
more of the time to the multiple-choice questions. All self-assessment
questions showed statistically significant improvement when responding
to the following: (1) appreciate the unique problems of the
increasing number of older adults undergoing abdominal surgery
(median=3pre/2post,p

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other age group (Krisberg 2005). One way to prepare future physicians
for increased demand may be to better integrate geriatrics education
into medical school. The study’s objective was investigate
whether taking a geriatrics elective class improves first-year medical
students’ perceptions and knowledge of geriatrics.
Subjects were 18 first-year medical students, 8 of whom had enrolled
in a 4-month geriatric elective class. Surveys were administered
to students within 1 month of the first class session. The surveys assessed
students’ interest in and comfort level with elderly patients
and included a modified version of Palmore’s Facts on Aging Quiz, a
validated geriatrics knowledge assessment survey (Fabiano 2005).
These surveys will be administered again to students within 1 month,
and again 1 year after the completion of the elective.
There was no significant difference between knowledge survey
scores for geriatrics elective (GE) and non-geriatrics elective (non-
GE) students; the average score was 13.9±0.5 out of 25. On a scale of
1-10 (1 being least and 10 being most interested), GE students’ average
geriatrics interest was 7.4±0.7, which was significantly higher than
that of non-GE students, 4.3±0.4 (p

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C71
Outpatient Anticoagulation Management in the Elderly Patients:
Attitude and Knowledge Survey in Geriatric Fellows.
A. S. Gangavati, L. Lipsitz. Gerontology, Beth Israel Deaconess
Medical center, Harvard Medical School, Brookline, MA.
Supported By: Geriatric Academic Career Award
Background: Despite ongoing national initiatives to reduce the
likelihood of patient harm associated with use of anticoagulant therapy,
little or no formal curricula on anticoagulation management in
the elderly are included in the majority of post-graduate training programs.
Methods: Eleven geriatric fellows were sent knowledge and attitude
survey questions in outpatient anticoagulation management in
the elderly patients. Questions were designed based on expert advice
and from comprehensive literature review.
Results:
Attitude Questions: Five out of eleven geriatric fellows (45.5%)
felt that they were “quite often” comfortable with managing anticoagulation
as compared to 54.5% (6/11) who felt that they were “very
often” comfortable with anticoagulation management in the elderly
patients. Seven out of the eleven fellows (63.6%) felt that they have
enough knowledge regarding anticoagulation management as compared
to 36.4% (4/11) who felt that they did not have enough knowledge
regarding anticoagulation management.
Knowledge questions: Table 1 shows results from knowledge
questions that specifically addressed outpatient dose initiation and
monitoring in elderly patients, drug interactions with Warfarin, cultural
influences of diet on Warfarin and dosage/storage of Dabigatran.
Conclusions: Most Geriatric fellows felt that they were comfortable
managing anticoagulation in the elderly patients and only 36.4%
felt that they don’t have adequate knowledge. Most fellows were able
to answer only 50% or less of all the questions. Based on these results,
formal education curriculum addressing the knowledge gaps is being
developed.
Table 1. Knowledge questions on anticoagulation management in
geriatric patients. (n=11)
C72
“Geriatrics Fellows’ Most Difficult Case Conference”- Knowledge
Sharing and Teaching through program networking: a one year
experience.
A. Khan, 1,2 T. Howell, 2 M. Malone, 1,2 P. Colon-Nieves, 1 K. Singh. 1,2 1.
Aurora Health Care, Milwaukee, WI; 2. University Of Wisconsin
School of Medicine and Public Health, Madison, WI.
Background:
A monthly “Most Difficult Case Conference” has emerged as a
promising strategy to teach the bio-psycho-social approach to complex
older adults.It has grown to involve 13 geriatrics fellowship programs
in 7 states, networked by simple conference call. The fellowship
teams rotate in selecting and presenting cases experienced as especially
emotionally and cognitively taxing. Teams at the other sites take
turns inquiring about the case, using the “Wisconsin Star Method” as
a format. This involves mapping clinical data onto five domains: medications,
medical, behavioral, personal, and social. Geriatric psychiatry
and medicine faculty from other sites take turns with summary
teaching points, and the discussions conclude with “the rest of the
story” from the presenting team.
Methods:
This is an on-line survey of participants during the second year
of the program. Data was compared to the survey of participants during
the first year.
Results:
The survey was sent to 43 participants and 18 responded. Of
these 56% were faculty, 33% fellows and 11% “other”.
When compared to last year an increased number of respondents
noted that the quality of program was good (72% current year
vs. 59% last year), enjoyed collaborating with colleagues across the
country (89% vs.74%), and would recommend it to their colleagues
(78% vs.69%).
As compared to last year more respondents noted learning
practical strategies for addressing complexity (61% vs.36%) and that
Wisconsin Star Method was effective in assessing complex cases
(61% vs. 49%). Regular use of the Wisconsin Star Method in clinical
practice did not change (18%). Similar to last year, responders found
the discussions of the “hardest part of the case” and the “summary
teaching points” to be most useful.
Participants noted that the conference allows them to a feel part
of a national interdisciplinary team (61%) and half noted that it has
helped build their emotional and cognitive skills.
Conclusion:
“Geriatrics Fellows’ Most Difficult Case Conference” has
demonstrated an improvement in participant satisfaction over the
last 2 years. This assessment of the conference will assist in making
the educational case for further dissemination to additional fellowship
programs.
C73
Interprofessional Geriatric Clinical Skills Fair.
B. Salzman, 1 L. Collins, 1 E. Hajjar, 2,1 A. Egras, 2,1 C. Hsieh, 1 L. Hersh, 1
S. Fleegle, 1 D. Snyderman. 1 1. Family & Community Medicine,
Thomas Jefferson University, Philadelphia, PA; 2. Jefferson School of
Pharmacy, Thomas Jefferson University, Philadelphia, PA.
Supported By: This project was supported by funds from the
Department of Health and Human Services (DHHS), Health
Resources and Services Administration (HRSA), Bureau of Health
Professions (BHPr), under Geriatric Academic Career Award number
5K01HP20486.
Background: The need to expand geriatric education for health
professionals at all levels of training has been well described (1). The
purpose of this study was to evaluate the experience of participants in
an Interprofessional Geriatric Clinical Skills Fair.
Methods: The objective of the fair was for learners to gain practical,
evidence-based skills and knowledge pertaining to the care of
older adults. Six interactive stations included cognitive assessment,
gait evaluation, older patient simulation, medication management,
code status conversation, and disposition discussion. Each station ran
for 15 minutes and the entire fair ran for 2 hours. The stations were
led by interprofessional faculty including 4 geriatricians, 1 palliative
care specialist, and 2 clinical pharmacists.
A short survey was administered after the fair to assess learners’
experience. Learners were asked to rate each station on a 5-point
scale. They were asked if there was anything they would change to improve
the fair and whether they learned something at the fair that
would change their clinical practice.
Results:
A sign-in sheet demonstrated 34 participants, including 17 residents
in Family Medicine (FM), 13 medical students on their 3rd-year
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clerkship in FM, 2 medical students on their 4th-year sub-internship
in Geriatric Medicine, and 2 second-year pharmacy students.
Surveys were distributed to all participants (34), and 28/34
(82%) completed surveys were returned.
On a 5-point scale (ranging from 1=poor, 2=fair, 3=good, 4=very
good, 5=excellent), the average rating for each station ranged from
4.65 to 4.85, with a mean of 4.73.
When asked if they would change anything to improve the program,
2 learners responded that they would have liked more time.
When asked if they learned anything at the fair that would
change their clinical practice, 24 out of the 28 (86%) responders
wrote, “Yes.”
Conclusion:
An Interprofessional Geriatric Clinical Skills Fair was highly
rated by learners at various levels of training. The fair was a fun and
effective method for providing education addressing geriatric competencies.
Reference:
Institute of Medicine of the National Academies. Retooling for
an Aging America: Building the Health Care Workforce. Washington,
DC: The National Academies Press; 2008.
C74
Improving Uptake of a Falls Educational Program by Focusing on
Staff Interactions.
C. Colon-Emeric, 1,2 S. Pinheiro, 1 K. M. Simpson, 2 K. Porter, 1
K. Corazzini, 1 R. A. Anderson. 1 1. Duke University, Durham, NC; 2.
GRECC, Durham VA Medical Center, Durham, NC.
Supported By: VA HSR&D EDU 08-417
NIH R56NR003178–09
Background: Traditional educational programs for nursing
home staff have not resulted in improvements in quality indicators or
fall rates. One potential explanation is that staff lack sufficient connections
with each other to effectively share information and problem
solve.
Methods: Eight nursing homes were block randomized to receive
either a traditional falls education program (FALLS only), or a
program teaching staff to improve their connections and interactions
with co-workers, followed by the traditional falls program (CON-
NECT+FALLS). The education programs were delivered by research
assistants over 3 months, targeted all staff with direct resident
contact (n=674), and used story-telling, role play, relationship mapping,
and coaching. Focus groups (n=16) were conducted with staff
who had participated in at least one intervention component (n=87).
Qualitative analysis identified thematic differences in staff-reports of
organization learning.
Results: Both groups expressed that the FALLS content was familiar,
reminded them about fall risk factors, and helped them engage
in teamwork. However, the CONNECT groups additionally noted: 1)
that relationship mapping sessions helped them identify and correct
communication weaknesses; 2) that improved understanding about
the roles of various disciplines led to a wider fall prevention network;
and 3) that improved job attitudes and cooperation resulted in
greater willingness to stick to interventions such as toileting programs.
One CONNECT participant stated that “with the two, the
CONNECT and the FALLS portion of it…it all flowed together, so it
helped us to understand and learn better.” Participants also mentioned
that the CONNECT intervention would be helpful for learning
about other topics, such as behavior problems.
Conclusions: An educational program focused on improving interactions
among nursing home staff was highly acceptable, and was
reported to enhance the uptake of a traditional falls education program.
Measurement of its impact on resident fall indicators and outcomes
is warranted.
C75
Community Based Advance Care Planning Education for Older
Adults.
C. W. Johnston. Betty Irene Moore School of Nursing, University of
California at Davis, Sacramento, CA.
Supported By: Betty Irene Moore School of Nursing, University of
California at Davis
Senior Citizens of Davis
Background: Advance care planning (ACP) includes health education,
anticipating future care, establishing a plan, choosing a
spokesperson, documenting wishes, and communication. The objective
of this pilot study was to determine whether a community based
educational program for older adults would increase participation in
ACP. Previous research has not shown whether community-based education
improves participation in ACP. Methods: This pilot study targeted
a population of older adults (>65 years), and was performed at
a small public community center. A convenience sample was recruited
and informed consent was obtained prior to the completion of
a pre-education survey to determine baseline knowledge of ACP. A
multi-component presentation was given by the researcher highlighting
CPR survivability and both forms primarily used in ACP; the Advance
Directive (AD) and Physicians Orders for Life Sustaining
Treatment (POLST) form. Results: 23 of the 30 attendees participated
in the survey, with a mean age of 72.9 years. 74% (n=17) were
college educated, with 43% (n=10) reporting their highest level of education
to be a Masters degree. 78% had an awareness of ACP and
had talked with someone about their wishes. 91% had a spokesperson
to make healthcare decisions on their behalf. 52% had a Durable
Power of Attorney (DPOA), and 87% knew what a DPOA was. 74%
(n=17) knew what an AD was and most (n=18, 78%) did not know
what a POLST form was. Most had not filled out an AD and a
POLST form. 96% reported knowing of CPR but 96% failed to correctly
estimate survivability after CPR. Percentages of survival were
on a Likert scale ranging from a score of 1 being equal to a survival
rate of 81-100% to a score of 5 being equal to a rate of 0-20% survival.
Conclusion: Participants were highly educated and indicated
they have made attempts to learn about their health, communicate
with others about their wishes for healthcare, know what CPR is, and
are somewhat aware of the process of ACP. Conversely, most have
not participated in ACP, are not aware of AD and POLST forms, and
are unable to correctly estimate CPR survivability. This pilot study illustrated
a need for more education about the benefits of ACP. More
research is needed to improve participation in ACP among older
adults and future studies should focus on community based ACP education.
Awareness of ACP may improve the likelihood that healthcare
wishes will be communicated and honored at the end of life.
C76
Effect of the Health Mentors Program on Student Attitudes toward
Team Care.
C. Arenson, C. Giordano, K. Lyons, L. Collins, E. Umland,
L. Hewston, K. Smith, R. Antony, M. Rose. Thomas Jefferson
University, Philadelphia, PA.
Supported By: This research was wholly funded by Thomas
Jefferson University, Jefferson InterProfessional Education Center
and the Jefferson Office of Institutional Research.
Background: Interprofessional education (IPE) is a key theme
in preparing the future geriatric workforce, yet there is a lack of robust
data documenting the benefits of IPE. Student attitudes toward
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IPE are generally positive and show little change after IPE. Attitudes
toward team care may be a more sensitive interim measure of IPE efficacy
(Rose et al). The Health Mentors Program (HMP) is a 2-year
longitudinal curriculum that brings entry-level interprofessional
teams of students together with a Health Mentor (a person living
with one or more chronic conditions) to learn patient-centered, teambased
care. Nearly 3,000 students have participated; 52% of Health
Mentors are age 60 or over.
Methods: Students entering HMP in Fall 2009 completed the Attitudes
Towards Interdisciplinary Teams scale (Heinemann et al) at
matriculation and at program completion in Spring 2011.
Results: A paired samples t test showed significant improvements
in mean attitude scores (scale 0-5, higher = more positive attitude)
between baseline and program completion in all disciplines
with sufficient sample size. A paired samples t test for students in all
programs (n=173) found significant improvements (p=.000) in attitudes
(baseline mean 3.27 (.45) and 3.75 (.58). ANOVA showed no
significant differences between groups.
Conclusions: The gold standard for measuring impact of IPE is
clearly improvement in patient outcomes. However, given the long
time-delay from entry into health professions training to independent
practice, interim measures to assess program outcomes are essential.
Improved attitudes toward team-based care may be one important
indicator of program success. A limitation of this study is lack of a
control group of students not exposed to formal IPE. Next steps include
measuring attitudes longitudinally during the remainder of
training and into clinical practice.
Rose M, et al. Attitudes of students in medicine, nursing, occupational
and physical therapy toward interprofessional education. J
Allied Health, 38:196-200, 2009.
Heinemann GD, et al. Development of an Attitudes Toward
Health Care Teams Scale. Eval & Health Professions, 22:123-42, 1999.
Discipline Specific Changes in Attitudes to Team-based Care
C77
Do physicians in-training assess for falls among the elderly
population in the outpatient setting?
D. Soto, 1 J. F. Fogel. 2 1. Division of Geriatrics, Montefiore Medical
Center Albert Einstein College of Medicine, Bronx, NY; 2. Dept of
Medicine,Division of Geriatrics, Beth Israel Medical Center, New
York, NY.
Falls are one of the most common geriatric syndromes threatening
independence and are one of the leading causes of injuries in the
older population. Patients 65 and older account for 39% Internal
Medicine (IM) ambulatory visits. There has been an impetus to incorporate
education on geriatric syndromes into IM residents curriculum.
This study aims to evaluate the assessment for falls and gait instability
provided to vulnerable elders by IM residents in an
ambulatory setting.
A retrospective chart review of total 150 randomly selected patients
followed by IM residents for one year period was conducted.
Inclusion criteria: >65 years of age, attendance at ambulatory clinic
for at least one year and treated only by in-training physicians. The
electronic medical records of these patients were reviewed for any
question regarding falls, past medical history including co-morbidities
and gait abnormalities as a problem, number of falls and consequences,
use of psychoactive medications. Physical exam was reviewed
for evidence of gait assessment.
Documentation of fall inquiry was noted in 25% (38) of records.
Of the 38 records gait was recorded in 12 occasions (P

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C79
Interprofessional, Evidence-Based Education to Reduce Falls.
E. Eckstrom, 1 K. Lasater, 1 V. Cotrell, 2 W. Simonson, 3 M. Neal, 2
T. Harvath. 1 1. Oregon Health & Science University, Portland, OR; 2.
Portland State University, Portland, OR; 3. Oregon State University,
Corvalis, OR.
Supported By: Health Resources and Services Administration
Fall prevention in older adults requires an interprofessional, evidence-based,
systems-oriented approach. We implemented a fall prevention
protocol for medical, nursing, social work, and pharmacy professionals.
Methods: Interprofessional project faculty met monthly to develop
the protocol and train ourselves in teamwork, motivational interviewing,
and content expertise. Interprofessional workshops were
offered onsite for ambulatory, long term care, hospital, and home
health practices focused on: (1) screening patients over 75 for falls, (2)
Vitamin D supplementation, (3) exercise prescription (tai chi), (4) environmental
assessment, and (5) medication review and reduction.
Study team members (“coaches”) partnered with each practice site to
develop an individualized action plan to implement a fall prevention
protocol. Outcomes data will be collected for one year at each site.
The study is ongoing.
Results: 1) Team members were reminded of the important roles
all professions play in fall prevention (e.g., social workers are trained
to reduce fear of falls but are rarely used for this role); 2) We needed
a shared lexicon on motivational interviewing for use both in training
of practice sites and in coaching individual teams, requiring multiple
training sessions; 3) Team members can be cross trained to deliver
content from other professions, enhancing the flexibility of the
“coach”/practice team pairings; 4) Practice settings have varying degrees
of “team-ness” and this impacts successful implementation of
the protocol; 5) Solutions to implementing evidence-based action
plans vary between practice sites, are innovative, and deserve further
research, e.g., adapting tai chi exercises for use by CNAs; 6) “Champions”
for practice change come from any profession; 7) Rural communities
can coordinate efforts effectively across inpatient, outpatient,
and long-term care settings, thereby facilitating culture change and
setting a new community standard.
Conclusions: Interprofessional education takes commitment
and training but can lead to effective evidence-based practice adoption.
Team member roles are often narrowly defined, and better identification
of expertise can improve team effectiveness. Interprofessional
teaching enhances everyone’s experience; the impact on
patient outcomes remains to be determined.
C80 Encore Presentation
The effect of a delirium e-learning program on nurses’ knowledge of
delirium.
E. Detroyer, 1,2 D. Debonnaire, 1 F. Dobbels, 1 J. Gommers, 2 K. Irving, 3
E. Joosten, 4 K. Milisen. 1,4 1. Center for Health Services and Nursing
Research, Katholieke Universiteit Leuven, Leuven, Belgium; 2.
Department of Health Service, Katholieke Hogeschool Limburg,
Hasselt, Belgium; 3. Department of Nursing, Dublin City University,
Dublin, Ireland; 4. Department of Geriatric Medicine, University
Hospitals Leuven, Leuven, Belgium.
BACKGROUND: Delirium is a common complication among
hospitalized elderly patients, but remains frequently unrecognized by
healthcare workers. Despite the evidence that educational packages
can improve awareness and knowledge of delirium among nurses, no
research testing e-learning in this area was found. This study determined
the effect of a delirium e-learning program on nurses’ knowledge
about delirium.
METHODS: A convenience sample of 56 nurses from a university
hospital (60% bachelor degree, all computer literate) were included,
and completed two validated questionnaires to assess their
knowledge about delirium and their ability to identify delirium before
and after the educational intervention. The intervention consisted
of (1) a one-hour information session with instructions on how
to use the e-learning program and (2) a two-month learning period
given access to the delirium e-learning program. This e-learning program
is organized into 11 submodules of approximately 10 minutes
each. It provides information about the epidemiology, the clinical
presentation, the risk factors, the causes and the prevention, screening
and treatment strategies of delirium in combination with case
studies, videos and tests for self-assessment.
RESULTS: Nurses’ knowledge about delirium was significantly
improved in the after-education period compared to the before-education
period (mean score (SD) of correct answers on the 23 items of
the questionnaire = 19.68 (SD 2.08) versus 17.61 (SD 3.52); p

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the outpatient setting. Our ultimate goal is to enhance the abilities of
medical students to work collaboratively with the disciplines of nursing
and pharmacy to consider the needs of older adults using an interdisciplinary
learning methodology.
C82
Geriatric Relocation Syndrome: A Marker for Frailty in Older
Adults?
A. Ahmed, S. Friedman, K. McCormick. University of Rochester,
Rochester, NY.
Background: Demographic changes have created a new dynamic
which results in substantial late life geographic relocation
within the United States. The aim of this study was firstly to assess if
there was a difference between patients who relocated and patients
who did not in terms of their overall health, and secondly to gauge
whether relocation contributed to risk of mortality longitudinally.
Methods: A convenience sample was obtained of 440 patients
who were newly enrolled in a Geriatric outpatient practice attached
to a university hospital in Rochester, NY. Subjects were identified as
having moved at least 60 miles in the past year (n= 64) or not
(n=376). Demographics, functional status, self-reported health, and
comorbidities were recorded. Comparisons were made between “relocators”
and “non-relocators” via Chi square and t-test analysis as
appropriate. A Cox Proportional Hazard analysis was completed to
assess impact of relocation status on mortality for the 429 subjects
who had complete data on mortality and death date.
Results: Subjects’ self report of health was more likely to be
“fair” or “poor” for relocated patients (27.0% vs 19.1%, P

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Conclusions: Although participants with PD demonstrated a
trend toward improved functional mobility after intensive training,
no change occurred in the frequency of urinary symptoms and participants
reported greater bother related to overactive bladder. Multicomponent
strategies are needed to impact both motor and nonmotor
symptoms of PD.
C85 Encore Presentation
Outcomes after Discontinuation of Proton Pump Inhibitor Therapy
in Geriatric Outpatients.
C. Eisenhower, 1 H. Sakely, 1,2 F. D’Amico, 1 S. Rana. 1,2 1. University of
Pittsburgh Medical Center St. Margaret, Pittsburgh, PA; 2. University
of Pittsburgh Medical Center St. Margaret Geriatric Care Center,
Pittsburgh, PA.
Chronic use of proton pump inhibitors (PPIs) in the geriatric
population without a clear indication creates opportunities for longterm
adverse events and drug interactions. A 2009 quality initiative at
University of Pittsburgh Medical Center Geriatric Care Center enrolled
eleven patients for a trial discontinuation of PPI therapy. Many
of the patients did not have a documented indication for a PPI, and
six patients were successfully discontinued. The purpose of this extension
study was to evaluate geriatric patients after discontinuation of
PPI therapy to determine rate of discontinuation and confirm that
the intervention did not worsen gastrointestinal (GI) symptoms or
quality of life.
From 10/2010 to 3/2011, charts were reviewed at the Geriatric
Care Center prior to routine appointments. Eligible patients were
aged 60 years and older, currently taking a PPI, or a new patient potentially
taking a PPI. Based on indication, current GI symptoms, and
concomitant medications, physicians determined whether PPI use
was still appropriate. Telephone follow-up was conducted by the
pharmacy resident for three months with each enrolled patient. Patient
charts were reviewed and pertinent demographic information
analyzed. Rate of discontinuation was calculated with 95% confidence
intervals using Poisson Distribution.
A total of 175 patients were seen at the geriatric clinic. Nine patients
were enrolled by their physician and five did not restart their
PPI therapy at any time after discontinuation. The rate of discontinuation
was estimated to be 0.076 (95% CI, 0.033-0.165). Duration of
therapy was estimated for many enrolled patients to be less than 10
years. GI symptoms continued after discontinuation for three patients,
began anew for one patient, and resolved for three patients.
Due to small sample size, a relationship could not be established between
PPI therapy and long-term adverse events, although history of
osteoporosis, B-12 deficiency, and hypomagnesmia were present in
some patients.
The majority of patients were successfully discontinued from
their PPI therapy, and persisting GI symptoms were controlled by alternative
treatments. While no significant adverse drug events occurred,
it is unknown whether the use of step-down therapy would
have resulted in a greater number of successful discontinuations.
C86 Encore Presentation
Factors associated with the care burden experienced by caregivers of
older patients.
C. Y. Yeo, 1 W. K. Ng, 2 W. Wong. 1 1. Geriatric Medicine, Tan Tock Seng
Hospital, Singapore, Singapore; 2. Nursing Service, Tan Tock Seng
Hospital, Singapore, Singapore.
Supported By: Nil.
Background: Caregiver burden experienced by caregivers of
older adults is expected to increase with the aging population. The
aim of this study was to determine the factors associated with caregiver
burden experienced by caregivers of a cohort of elderly patients
attending an outpatient geriatric clinic.
Methods: This was a cross-sectional study of caregivers of patients
referred to an outpatient geriatric clinic. Demographic information,
medical history, functional and psychosocial status of patients
were recorded. The relationship of the caregivers to the patients was
also recorded. Caregiver burden was assessed using the short-form of
the Zarit Burden Inventory (ZBI).
Results: 240 caregivers were included in the study. 68.3% were
female. 19.6% of the caregivers were spouses, 55.8% were children
and children-in-law, 4.2% were other relatives and 20.4% were domestic
helpers. Mean ZBI score was 16.15. Spousal caregivers had the
highest ZBI score (mean 18.04), followed by other relatives (mean
16.70), children and children-in-law (mean 16.56), and domestic
helpers (mean 13.14). Using multivariate analysis, factors that were
significantly associated with higher ZBI scores were male patients
(Beta coefficient = 3.14, 95% CI 0.50 to 5.78), patients who were independent
in feeding (Beta coefficient = 3.51, 95% CI 0.39 to 6.64),
patients who were dependent in grocery shopping (Beta coefficient =
2.11, 95% CI 0.23 to 4.00), patients with behavior problems (Beta coefficient
= 2.85, 95% CI 0.37 to 5.33) and spousal relationship with
patient (Beta coefficient = 1.70, 95% CI 0.57 to 2.83). There were no
significant association between the ZBI score and patients’ diagnosis
of dementia or depression, nor with caregivers’ gender.
Conclusion: Patient factors that were associated with higher
burden of care in our study include male gender, independence in
feeding, dependence in grocery shopping and presence of behavioral
problems. Familial relationship between caregivers and patients was
also associated with higher care burden. Further research can be
done to explore carer stress among spousal caregivers for elderly and
their coping abilities and utilisation of family and community resources,
given our aging population and low birthrate resulting in
smaller families.
C87
Effects of Sub-acute Care on Hospital Acquired Anemia in the
Elderly.
C. Bocirnea, M. V. Corrigan, S. K. Sandhu. MetroHealth Medical
Center, Cleveland, OH.
OBJECTIVES: To determine if sub-acute care results in further
hemoglobin decrease in elderly patients with hospital acquired anemia
and if there is an association between development of anemia
and patient demographic characteristics, medical conditions, medications,
and length of stay.
DESIGN: Retrospective observational study.
SETTING: Academic medical center.
PARTICIPANTS: Patients over the age of 65 admitted to an academic
hospital based sub-acute care unit, post hospitalization for a
medical illness from January 2007 to July 2011. Exclusion criteria: patients
transferred from ICU, those who underwent surgical procedures,
had documented blood loss, active leukemia or recent
chemotherapy.
MEASUREMENTS: Demographics; chronic medical conditions
and medications; hemoglobin levels; number of blood tubes
drawn; length of stay.
RESULTS: Of 835 patients transferred to sub-acute care after a
medical hospitalization between 01/2007-07/2011, 393 met the inclusion
criteria. Median age was 78 years, 65% Caucasian, 65% female.
Nearly half had heart disease, one third heart failure, and 85% hypertension.
Median length of stay was 7 days for acute care and 13 days
in sub-acute care. Anemia was present on hospital admission in 57%
of patients, with 80% of patients anemic upon sub-acute care discharge.
43% of patients did not have anemia on admission; at discharge
from sub-acute care this group had a mean decrease in Hgb of
1.9 g/dL, significantly greater compared with anemic patients. Factors
predicting a significant drop in Hgb levels of more than 2.0 g/dl(25%
of patients) were longer los in acute care (p 0.002), number of tests
obtained during sub-acute stay (p 0.001), presence of cognitive
deficits (p 0.009), coronary artery disease (p 0.02) and lower BMI (p
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0.03). Age and subsequent admission to the sub-acute unit did not influence
the presence of anemia.
Conclusions: A high percentage of elderly patients were admitted
to the sub-acute unit with anemia; nearly 30% of these patients
acquired anemia during the hospitalization. However, subsequent
blood draws during sub-acute care did not worsen underlying anemia.
Patients admitted without anemia experienced more significant
decrease in hemoglobin level during both acute and sub-acute stay.
This finding warrants further investigation. Judicious testing, use of
pediatric tubes and elimination of routine ordering may decrease the
risk of anemia.
Key words; anemia; elderly; sub-acute; hospitalization
C88
C-Reactive Protein Fails to Predict Geriatric Depression: The
Cardiovascular Health Study.
D. C. Hsu, 1,2 D. Tancredi, 3,4 C. Hirsch. 1,4 1. Internal Medicine,
University of California, Davis, Sacramento, CA; 2. Psychiatry,
University of California, Davis, Sacramento, CA; 3. Pediatrics,
University of California, Davis, Sacramento, CA; 4. Center for
Healthcare Policy and Research, University of California, Davis,
Sacramento, CA.
Background: Although depression and inflammation are associated
with an increased risk of cardiovascular outcomes (CVO), the
extent to which depression is in the causal pathway between inflammation
and CVO is unknown. Our objective was to assess whether
higher levels of C-reactive protein (CRP) are associated with greater
increases in depressive symptoms among older persons up to eight
years after baseline measurement.
Methods: We performed a retrospective analysis of data from
the Cardiovascular Health Study (CHS), a prospective cohort study
of 5,888 persons 65 and older from four communities in the U.S. They
included Forsyth County in North Carolina, Washington County in
Maryland, Sacramento County in California, and Allegheny County
in Pennsylvania. 5201 men and women aged 65 and older enrolled in
the original cohort group of 1989, along with 687 African-American
participants in 1992 and 1993. Levels of CRP were obtained at baseline
and year 5 of the study, and depression was evaluated with the 10-
item Center for Epidemiologic Studies Depression Scale. Selected via
directed acyclic graphs, variables for demographics, chronic medical
diseases, medications, and life events were controlled in the multiple
linear regression models for changes in depression score.
Results: No statistically significant association between CRP
and mean changes in depression score was found in this cohort. CRP
levels showed only modest within-person correlation (r=0.25) from
baseline to year 5.
Conclusions: Infrequently assessed levels CRP cannot help predict
geriatric depression up to eight years after initial measurement.
Further study of the relationship between inflammatory markers and
geriatric depression is needed.
C89
Under the radar - previously undocumented dementia among older
veterans on an inpatient medical service.
E. Clark, 1,2 J. Burns, 3,4 L. Leon, 5 E. Gottesman, 1 E. Livote. 1 1. JJ
Peters VA Medical Center, Bronx, NY; 2. Mt. Sinai School of
Medicine, New York, NY; 3. Union Square Family Health, Somerville,
MA; 4. Harvard Medical School, Boston, MA; 5. Staywell Health
Center, Waterbury, CT.
Background: Dementia compromises individuals’ abilities to
live independently and to manage their healthcare and thus often
confounds safe hospital discharge. With advancing age, the incidence
of dementia and the complexity of medical problems increase yet dementia
frequently remains unrecognized.
Objectives: Identify likely cases of previously undocumented
dementia among inpatient older veterans at a VA medical center
Methods:
1) Brief battery of cognitive and functional assessment tools
performed within 48 hours of admission to a general medical service,
January – March 2009
2) Chart review of the electronic medical record (EMR) for
documentation of dementia, memory loss or cognitive impairment
during the year prior to study enrollment
Subjects:
Convenience sample of 50 veterans: all male; median age 77.5
(range 65-91);26.7% did not graduate from high school, 28.9% were
high school graduates, and 44.4% had at least some college.
Results:
Of the 50 subjects, 32 (64%) had no EMR documentation of
memory loss, dementia, or cognitive impairment during the prior
year. Among these, 2 (6.7%) had a Mini Mental Status Exam score <
20/30; 22 (71%) had an abnormal Clock; 8 (25%) named few than 12
animals in 60 seconds. Only 9 (28%) of these 32 subjects had no abnormalities
on cognitive testing. Of the 40 total subjects with at least
1 abnormal cognitive test, 25 (62.5%) reported 2 or more deficits in
IADLs.
Of the 32 subjects with no prior documentation of cognitive impairment,
only 2 had documentation of prior formal cognitive testing.
Of the 18 subjects who did have prior diagnosis of cognitive impairment,
15 (83%) had documentation of prior testing.
Discussion: Cut offs for abnormal test values were chosen to be
consistent with cognitive impairment independent of educational attainment.
While this was a small pilot study, the high prevalence of
abnormal results on cognitive testing coupled with self reported
deficits in IADLs among hospitalized subjects with no prior documentation
of memory loss, cognitive impairment or dementia, supports
the contention that cognitive impairments often go unrecognized
among older veterans. Further studies are needed to assess the
true extent of dementia under-recognition in this population.
C90
Outpatient medication reconciliation: Does accuracy improve if
patients “brown bag” their medications?
E. Sarzynski, S. Zhou, C. Rios-Bedoya, C. Luz. Michigan State
University, East Lansing, MI.
Background: Most medication reconciliation research conducted
in outpatient settings has focused on general medical patients,
where average age is 50-60. Among this cohort, medication discrepancies
are prevalent. Studies often rely on multiple methods to determine
what medications patients are actually taking, including patient
recall, “updated” medication lists, medication containers (“brown
bag” review), and phone interviews. There is little data to suggest that
lists generated by these methods are equivalent.
Methods: A study was conducted to assess whether providerdocumented
medication lists were more accurate among patients that
bring their medications to outpatient appointments (“brown-baggers,”
BBs) compared with patients who do not bring their medications
to appointments (“non-brown-baggers,” NBBs). Subjects were
patients at a community geriatric clinic. Three medication lists were
generated for each subject: 1) a provider-documented list in the patient’s
chart (recorded list); 2) an immediate post-appointment list
(point-of-care list); and 3) a post-appointment telephone interview
(reported list, gold standard). Investigators identified prescriptions
from other providers, non-oral medications, and over-the-counter
medications in order to generate the most robust lists. Completeness
and correctness 1 among these lists were compared between BBs and
NBBs.
Results: The study enrolled 46 cognitively intact elders who
managed their own medications. Average age was 79.8 and 33% were
men. Overall, 89% of subjects self-reported that their physician reviewed
medications during the office visit, although significantly
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fewer NBBs (62%) reported the same. Subjects reported taking an
average of 9.9 medications, of which 5.7 were prescription drugs. Of
the 46 subjects, 34 brought at least 1 of their medications to their office
visit (BBs). Among BBs, only 38% brought all of the medications
they reported taking. Additional analyses are pending, including assessment
of recorded lists for completeness, correctness, errors of inclusion/exclusion,
and comparison of recorded list accuracy between
BBs and NBBs.
Conclusions: Among elderly patients who “brown bag” their
medications for outpatient primary care visits, most do not bring all of
the medications that they report taking. Additional conclusions are
pending.
1 Nassaralla et al. Qual Saf Health Care. 2007. 16: 90-94.
C91 Encore Presentation
Group Medical Visits for Alzheimer’s Dementia Patients and Their
Caregivers.
G. Fujikami, S. Lai. Santa Clara Valley Medical Center, San Jose, CA.
Introduction: Alzheimer’s Dementia (AD) is a growing terminal
disease that affects not only the patients but also their loved ones and
caregivers. Caregiver burden is common and can manifest as mental,
physical, social, and financial problems. Current outpatient models of
care poorly address dementia-related issues. Outpatient group visits
for a variety of chronic diseases have been studied. We applied a similar
model to a group of AD patients and their caregivers. Our hypotheses
were that patients’ behavioral problems and caregiver burden
would be more adequately managed and improved with a
structured group medical visit facilitated by a physician and social
worker.
Methods: 10 patients diagnosed with AD and their caregivers
from a community geriatric clinic agreed to participate in this observational
study. Participants met monthly for 1.5 hours for 1 year.
Group medical visits began with an educational talk of interest to the
group followed by a series of interval histories focused on one patient-caregiver
dyad at a time facilitated by the physician and medical
social worker. Caregivers filled out the Zarit Caregiver Burden Interview
and Neuropsychiatric Inventory Questionnaire before and after
the year-long intervention to assess caregiver stress and the severity
of patient’s behavioral problems. Paired t-tests were employed.
Results: 5 patient-caregiver dyads had complete data sets. There
was a trend toward decrease in caregiver burden and stress as well as
in severity of patients’ behavioral problems at the conclusion of the
group meetings although the results were not statistically significant
(p=0.43 and p=0.09, respectively). 4 of the 5 dyads experienced improvement
in caregiver stress and patient’s neuropsychiatric score. If
the remaining outlier dyad was excluded, scores became statistically
significant (p=0.05 and p=0.02, respectively). Even though that particular
dyad experienced worsening of behavior and caregiver stress, the
caregiver expressed an appreciation for the support from the group.
Caregivers also felt more knowledgeable about AD and about resources
in the community.
Conclusion: Outpatient group medical visits focusing on AD education
and care may be beneficial for reducing both patient behavioral
problems and caregiver stress. Future directions include focusing
on specific ethnic groups and assessing for differences in health
care usage and medical costs.
C92
Gait Speed in Older Patients Admitted to an Acute Care for Elders
Hospital Unit.
G. Ostir, I. Berges. UTMB, Galveston, TX.
Supported By: (R01-AG031178) from the National Institute on Aging
Background. Assessment of mobility on geriatric hospital units
relies primarily on subjective observation or patient self-reports. We
objectively examined the gait speeds of hospitalized older patients.
Methods. Prospective study of 322 patients aged ≥65 years admitted
to a geriatric hospital unit from the community between
March, 2008 and October, 2009. Associations between gait speed
(m/s) and ADLs on length of stay and home discharge were examined
in multivariable logistic and generalized linear regression models.
Results. About two-thirds (206/233) of older patients completed
the walk with a mean gait speed of 0.53 m/s. A strong gradient of association
was found between increasing gait speed and shorter hospital
stays. Older patients unable to complete the walk or with gait
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C94
Exploring the Relationship between Computerized Measures of
Gait and Lower Extremity Function, Balance and Fear of Falling.
E. McGough, H. J. Thompson, T. Le, S. Chaudhuri, G. Demiris.
University of Washington, Seattle, WA.
Background: Up to 40% of elders experience a fall at least annually,
and of those who fall, up to 10% have a significant injury. Even
when no injury occurs, older adults may develop fear of falling, resulting
in self-imposed activity restriction, increasing the risk of falling.
The present study explored the extent to which features of gait measured
by computerized gait analysis system were correlated to measures
of lower extremity function, balance, and self-reported fear of
falling. The goal was to determine if the system was feasible to implement
and would be a useful addition to the clinical armamentarium.
Methods: Community dwelling elders were observed during the
completion of the Short Performance Battery (SPPB), and the Berg
Balance Scale (BBS). Participants were asked to walk at 1) usual pace
and 2) as quickly as possible on the GAITRite walkway. Measures
obtained included gait velocity, cadence, double support time, swing
time variability, and stride length variability. Subjects completed the
Falls Efficacy Scale (FES). Correlations between measures were analyzed.
Results: Mean age of subjects was 88.4 years, 37.5% were male
(N=16). Average SPPB score was 8.06 (SD 2.95) and average BBS
score was 43.75 (SD 11.7). The average FES score reported was 9 (SD
0.97) indicating low concern about falls in this sample despite an average
score on the BBS indicating balance impairment (

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C98
Effect of level of education on regular physical activity in an elderly
population within a Military Health System.
H. Kumar, T. Combest, S. George. Internal Medicine, Walter Reed
National Military Medical Center, Bethesda, MD.
Supported By: No funding to disclose
Background:Previous research has shown that those with higher
levels of education are also more physically active.The effect of level
of education and participation in regular physical activity is currently
unknown among patients aged 60 and older in a military health system.We
conducted a descriptive study utilizing survey data from participants
of a fall prevention program to determine the effect of level
of education on physical activity.
Methods:The study involved surveys of 135 community dwelling
older adults aged 60 and older who were falls clinic participants. The
surveys were conducted over three years.Physical activity and exercise(Regular
physical activity, consisting of 3 days a week for 30 minutes
and at least 2 days with muscular conditioning) was self reported
in the initial screening of all participants in the falls clinic.Demographic
information was analyzed using means and simple frequencies.
Univariate analysis was performed using chi square and the
Fisher Exact test where appropriate, with the primary outcome being
reported exercise.Groups were stratified according to level of education
(high school or less, college education, and graduate level education).Results:135
surveys were collected over the three year study period.
There were almost equal proportions of males (43%) and
females (57%). The average age was 80 years. About one third of the
participants (33%, n=46) reported that were exercising. Of those surveyed,
47% (n=63) reported a high school education, 39% (n=53) a
college education, and 14% (n=19) a masters degree or above.
Among those that reported a high school education, 25% (n=16)
were exercising; those with a college education, 45% (n=24) were exercising;
and those with a masters or higher, 37% (n=7) were exercising.
Univariate analysis did not show a significant difference among
those that reported exercising based on gender (p=0.92). This held
true when analyzed according to exercise and gender among those
with a high school education (p=1.0), college education (p=1.0), and
masters education (p=0.47). Univariate analysis was significant
among groups stratified by education (p=0.03).
Conclusion: Level of Physical activity was positively associated
with the level of education amongst those over sixty in this military
medical system. Lowest level of physical activity was associated with
the high school and lower level education from the three groups.
C99
Can a real-time checklist, automatically generated by the electronic
medical record, predict 30-day readmissions in hospitalized elderly?
A. Khan, 1,2 K. Padua, 1 M. Malone, 1,2 M. Volbrecht, 1 P. Pagel. 1 1.
Aurora Health Care, Milwuakee, WI; 2. University Of Wisconsin
School of Medicine and Public Health, Madison, WI.
Background
Approximately one-fifth of Medicare beneficiaries are readmitted
within 30 days. A software called “ACE Tracker” enables the
health care team to quickly view risk factors that may be correlated
with readmission at the bedside and identify vulnerable seniors in the
hospital.
Research Question
Can a real-time “ACE Tracker” tool embedded in the electronic
medical record (EMR) predict 30-day readmissions?
Description of ACE Tracker and readmission risk tool:
The Acute Care for Elders (ACE) Tracker is a real-time report
that captures relevant data from the electronic medical record of
older patients including: readmission risk score, number of medications,
Morse fall score, urinary catheter usage, functional status,
Braden and pain score.
The readmission risk score is generated from the electronic
medical record ranging from 0-20 based on presence of following risk
factors.
1) Admitting diagnoses: congestive heart failure (CHF), psychosis,
other vascular surgeries, chronic obstructive pulmonary disease
(COPD), pneumonia, gastrointestinal problems 2) Chronic diseases:
CHF, COPD, diabetes mellitus, shortness of breath, skin ulcers,
cirrhosis, leukemia, peripheral vascular disease, stroke, metastatic
cancer, malnutrition, acute respiratory failure, rheumatoid arthritis,
hypertension. 3) Demographics: hospital admission in prior 6 months,
length of stay. 4) Social factors: functional status, medicaid, living situation
and educational barriers.
Validation of readmission risk tool
The readmit risk score was determined for 227 patients at four
hospital on one day and those patients were followed for thirty days
afterwards.
Forty one percent had a value score of 7 or more. Using a cutoff
value of 7, sensitivity was 61%, specificity= 22%, positive predictive
value=12%, negative predictive value= 77%. The positive and negative
likelihood ratios were 0.8 and 1.8.
Univariate and multivariate analyses were performed on variable
predictors available on “ACE Tracker”. The risk of readmission
was correlated with number of medications (p=0.03).
Conclusion
The number of medications variable on “ACE Tracker” correlates
with readmission. The readmission risk score is better in identifying
those who are not at risk for readmission.
C100
Evaluation of a computerized physician order entry (CPOE) alert
program on prescribing of selected drugs among the elderly.
L. E. Rios Rojas, 1,2 I. H. Gomolin, 1,2 P. Lester. 1. Geriatric Medicine,
Winthrop University Hospital, Mineola, NY; 2. Medicine, State
University of New York, Stony Brook, NY.
Background:
Emphasis is placed on reducing adverse drug reactions
(ADR)among elderly. Knowledge of predisposition to ADRs or poor
efficacy may improve prescribing. Diphenhydramine is commonly
prescribed to decrease transfusion reactions or as a hypnotic. Studies
show no efficacy for these indications and use predisposes to ADRs 1 .
Antipsychotics are commonly prescribed in the hospital with potential
for continued treatment despite increased risk of death associated
with their use.
Methods:
Winthrop Hospital is a community teaching institution. CPOE
became operational by 2009. In January 2011, a series of alerts were
built into CPOE for selected medications and include links to relevant
papers. We evaluated the effect of alerts on prescribing frequency
by comparing the number of patients for whom these medications
were prescribed during second quarters of 2009 and 2010 to
the second quarter of 2011. Alerts were created for diphenhydramine,
metoclopramide and all antipsychotics. Prescribing patterns
were evaluated by ascertaining the pharmacy database which contained
all medication orders since the introduction of CPOE. Frequency
was adjusted for total admissions among those over 65 years
during each quarter of interest. Chi square was used to compare pre
and post frequencies.
Results:
Diphenhydramine prescriptions were reduced when comparing
2011 vs. 2010 (38% reduction, RR 0.63, 95% CI = 0.58 to 0.67) p

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with the least efficacy and greatest potential for short term
ADR(e.g.diphenhydramine) may be most amenable to this type of
alert system. Follow up studies to test such systems are warranted.
Ref:
1. Kennedy LD et al. Double-blind trial of acetaminophen vs
diphenhydramine pretransfusion. Transfusion 2008;48:2285-91.
2011 vs 2010 and 2009
C101
Assessment of knowledge gaps relevant to antibiotic stewardship
among health care workers in long term care facilities.
A. Krishna, 1,2 C. Biedron, 2 L. Mody, 5 P. Lichtenberg, 3 R. Severson, 2
C. Cassidy, 3 C. M. Pickney, 4 K. S. Kaye, 1,2 T. Chopra, 1,2 M. Johnson. 4 1.
Infectious Disease, Detroit Medical Center, Detroit, MI; 2. Infectious
Disease, Wayne State University, Detroit, MI; 3. Nexcare Health
System, Westland, MI; 4. Dominican Life Center, Westland, MI; 5.
University of Michigan, Ann Arbor, MI.
Background: Long Term Care Facilities (LTCFs) provide a
major reservoir for multi-drug resistant organisms (MDROs), however
standard Antibiotic Stewardship Programs (ASPs) are lacking in
most LTCFs. The objective of our survey was to identify knowledge
gaps of health care workers [HCWs] relevant to antibiotic stewardship
(AS) at LTCFs.
Methods: A 71 item voluntary survey was completed by health
care workers in August 2011 at two LTCFs (Dominican Life Center a
174 bed facility and Nexcare Health System, a 111 bed facility) in
South East Michigan.
Results: 44 HCWs (36 nurses, 4 infection control professionals, 2
physician assistants and 1 staff physician) responded to the survey.
Mean age of respondents was 42 + 14 and 93% were females. 61% of
respondents believed that over prescribing of antibiotics was a very
important cause of antibiotic resistance. Most respondents believed
that prescriber education [51%], institution specific guidelines [54%]
or accessible advice from infectious disease physician [58%] were effective
interventions in reducing antibiotic resistance.
100% of the respondents were familiar with methicillin-resistant
Staphylococcus aureus [MRSA], 73% were familiar with vancomycin-resistant
enterococci [VRE], 34% were familiar with Klebsiella
pneumoniae carbapenemase [KPC] and 27% were familiar with
extended-spectrum beta lactamase [ESBL]. Percentage of respondents
confident in caring for a patient with MRSA, VRE, KPC and
ESBL were 98, 95, 56 and 47 respectively. 30% and 26% of the respondents
were not familiar with differences between definitions of
colonization and infection respectively.
Conclusions: Significant knowledge gaps among HCWs remain,
specifically related to treating infections with KPCs and ESBLs. Educating
HCWs on the differences between colonization and true infection
is crucial. Formal ASPs are urgently needed in LTCFs to optimize
antibiotic use and decrease colonization pressure by MDROs.
C102
Staff Responses to Resident-to-Resident Elder Mistreatment in
Nursing Homes: Results of a Multi-Site Survey.
A. Rosen, 1,2 M. S. Lachs, 1 K. Pillemer, 3 J. Teresi. 4,5 1. Medicine,
Geriatrics, Weill Cornell Medical College, New York, NY; 2. Emegency
Medicine Residency, New York Presbyterian Hospital, New York, NY;
3. Human Development, Cornell University, Ithaca, NY; 4. Research
Division, Hebrew Home at Riverdale, Riverdale, NY; 5. Columbia
University Stroud Center and New York State Psychiatric Institute,
New York, NY.
Background: Resident-to-resident elder mistreatment (RREM)
in nursing homes is a likely frequent phenomenon that may lead to
severe outcomes for victims and perpetrators. Nursing home staff actions
in response to this behavior may significantly mitigate its impact,
but little is known about prevention and management strategies.
Objective:To identify the most common staff responses to RREM
Methods: We conducted this study as part of a large, multisite
NIA-funded study attempting to estimate the prevalence of RREM
in long term care facilities. For this project, the behavior of 1,688 residents
of 5 nursing homes in New York City was evaluated. Certified
nursing assistants primarily responsible for the care of residents
under study in the parent project were asked about their responses to
RREM during the previous two weeks. A modification of a validated
instrument initially created to measure behavioral problems in nursing
home residents was used.
Results: Staff reported taking some action for RREM incidents
involving 277 residents (16.4%) during the previous two weeks, and
22 different responses were described. Most common responses were:
physically intervening / separating residents (84), talking calmly to
settle residents down (65), and verbally intervening to defuse the situation
(59). Not included among staff responses was requesting consultation
of a physician or psychiatrist.
Conclusion: RREM is a potentially common and dangerous occurrence,
and nursing home staff report many varied responses to it.
Despite this, physicians and psychiatrists are seldom called upon to
assist in RREM prevention and management. The effectiveness of existing
responses and the potential for physician contribution needs to
be examined in greater detail, and comprehensive evidence-based interventions
should be developed.
C103
Care Delivery Consequences of Poor Quality Hospital-to-Skilled
Nursing Facility Transitions: A Qualitative Study.
B. King, 1 A. Kind, 2 A. Gilmore, 1 R. Roiland, 1 K. Pecanac, 1
M. Hovanes, 1 N. Husain, 2 B. Bowers. 1 1. Nursing, University of
Wisconsin, Madison, WI; 2. Medicine, University of Wisconsin,
Madison, WI.
Supported By: This study is funded by a NIA Beeson K23 Award
Background: Poorly executed, transitions from the hospital to
home can result in care fragmentation and lapses in patient safety.
Research has focused on transitions from hospital to home with few
studies on the highly vulnerable population: older adults transferring
from the hospital to a Skilled Nursing Facility (SNF). Nurses in SNFs
design a resident’s plan of care based on orders/information received
from the hospital physician and nursing staff. The purpose of this
study is to explore how nurses in SNFs transition care of residents admitted
from hospitals, the barriers they experience and their views of
the consequences of poor quality care transitions.
Methods: This qualitative study utilized Grounded Dimensional
Analysis, a variant of Grounded Theory. Registered nurses (n=9) employed
at 3 SNFs in Wisconsin participated in focus groups with indepth
interviews. Constant comparisons were used to expand the
richness of the data. Data was analyzed using open, axial and selective
coding.
Results: Nurses in SNFs engage in a complex process of getting
prepared to transition residents from hospital-to-SNFs. Despite this
complex preparation, the information SNF nurses receive from the
hospital is often incorrect or incomplete. Nurses cited multiple inadequacies
of hospital discharge information, including regular problems
with medication orders (including the lack of opiod prescriptions for
pain), little information on resident’s psychosocial/functional history,
and inaccurate information regarding the resident’s current health
status. These inadequacies necessitated repeated call backs to the discharging
hospital, created delays in care delivery to SNF residents
(including delays in pain control), increased SNF staff stress and frustrated
patients/family members. SNF nurses identified a specific list
of information/components that they need to initiate a high-quality
SNF plan of care.
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Conclusions: Nurses in SNFs identify multiple quality deficiencies
in hospital-to-SNF transitions, which they feel impact care. Future
qualitative work with SNF nurses will assist in designing interventions
to improve hospital-to-SNF care transitions.
C104
Primary Care Providers’ Experiences of Assessing and Minimizing
Treatment Burden of Multimorbid Older Adults.
B. Limm, 1 T. B. Hughes, 2 C. Boyd, 2 C. Rand. 2 1. John A. Burns
School of Medicine, University of Hawaii, Honolulu, HI; 2.
Department of Medicine, Johns Hopkins University School of
Medicine, Baltimore, MD.
Supported By: The Robert Wood Johnson Foundation Physician
Faculty Scholars Program, and the Paul Beeson Career
Development Award Program (NIA K23 AG032910, AFAR, The
John A. Hartford Foundation, The Atlantic Philanthropies, The Starr
Foundation and an anonymous donor).
Purpose: Comorbidity is associated with poor outcomes including
worse quality of life, mortality, disability, and complications from
treatment. Older patients with multiple chronic conditions present
substantial challenges to delivering medical care that is both patientcentered
and guideline-based. Patients are often overwhelmed by the
aggregate weight of all the actions and resources that they must devote
to maintain their health. To gain insight into the experience of
managing and treating multimorbid older adults, focus groups were
conducted with 20 primary care physicians. Methods: Participants
were asked to discuss how treatment burden affected the treatment
plans and adherence of older adults with multiple chronic conditions,
and how they made decisions with these patients. Focus group sessions
lasted one to two hours in duration, were audio-taped and transcribed.
Content analysis of data was performed for emergent themes
by two independent investigators utilizing Atlas.ti 5.2. Results: Nearly
all respondents reported challenges in the treatment of patients with
multiple chronic conditions, particularly among patients with complex
medication regimens, financial constraints, inadequate social
support, and those in need of prolonged visits. Findings revealed the
following emergent themes: physicians prioritized treatment decisions
based on patient preferences, level of motivation, finances, disease
severity, and level of social support; system regulations were barriers
to the provision of comprehensive care; and non-physician office
staff was a link to better patient care. Conclusions: Treatment burden
presented challenges by affecting decision-making, actual treatment
plans, and adherence among primary care providers. Research findings
will contribute to the development of a screening tool for health
care providers to assess the burden of prescribed treatments and recommendations
among patients, promote communication between patients
and physicians, and guide medical decision-making regarding
treatment regimens.
C105
For a seat at the table, bring the table: A transdisciplinary model for
aging-related advocacy in non-health policy.
B. Williams, 1 C. Ahalt, 1 D. Faigman. 2 1. UCSF, San Francisco, CA; 2.
UC Hastings, San Francisco, CA.
Supported By: The Langeloth Foundation and The UCSF Program
for the Aging Century
Background: Policy decisions that are not health-specific may
increasingly cause unintended health consequences for older adults.
As a result, broader reaching geriatrics advocacy is needed. Health
Impact Assessment (HIA) is an emerging conceptual model for identifying
the health consequences of policies and communicating that
information to policymakers. Using the HIA transdisciplinary approach,
we convened a roundtable of national experts in geriatrics,
correctional health, and the law to assess “Realignment,” a new criminal
justice policy in California that will redistribute thousands of
older adults from prisons to jails and community corrections. We explored
HIA as a platform for geriatrics advocacy to develop recommendations
to minimize the adverse consequences of Realignment
for older adults.
Methods: The 26 Roundtable participants received a short crossdisciplinary
lecture to convey basic knowledge in 3 areas: geriatrics,
older prisoner health, and Realignment. Next, transdiscipline working
groups brainstormed critical issues to address.Facilitators grouped highpriority
issues into 4 “topic areas” and assigned each to a transdisciplinary
group to develop recommendations. Each group then presented
their policy recommendations to the Roundtable to achieve consensus.
Results: 26 of 32 (81%) invitees participated: Correctional physical
or mental health providers (4), Law professors (4), Public Defenders
or District Attorneys (3), Pre-Trial Diversion or Probation officials
(2), Community service providers for the formerly incarcerated (2),
Criminal justice experts (4), and Academic physicians/geriatricians
(7). Consensus was reached on 6 recommendations: Collect age-stratified
data; Improve access to incarceration alternatives; Develop geriatric
assessments for arrest and incarceration; Expand peer-mentoring
for older inmates; Improve transitions of care; Expand geriatric training
for professionals in contact with older correctional populations.
Each recommendation incorporated the expertise of multiple disciplines.
95% of participants would participate in a similar future event.
Conclusion: While many policy changes could affect older
adults’ health, policymakers in non-health related fields rarely reserve
a “seat at the table” for geriatricians. Our findings show that the
HIA approach works as a mechanism for achieving transdiciplinary
geriatrics advocacy in non-health-specific policy.
C106
Knowledge of and perceived need for evidence-based educational
materials about antipsychotic medication safety by nursing home staff.
C. Lemay, S. Foy, K. Mazor, L. R. Harrold, J. Donovan, A. Kanaan,
B. A. Briesacher, J. Gurwitz, J. Tjia. Geriatrics, University of
Massachusetts Medical School, Worcester, MA.
Supported By: This study was funded by the Agency for Healthcare
Quality and Research.
Background: Given the widespread overuse of antipsychotic
medications among US nursing home (NH) residents, we sought to
identify knowledge of and perceived need for the AHRQ Comparative
Effectiveness Research Summary Guide (CERSG) “Off-Label
Use of Atypical Antipsychotic Drugs”.
Methods: We conducted a baseline needs assessment with 12
NHs participating in a randomized controlled trial evaluating evidence
dissemination strategies. Using a mixed-methods approach, we
conducted in-depth assessments of knowledge, attitudes, and practice
behavior using telephone interviews with NH leadership (administrators,
directors of nursing [DONs], and medical directors), and questionnaires
with NH leadership, consultant pharmacists and direct care
staff. Interviews were transcribed and verbatim responses were coded
independently by 2 project staff. The coding scheme was revised after
each round until substantial agreement (85%) was reached.
Results: Interviews revealed that 70% of medical directors and
46% of DONs & administrators believed that antipsychotics decreased
agitation and controlled harmful behavior; 50% of medical
directors and 7% of DONs & administrators reported knowledge of
the increased risk of morbidity amd mortality due to atypical antipsychotics.
Half of administrators and DONs expressed interest in receiving
information for NH staff pertaining to understanding dementia
and dementia-related behaviors, and 42% believed families would
benefit from information about antipsychotic use for dementia-related
behaviors. Questionnaire results were similar. When leaders
were asked to list any risks associated with antipsychotic use for residents
with dementia, only 17% reported death as a possible adverse
event; licensed nursing staff (RN and LPNs) reported death 5% of
the time. Over half of consultant pharmacists reported that their
biggest barrier to improving medication use in challenging NHs was
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physician resistance to accepting prescribing recommendations, including
gradual dose reductions.
Conclusions: The responses of the NH leaders, staff and consultant
pharmacists suggest widespread knowledge gaps regarding antipsychotic
benefits and risks, and suggest a need for increase evidence
dissemination and broad organizational change.
C107
A Discrete Choice Analysis of Older Adults’ Preferences for
Colorectal Cancer Screening Tests.
C. E. Kistler, 1 T. Hess, 2 M. Pignone, 1 S. Hawley, 3 C. Lewis. 1 1.
University of North Carolina at Chapel Hill, Chapel Hill, NC; 2.
North Carolina State University, Raleigh, NC; 3. University of
Michigan, Ann Arbor, MI.
Supported By: This study was supported by the Agency for
Healthcare Research and Quality K12 HS19468-01 (Kistler) and institutional
support from the University of North Carolina at Chapel
Hill and North Carolina State University.
Background: Tailoring colorectal cancer (CRC) screening tests
to older adults’ preferences may improve adherence to CRC screening.
Given the heterogeneity of health status among older adults, different
attributes other than mortality reduction may be key factors
when deciding upon a preferred CRC screening test. This study aims
to describe older adults’ preferences for colorectal cancer screening
test attributes via a discrete choice analysis.
Methods: We conducted a discrete choice analysis among adults
aged 70 and older who volunteered at either a local Family Medicine
clinic or a local research site. Participants were first asked to rank
four key attributes in order of importance: mortality reduction, risk of
complications, test frequency, and testing procedure. Next, in 10 different
scenarios, they were asked to choose between two hypothetical
CRC screening tests. Each hypothetical test contained varying levels
of the four key attributes. Responses were used to calculate the overall
importance of these attributes. These results were then compared
to the initial ranking exercise.
Results: Preliminary results include 63 participants with a mean
age of 76 years (range 70-90) of whom 51 were White, 11 African
American, and 1 American Indian. All but 3 participants had been
screened at least once for colorectal cancer. Initially, 44% of participants
(28/63) ranked mortality reduction as the most important test
attribute; 44% (28/63) ranked risk of complications second; 40%
(25/63)ranked test frequency third; and 48% (30/63) ranked testing
procedures as the least important attribute. A discrete choice analysis
determined the attribute importance from most to least was: testing
procedure (28%), test frequency (27%), risk of complications (23%),
and mortality reduction (23%).
Conclusion: Older adults appear to have differing preferences
for CRC screening test attributes depending on how the information
is presented. A discrete choice analysis appears to shift older adults’
preference away from prioritizing mortality reduction and towards
other test attributes.
C108
Qualitative Approach to Understanding Medication Challenges
among Older Adults after Hospital Discharge.
D. Liu, 1,2 S. Rennke, 1 H. Chi, 1 M. Steinman. 1,2 1. Internal Medicine,
UCSF, San Francisco, CA; 2. Geriatrics, SF VA Medical Center, San
Francisco, CA.
Supported By: Supported in part by NIH grant 1K23-AG030999
(PI: Steinman, M)
Background: Patients age 65 years and older have a 19% risk of
30 day readmission after hospital discharge, and medication safety
plays an important role in reducing this risk. We piloted a telephonebased
qualitative study to better understand the needs older adults
have with medications after recent hospital discharge.
Methods:The study population included patients 2-4 weeks after
discharge from the general medicine service at an academic teaching
hospital. Inclusion criteria were age ≥65 years, English-speaking, and
discharged home with ≥ 5 medications. We used semi-structured,
open-ended questions assessing problems with medication since discharge,
resources patients have, and what additional help they need.
Transcriptions were analyzed from a grounded theory approach.
For participants who answered “no problems,” we used common scenarios
based on the medical literature as prompts. Concurrent with
our study, hospital discharge nurses attempted to reach all participants
with a standard post-discharge telephone call that included 2
medication questions (Did you fill your prescriptions? Did you understand
your medication instructions?).
Results: We have conducted 9 interviews. All interviewees endorsed
some medication-related problem including adherence, titration,
side effects, and financial difficulty. Three initially denied any
problems, but in response to prompts did endorse at least one. Six of
the participants received the standard post-discharge phone call, but
none of these revealed any medication problems. Participants identified
needs at discharge along themes of lack of communication (“I
don’t think anyone has any time to discuss with me before I left”) and
inclusion of family in discharge planning. Four participants denied
needing any additional help at discharge with reasons being family
support or confidence in self ability. The latter group, however, qualified
their response by saying they did “not yet” need assistance.
Conclusion: Our study suggests that the brief post-discharge
phone call after discharge fails to identify common medication problems
among older patients. The themes of family and communication
suggest focal points for future study and design of discharge programs.
Even participants who denied needing assistance still qualified
their response with a “yet,” suggesting needs are a moving target.
C109
Effects of a randomized controlled trial comparing reimbursement
of care coordination to pay-for-performance in primary care.
D. A. Dorr, 1 G. S. Olsen, 1 M. Pierre-Jacques Williams, 1
C. P. Brunker. 2,3 1. Medical Informatics & Clinical Epidemiology,
OHSU, Portland, OR; 2. Geriatrics, Intermountain Healthcare, Salt
Lake City, UT; 3. Geriatrics, University of Utah, Salt Lake City, UT.
Supported By: The John A. Hartford Foundation, AHRQ
Background:Addressing patients’ longitudinal coordination needs
may reduce hospitalizations and improve quality while lowering costs,
particularly for older adults with multiple chronic illnesses. Yet, most
payment structures are fee-for-service or quality measure-based rather
than coordination-based. We tested the hypothesis that incentives for
care coordination would increase coordination activities and reduce utilization
more than traditional quality measure-based pay-for-performance
in a cluster randomized controlled trial of 6 primary care clinics.
Methods: Clinics were randomized into two arms: 3 received payment
for improvement on a self-selected set of 5 validated quality measures
(quality) and 3 received payment for assessment, education, goal
setting, motivational interviewing, and communication activities (coordination).
All clinics had designated, trained care managers and health
IT that provided interactive quality reports, tracked and reminded
about services, and facilitated risk-based population management. Patients
were eligible if seen twice during the 3 year study period. Patients
were analyzed in two groups: 1) preselected based on risk of hospitalization
and death; 2) enrolled by the care manager. Descriptive statistics
were computed to compare quality and care coordination encounters.
Results: 27,001 patients were eligible for the study; 18% were
preselected as high risk; 15% were enrolled in care management. In
all, 20% of patients were >65; however, they were 50% of high risk
and 36% of referred patients. Coordination clinics performed 1.8
times the coordination activities, including 4.3 times the education,
3.1 times the communication, and 3.9 times the motivational interviewing
as quality clinics. Quality clinics increased their absolute performance
on selected quality measures by 10.8% vs 5.1%.
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Conclusion: The focus of incentives motivated clinic activity, but
the impact of care coordination incentives was greatest. Information
about which had greater effect on utilization, patient outcomes, and
clinic quality metrics is required to determine how to alter health policy.
C110
Person and Organizational Correlates of HEDIS High-Risk Drug
Utilization within Veteran’s Administration Nursing Homes.
D. M. Dosa, 2,1 O. Intrator, 2,1 G. Kochersberger, 3 P. Katz. 4 1. Medicine,
Brown University, Providence, RI; 2. Providence Research
Enhancement Award Program, Providence VA Medical Center,
Providence, RI; 3. Canandaigua VAMC, Rochester, NY; 4. Baycrest
Hospital, Toronto, ON, Canada.
Supported By: Veteran’s Administration
Objectives: A common error described in the literature is the
utilization of high risk medications in the elderly—a population most
likely to experience morbidity. This study evaluates the use of medications
classified by the Healthcare Effectiveness Data Information
Set (HEDIS) as high risk in VA Nursing Homes (NHs) and identifies
any patient/organizational correlates of high use.
Methods: Minimum Data Set (MDS) records from 2009 were
merged with VA Pharmacy Data to identify residents of VA NHs who
received at least one medication on the HEDIS high risk list. Utilizing
HEDIS medication use as a quality indicator (QI), the MDS was
then used to identify patient specific correlates of high use (e.g. demographics,
cognitive status, and functional status.) Organizational
practices within specific NHs were identified from a 2010 VA NH
medical director survey. Descriptive statistics (Chi- Square, t-tests)
were used to test associations between person level variables and a
Poisson Regression analysis was conducted to test associations of organizational
characteristics with the QI.
Results: Of 43,577 veterans residing in any of 132 NHs, 2666
(6.4%) received at least 1 HEDIS medication. Females were more
likely to receive a HEDIS drug (10.5 versus 5.9%). Those with better
cognition (7.1%) were more likely to receive a HEDIS drug compared
to those with intermediate(4.6%) or severe cognitive status (4.0%).
Conversely, residents were more likely to get a HEDIS medication as
their functional status declined on a 28-point scale. Among organizational
correlates, increased HEDIS medication use was noted at
homes with increased hospice care, short stay rehabilitation, low cognitive
impairment, and higher acuity. Decreased HEDIS use was associated
with the perception of greater physician supervision by the medical
director (Estimate: -0.69, 95% confidence interval (CI) -0.94 to
-0.43) and by the perception of better NH leadership (Estimate: -0.47;
95% CI: -0.73 to -0.21).All estimates were significant at less than 1%.
Conclusions: The HEDIS QI appears to be important in targeting
veterans receiving high risk medications in VA NHs. Certain subpopulations
are at higher risk for receiving HEDIS medications and
can be targeted for quality improvement efforts.
C111
Food Access in Aging Adults with Impaired Mobility.
D. L. Huang, 1,2 D. E. Rosenberg, 3 S. D. Petz, 4 B. Belza. 4,5 1. Veterans
Affairs Puget Sound Health Care System, Seattle, WA; 2. Division of
Gerontology and Geriatric Medicine, University of Washington,
Seattle, WA; 3. Group Health Research Institute, Seattle, WA; 4. School
of Nursing, University of Washington, Seattle, WA; 5. Health
Promotion Research Center, University of Washington, Seattle, WA.
Supported By: FUNDING: CDC Prevention Research Centers
Program, through a grant to the University of Washington Health
Promotion Research Center (cooperative agreement #U48-DP001911).
Dr. Huang receives salary support from the Department of Veterans
Affairs Advanced Fellowship in Geriatrics.
BACKGROUND: Food access is essential and may be difficult
for aging adults, especially those with impaired mobility. Many aging
adults may not live near locations where they can access food outside
their residence, such as grocery stores. The purpose of this study was
to determine where aging adults access food and built environment
factors affecting their ability to access food.
METHODS: Thirty-five older adults living in the Seattle, WA
metropolitan area who used assistive mobility devices completed
in-depth interviews focusing on built environment barriers and facilitators
in their neighborhood and wore a Global Positioning System
(GPS) device for 3 days. Qualitative data analysis of 20 interviews
to date was completed to date by 2 researchers using Atlas.ti
software.
RESULTS: Participants’ mean age was 66.8 years (range 50-86
years), 9 (25.7%) lived in low-income ( 80 years
old, but evidence-based guidelines specific to the elderly are scarce.
OBJECTIVES To correlate serious episodes of hypoglycemia
(blood sugar < 65 with symptoms) with patient-specific factors and
medication use. METHODS Prospectively designed retrospective
explicit electronic chart review of 140 patients randomly selected out
of a pool of 525 consecutive patients with diabetes that visited our
clinic 8/1-10/30/2010. We excluded subjects as follows: age < 65
(n=3), mislabeled as diabetics (n=6), no follow up visit
4/1–10/30/2011 (n=6), or no follow up HbA1c after enrollment
(n=8). Serious hypoglycemia was defined as blood sugar less than 65
with reported symptoms. Chi 2 and logistic regression techniques
were used to investigate the efficacy (levels of HbA1c, LDL) and
safety (serious hypoglycemia) of chosen medication classes and
achieved therapeutic goals. RESULTS The mean age was 78±8 years
(range 65-100). Other baseline characteristics and univariate results
are shown in table 1. 96% were on statins, yet only 32% had an LDL

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Table 1. Effect of co-morbidities and medications on 1-year rate of
hypoglycemia in elderly patients
§ Comparison of hypoglycemia rates with vs. without factor
C113
Baby Boomers Caring for Aging Parents: Pilot Data from a
Validated Survey Measuring Caregiving Effect on Attitudes,
Expectations and Healthcare Practices of Caregivers.
D. Kaplan, 1 L. Kaplowitz, 2 M. Reid, 1 E. Finkelstein. 1 1.
Medicine/Geriatrics, Weill Cornell Medical College, New York, NY; 2.
State University of New York, Buffalo, NY.
Purpose: Over 45 million adult children provide informal care
to aging parents. The effect of caregiving on caregiver’s health and
well-being has been well documented. However, little information exists
regarding how providing care for an aging parent affects caregivers’
attitudes, expectations and behaviors toward their own aging.
This study uses a novel, validated survey instrument that aims to expand
our knowledge of caregiving and its effects in those particular
domains. Pilot data are reported here.
Methods: The Caregiver’s Aging Trajectory Survey (CATS) is a
41-item instrument that measures respondents’ attitudes of and expectations
for aging, plans for aging and healthcare practices of caregivers
providing or who have provided care to aging parents. CATS
also captures relevant data about caregivers and the quality and extent
of the caregiving experience. Participants are being recruited at
an urban academic geriatric practice, as well as at local caregiver support
groups. Our target “n” is 100 caregivers and 100 non-caregiver
controls.
Results: As of 12/5/11, we have collected data from 58 adult
child caregivers. Mean age is 56 (SD +/- 5), 82% female, 58% married,
77% Caucasian. Time spent caregiving ranges from 40 hrs/wk.
Participants are well-educated (64% college graduates), 58% rate
their own health as excellent or very good; 40% report feeling depressed.
Caregiver strain was reported as severe in 55% of participants
using the Caregiver Strain Index (> or = 7 on a scale of 1-13).
Caregiver’s expectations regarding aging (as per Expectations Regarding
Aging Survey-12, which is on a scale of 0-100, 0=lowest) are
low overall – mean of 34 for physical health and 36 for cognitive function.
Though 78% reported having a routine check-up in the past
year, only 10% reported having advanced directives, 24% a living
will, and 29% a health care proxy. 24% of participants indicated that
they had long-term care insurance, and of those who had not, only 18
indicated that they may plan to in the future.
Conclusions: The purpose of the present study is to gain a better
understanding of the nuanced effects of caregiving on the aging
child caregiver. This can in turn help the health care system provide
better care to the growing number of baby boomers who are informal
caregivers.
C114
How similar are Medicaid’s PACE payments to its outlays on
alternative long-term care for comparable patients?
G. D. Wieland, 1 B. Kinosian, 2 E. Stallard. 3 1. U South Carolina,
Columbia, SC; 2. Department of Medicine, University of Pennsylvania
School of Medicine, Philadelphia, PA; 3. Center for Population Health
and Aging, Duke University, Durham, NC.
Supported By: None to declare.
Background. In rebalancing from nursing homes [NH], states
are increasing access of NH-certified dual eligibles to aged/disabled
waiver programs, and—in 29 states—PACE. Evaluations using community
controls suggest Medicaid’s [MA] PACE capitation exceeds
its spending for alternative fee-for-service [FFS] care. By design, these
studies did not compare PACE payments to outlays for patients with
equivalent health deficits/needs in both waiver and NH. Here, we develop
a multiattribute model of PACE-eligible admissions to waiver,
NHs and PACE to test whether MA PACE payments are lower than
FFS outlays for equivalent controls. Methods. Using grade-of-membership
methods, we model health deficits for duals >= 55 admitted
from 1997 to 2005 (n=3,988) using SC data. Pure patient types, membership
vectors, and program type prevalences are described. We calculate
a PACE blend-—fitting PACE between waiver & NH entrants.
FFS utilization was measured to 1-year from admission and converted
to attrition-adjusted FY05$ outlays. The PACE blend locates
FFS estimates for PACE entrants between mean waiver and NH payments,
adding the waiver base cost. PACE’s capitation is then compared
to the expenditure prediction. Results. Four clinical types describe
population health deficits/service needs. The waiver cohort is
most represented among the least impaired type (1: 47.1%), NH entrants
in the most disabled (4: 38.5%). PACE’s highest prevalences
were in Types 3 (32.7%) & 2 (32.3%). PACE’s blend probabilities are:
Waiver—0.5602; 95% c.i., 0.5472, 0.5732, and NH—0.4398; 0.4268,
0.4528. MA attrition-adjusted 1-year per capita payments for waiver
& NH were $4,177 & $77,945. The PACE blend is 43.98% of the difference
atop the waiver base, i.e., $36,620 (95% c.i.: $35,662, $37,580).
PACE’s MA capitation was $27,648—28% below the lower limit of
predicted FFS payments for the PACE cohort. Discussion. PACE entrants
in SC comprise a 56/44% blend of the health deficits/service
needs of waiver & NH patients. PACE’s capitation was well below
outlays for equivalent patients in alternative placement—a substantial
savings for the MA program. Further, our methods provide an element
of PACE rate setting which states presently lack.
C115
Hospitalizations and Emergency Room Visits in Older Adults
Receiving Care Transition: a Cohort Study.
H. Syed, K. Swanson, A. Rahman, J. Naessens, N. Shah, G. Hanson,
P. Takahashi . Mayo Clinic, Rochester, MN.
Background: Management of care transitions from the hospital
to home is an important area of need for older adults. It has been
widely recognized that older adults are readmitted to the hospital at
high rates which can potentially be reduced. Our clinical practice has
initiated a nurse practitioner (NP) care transitions program (CTP) to
help address the immediate needs of the patient after hospital stay.
The aim of this study was to determine the change in number of hospitalizations
from the 60 days prior to enrollment in CTP to 60 days
after enrollment in CTP.
Methods: This was retrospective cohort study of patients within
CTP from March 2011-September 2011. Patients discharged from the
hospital were selected for CTP based on risk stratification using the
elder risk assessment index. The intervention included a home visit by
the NP after discharge (within 7 days as goal). Primary outcomes included
a within group comparison of average hospitalizations, number
of hospital days and average emergency room visits for all subjects.
McNemars test or paired t tests were used for analysis.
Results: 95 subjects were enrolled in the cohort. The average
number of hospitalizations prior to CTP enrollment was 1.03 (SD
0.7) compared to 0.38 (SD 0.6) after enrollment (p value

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flect the natural course of healing for these individuals. This within
group study points to a potentially better model of care for at-risk
older adults.
C116
Discharge, Drugs, and Discrepancies: The Pharmacological
Intervention in Late Life (PILL) Project.
A. M. Paquin, 1,2 T. Kostas, 1,3 M. Salow, 1,2 J. L. Rudolph. 1,3 1. Geriatric
Research Education and Clinical Center (GRECC), VA Boston
Healthcare System, Boston, MA; 2. Pharmacy Department, VA
Boston, Boston, MA; 3. Aging, Brigham and Women’s Hospital,
Boston, MA.
Supported By: Department of Veterans Affairs, Office of Geriatrics
and Extended Care (GEC) Patient-Centered Alternatives to
Institutional Care Initiative
Background: Hospital discharge, polypharmacy, and medication
discrepancies pose risks for elders, especially when they occur simultaneously.
The Pharmacological Intervention in Late Life (PILL)
Project is a quality improvement program that provides proactive
medication follow-up after a hospital stay. We aim to reduce acute
care utilization by addressing medication discrepancies and difficulties
in older patients.
Methods: This project targeted veterans >65 years old with
cognitive impairment, who were discharged home after an inpatient
admission at VA Boston. Patients received PILL pharmacist followup
after discharge which included: telephone medication review
and evaluation of regimen for pharmaceutical care issues (i.e. dosing,
drug interactions, etc.) and medication discrepancies. Medication
discrepancies were collected by comparing discharge medication
lists and actual medication orders. Patients were followed 60
days after discharge for the primary outcome of acute care utilization
(readmission, emergency department or urgent care visit) or
death.
Results: Of 285 eligible veterans, 242 patients with a mean age
of 78.9 ± 8.0 were reached by PILL pharmacist after discharge. Patients
with PILL follow-up were not significantly different than
those without (n=43) with respect to age, number of medications,
length of stay, or discrepancies. The mean number of discharge medications
was 15.1 ± 5.8, with 2.9 ± 2.3 medication changes per patient.
Among veterans receiving PILL intervention, fifty-nine percent
(59%, n=143) had at least 1 medication discrepancy, with an
average of 1.5 ± 2.1 discrepancies per patient. After adjustment for
number of medications and discrepancies, patients with PILL follow-up
had a 24% relative risk reduction in acute care utilization or
death compared to those with usual care (RR 0.76, 95% CI 0.58-
0.98).
Conclusion: Cognitively-impaired elders were discharged
home with medication lists characterized by polypharmacy, frequent
medication changes, and discrepancies. The PILL Project
demonstrated that pharmacist telephone medication review and
reconciliation results in a significant reduction in acute care utilization
or death after hospital discharge. Pharmacist post-discharge
medication follow-up shows promise as a successful model
of care.
C117
The VA Coordinated-Transitional Care (C-TraC) Program: A
Registered Nurse Telephone-Based Initiative to Improve Transitions
for Hospitalized Veterans with Dementia and Other High-Risk
Conditions.
A. J. Kind, 1,2 L. Jensen, 2 S. Barczi, 1,2 A. Bridges, 1,3 R. Kordahl, 3
M. Smith, 1 S. Asthana. 1,2 1. Univ of Wisconsin, Madison, WI; 2.
Madison VA Geriatric Research Education and Clinical Center
(GRECC), Madison, WI; 3. William S Middleton VA Hospital,
Madison, WI.
Supported By: This project was supported by a VA Transformation-
21 Grant and by a National Institute on Aging Beeson Career
Development Award (K23AG034551, National Institute on Aging,
The American Federation for Aging Research, The John A.
Hartford Foundation, The Atlantic Philanthropies and The Starr
Foundation). Additional support was provided by the University of
Wisconsin School of Medicine and Public Health’s Health
Innovation Program, and the Community-Academic Partnerships
core of the University of Wisconsin Institute for Clinical and
Translational Research (UW ICTR), grant 1UL1RR025011 from
the Clinical and Translational Science Award (CTSA) program of
the National Center for Research Resources, National Institutes of
Health.
Background: The Accountable Care Act encourages dissemination
of evidence-based transitional care programs designed to improve
patient safety and outcomes after hospital discharge, but no existing
program fully addresses the challenges of distance, dementia
and patient vulnerability common in a Veterans Affairs (VA) hospital
setting. Our objective was to test the feasibility of C-TraC — a low-resource,
nurse-led, telephone-based program which builds upon Coleman’s
transitional care model and is designed to improve care coordination
and outcomes in hospitalized veterans with dementia and
other high-risk conditions.
Methods: C-TraC launched at Madison VA Hospital in April
2010. Hospitalized veterans discharged to community settings had
to have dementia/delirium/cognitive impairment, or had to live
alone or have prior hospitalizations and be >65 years to be eligible.
Veteran characteristics, process measures and outcomes were
abstracted from the medical record for all eligible patients during
the 6 months prior to the intervention launch (N=144) and for patients
enrolled in C-TraC during its first 6 months of operation
(N=116).
Results: In the first 6 months, C-TraC successfully enrolled 116
veterans using 1.0 FTE nursing staff. No patients refused enrollment.
52% of C-TraC veterans had medication discrepancies detected/rectified
during the 48-72-hour post-discharge phone call, averaging 2 discrepancies/veteran
(range 0-9). As compared to usual care, C-TraC
veterans were more likely to leave the hospital with a scheduled follow-up
appointment (85% vs 60%, p

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C118
Patient and Family-Centered Rounds on a Geriatric Inpatient
Service: Patient Perspectives.
A. M. Stecher, 1 J. D. Schlaudecker. 1,2 1. University of Cincinnati,
Cincinnati, OH; 2. Department of Geriatric Medicine, University of
Cincinnati, Cincinnati, OH.
Supported By: Funded with support from a Geriatric Academic
Career Award and the American Federation of Aging Research
Medical Student Training in Aging Research.
Background: While well studied in the pediatric setting, little is
known about the application of patient- and family-centered rounds
(PFCR) to the geriatric population, but the potential for care improvement
is great. PFCR is a model for empowering patients and
families and improving communication and care in the hospital. In
contrast to traditional rounding, PFCR occurs at the bedside and actively
includes patients and families as well as other members of the
healthcare team.
Methods: Fourteen adults (mean = 68 years) admitted to the
Christ Hospital received either traditional care (n=4) or PFCR
(n=10) during their stay. Patients and their families were asked to
participate in semi-structured interviews focused on:
-communication with physicians
-satisfaction
-clarity of DC instructions
Follow-up interviews via phone were performed two to four
weeks following discharge.
Results: Statistical comparison of the Likert ratings between patients
receiving PFCR and traditional care were inconclusive due to
small sample sizes; however, descriptive statistics found no apparent
differences between these groups. During the interviews, patients expressed
very positive opinions about care under PFCR.
“I felt I wasn’t alone and someone was in my corner, trying to
find out what was happening in my body. It was great to get an update
on a daily basis…It was comforting, really, to have so many heads in
on it.”
Patient 514 - PFCR
“In the past, you get one doctor and you feel like you are taking
up their time, whereas when there are a lot of people here you feel
like they are here as a group to answer questions…I really like that!”
Daughter 511 - PFCR
Conclusions: The positive responses of those receiving PFCR indicate
that PFCR can lead to positive care experiences for geriatric
patients and their families. The similar Likert ratings of care quality
statements between those receiving PFCR and traditional care
demonstrates that PFCR is at least as effective in providing quality
care as traditional care. However, the positive interview responses of
patients and families receiving PFCR suggest that PFCR may result
in higher satisfaction among geriatric patients and their families.
More research is needed with a larger sample to investigate how
PFCR outcomes and satisfaction compare to traditional care.
C119
The PACE Approach to Keeping Older Adults with Dementia in
Private Homes.
A. Dunbar, 1,2 K. Ward, 1 A. Beeber. 1,3 1. Cecil G Sheps Center for
Health Services Research, Chapel Hill, NC; 2. School of Medicine, The
University of North Carolina at Chapel Hill, Chapel Hill, NC; 3.
School of Nursing, The University of North Carolina at Chapel Hill,
Chapel Hill, NC.
Supported By: AFAR Medical Student Training in Aging Research
Program 2010 (Recipient: Anne Dunbar), NC TraCS CTSA Pilot
Award (Awardee: Dr. Beeber), Building Interdisciplinary Careers in
Women’s Health K12 Career Development Award (Awardee: Dr.
Beeber)
Background: Evidence suggests that the multidisciplinary care
provided by Programs of All-inclusive Care for the Elderly (PACE)
can postpone or prevent nursing home placement for older adults.
PACE participants with dementia are one of the most challenging
subpopulations within PACE because they require complex care
management. Thus, we aim to examine the challenges PACE sites
face and the services they have found to be the most useful in successfully
keeping PACE participants with dementia in private homes.
Methods: This analysis examines the data from a web-based survey
of 32 PACE sites from 19 different states. The survey respondents
were composed of leadership personnel within the PACE sites. Three
independent coders performed a qualitative content analysis, reviewing
text responses from two questions: 1)What are the biggest challenges
your program faces when trying to keep participants with dementia
in a private home? and 2)What have you found to be the most
useful for helping these participants stay at home? The text responses
were coded for similarities and then were categorized. The research
team met to discuss similarities and differences found during coding
and reached consensus on the main categories for each question.
Results: Survey respondents reported that issues relating to
family caregiving are the biggest challenges faced when trying to
keep participants with dementia in a private home. Availability and
commitment of the family, stress and burden of caregiving, caregiver
burnout, and PACE providing support for the family were all identified
as challenges. Respondents identified safety concerns, behavioral
changes, medication management, cost, staffing, PACE in-home services,
importance of early enrollment, and care plan compliance as barriers
to keeping these participants in private homes. Respondents reported
that day center attendance was the most useful for helping
participants with dementia stay at home as well as home health, family
caregiver support, personal companions, dementia specific strategies,
and respite services.
Conclusions: The results from this work will provide information
about the types of services used to provide care for PACE participants
with dementia. Conclusions will include recommendations for
future practice and research.
C120
Interventions to Prevent Hospitalizations of Elderly Patients:
Quality Care with Cost Benefit.
A. Kaul, M. Bansal, R. Bhandari. Wyckoff Heights Medical Center,
Brooklyn, NY.
Background:
Repeated hospitalizations of geriatric patients stigmatize the
quality of care and place an added strain on the economics of healthcare
delivery. Over the past two years at Wyckoff Heights Medical
Center (WHMC), we have established three different heath care delivery
goals for our geriatric patients; 1) extend services to home
bound patients, 2) carefully survey and manage nursing home (NH)
residents, and 3) promote palliative care services and counseling.
These agendas provide high quality care and have significant cost
benefit in preventing futile hospitalizations and unnecessary aggressive
treatment.
Methods:
1) HOPE Program: Conduct visits for home bound elderly patients
by geriatric MD or NP, closely monitor functional decline and
medication compliance, provide certain lab/radiology services and
preventive management; and avoid progression to long term care facility.
2) INTERACT II Program: Established modified clinical pathways
for early recognition and management of patients at the NH to
decrease ER transfers and subsequent inpatient admissions. Formed
a partnership between healthcare providers at the NH and WHMC
through coordinated care and communication, allowing for ER evaluation
and management of certain acute care conditions (eg. PICC
line, peg tube replacements) without admission. 3) Enhancing Palliative
Care: Expanding palliative care service at WHMC by dedicating
hospital beds and advocating physician accountability through policy
changes and awareness.
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Results:
The HOPE program has 175 enrolled patients, showing 25% reduction
in acute care hospitalizations, only 5% readmission rate, and
a cost saving of $1.3million/year. The INTERACT II program has
generated a saving of at least $500,000/year in avoided inpatient admissions.
The Enhanced Palliative Care program is estimated to reflect
a cost avoidance of $600,000 over the first two years by minimizing
aggressive management.
Discussion:
In today’s climate of healthcare reform, our approach seeks to
improve patient care quality with cost effective implications. We present
a three pronged intervention of managing the most vulnerable
geriatric population through patient centric home monitoring, integrated
care of NH residents, and appropriate evaluation for terminal
care needs. We hope to expand our pilot programs to suit the need of
a managed or accountable care organization.
C121
Transitions Bundle: Ensuring smoother transitions at hospital
discharge.
A. Hayward, 1 R. Rastogi, 2 T. J. Hillstrom, 2 C. A. Barnes. 1 1. Care
Management Institute, Kaiser Permanente, Portland, OR; 2. Sunnyside
Medical Center, Kaiser Permanente, Clackamas, OR.
Supported By: Project undertaken as quality improvement activity
by Kaiser Permanente
Background: Across the US one in five Medicare patients is
readmitted to the hospital within 30 days after discharge. Some readmissions
are preventable. After discharge, patients don’t always know
whom to call with questions, what medicines to take, or how to obtain
follow-up care. Those physicians and clinicians responsible for providing
post-hospital care don’t always receive timely, accurate, and
complete information about these patients.
Methods: Kaiser Permanente’s Sunnyside Medical Center created
a process to improve the transition for all patients discharged to
post-hospital care. First, a diagnostic evaluation identified that 10 to
40% of readmissions were preventable. Next, a design team including
staff and patient input developed, tested and implemented a “transition
bundle”, the aim of which was to improve care for every patient
after hospital discharge. Thirty-day readmission rates were measured
before and after implementation. Components of the “bundle” included
the following:
1. risk assessment and care tailored to likelihood of re-hospitalization
2. standardized discharge summary completed on the day of discharge
and available in the electronic medical record
3. pharmacist’s review of medications, followed by a phone call
to those patients at high risk, as well as review for all patients discharged
to a skilled nursing facility
4. first follow-up appointment scheduled before discharge for all
patients: within five days for those identified at high risk, within 10
days for those at medium risk, and within 30 days for all others
5. follow-up RN phone call within 72 hours of discharge for all
high risk patients
6. discharge instruction sheet with dedicated phone number for
all questions
Results: Overall year-to-date readmission rates at Sunnyside
Medical Center decreased from 12 to 9.8% in 2011 and rates for
Medicare members from 14 to 13%. More than half of patients discharged
were seen for a follow-up visit within five days. Ninety-two
per cent of discharged patients reported that they received written
information.
Conclusions: A transitions bundle composed of six elements improved
continuity of care for patients discharged from the hospital
and has been associated with a decrease in readmission rate.
C122
Changing the norms for trainees to prevent inappropriate
emergency room referrals.
N. K. Patel, 1,2 C. M. Espinal, 1,2 U. T. Efoevobokhan, 1,2 R. W. Parker. 1,2
1. Geriatrics, University of Texas Health Science Centera at SA, San
Antonio, TX; 2. Geriatrics, Christus Santa Rosa, San Antonio, TX.
Background: Transfers between settings of care are referred to
as transitions. Emergency Room (ER) transfers of patients from
nursing homes(NH) for inappropriate reasons is expensive, worsens
patient outcomes, hastens functional decline and decreases the quality
of life. The average wait time in an ER in San Antonio is 4-6 hours.
The average local ER visit for a geriatric patient costs anywhere from
$4,000-$6,000. This project done at the University of Texas Community
Geriatrics directed nursing homes where residents in family
medicine are the first called for the group. On reviewing call center
calls it was noted that many residents from NH were being sent to the
emergency room for inappropriate reasons, majority of the referrals
were afterhours and by trainee residents who were unfamiliar with
the patients, lacked the confidence, knowledge and skill of managing
frail elders.
Objectives:To sustain the norm of preventing inappropriate ER
transfers of patients by trainees from UT Medicine nursing homes by
100% in response to after hour calls. This project also sought to open
a dialogue between the NH, clinical staff, the residents, and the after
hour call center to facilitate better care for the residents in the nursing
homes.
Design: Quality improvement project.
Metric: ER visits of NH patients obtained from call center logs,
calls tracker and chart reviews.
Study Period: July 2010 to June 2011.
Intervention: The norm was changed. All residents in training
could not send a patient to ER without discussing the patient with the
attending on call. The on call team maintains a call tracker and the
call center maintains a log.
Results: Tracking the calls and following the intervention decreased
the number of inappropriate ER visits to zero.The norm is sustained
even beyond a year because of reinforcement and monitoring.
Conclusions: Changing the norm of residents in training helped
reduce the inappropriate ER visits. This also influenced the faculty
behavior. Total number of calls reduced with the use of the SBAR
tool and fact that calls were being tracked.
Next Step: The call logs will continue to be collected from the
clinical staff on call after hours. Complement with the Interact II
program, track day time calls and education of families regarding
ER transfers vs. treatment either in NH or direct admission to the
ACE unit.
C123
Facilitating Geriatric-focused Primary Care Electronically: A
Follow-up.
C. Gardner. Elder Care, Kaiser Permanente, Atlanta, GA.
Kaiser Permanente Georgia recognizes the importance of identifying
and meeting older patients’ needs. In 2010 we developed and
implemented interventions for non-geriatricians to easily address
topics not routinely discussed with younger patients, leveraging our
electronic medical record. A template is used at new patient and annual
40-minute visits for patients 65 and older. This decision support
tool prompts primary care physicians to assess, discuss, and appropriately
document actions re: topics including functional status, incontinence,
falls, cognition, and advance directives. It provides options for
interventions and prompts ordering recommended screenings and referring
to Geriatrics. Patient instructions important in older people
(e.g., regarding screenings, fall prevention, incontinence) automatically
print. The elder-focused review of systems and patient instructions
are also available to all clinicians for use in patients not scheduled
for a comprehensive primary care visit.
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We monitor the template’s use and encourage physicians not
using it to do so. Performance on quality measures such as HEDIS,
which include topics addressed in the template, is measured annually
and has improved. For example, glaucoma screening increased from
54.84% in 2010 to 60.88% in 2011. For a sub-group of our population,
metrics include annual discussion of advance directives, medication
review, assessment of functional status and comprehensive pain
screening. Along with other initiatives, template implementation was
associated with improvements between 2010 and 2011: Advance Care
Planning increased from 22.14% to 70.07%; Medication Review
74.94% to 98.30%; Functional Status Assessment 13.63% to 91.48%;
and Pain Screening from 39.42% to 95.13%. Referrals to our Geriatrics
team increased with template use, from 21 to 35 per month. Issues
identified for referral included previously unrecognized cognitive
disorder/dementia and gait problems/falls.
Because our physicians are now familiar with the need to address
these topics, we recently modified the template and developed
and refined workflows to enable nursing staff to ask many of the
screening questions. This will increase efficiency and better enable
physicians to focus on evaluating and treating the problems identified.
Overall, implementation of the tool appears to be an effective
means of improving primary care physicians’ awareness of, attention
to, and appropriate referral for, issues important in older patients.
C124
Care of the Older Adult Continuing at Home (COACH):
Optimizing Medical Resident Understanding of the patient at home.
D. C. Hayley, 1,2 J. Kalender-Rich, 1,2 B. Lowry, 1 M. Brimacombe. 3 1.
Internal Medicine, University of Kansas, Kansas City, KS; 2. Landon
Center on Aging, University of Kansas School of Medicine, Kansas
City, KS; 3. Biostatistics, University of Kansas School of Medicine,
Kansas City, KS.
Supported By: Landon Center on Aging
Purpose-To determine differences between what Internal Medicine
residents expect to find and what they actually observe on posthospitalization
home visits of frail elderly.
Methods—Internal Medicine Residents on their month of Geriatrics
rotation make a home visit through COACH (Care of the
Older Adult Continuing at Home) on an elderly patient discharged
from the hospital in the last month. After chart review, the resident
completes a pre-visit questionnaire with questions on discharge diagnosis,
predicted functional status, number of medications and support
at home. After the home visit and primary data collection in these
same domains, a post-visit questionnaire is completed including
quantitative and qualitative differences between what was expected
and what was found.
Results—Of the 12 residents who have completed this study
thus far, 10 reported that there was NO difference between diagnosis
on the hospital discharge summary and the patient/family report. In
all cases, the patients had someone with them at all times and 4 residents
reported that this was more supervision than expected. Patient
functional status was different than expected in 5 of 12 cases. There
were from 0 to 16 differences in number of medications at home as
compared to expected and in only one case was it reported that there
were no discrepancies. 10 of 12 residents reported the experience was
superior. Qualitative responses regarding suggestions on discharge of
elderly patients to home include attending to patient’s social support,
functional status and medications. There were repeated requests for
more of this experience in residency.
Conclusions—Residents did a fair job of predicting discharged
patient’s supervision and functional status but still missed many important
issues at home, especially medications the patient is actually
taking. Most residents acknowledged the importance of these aspects
in elderly patients and request more of this geriatrics and home visit
experience in residency. They found this was useful for their learning
and improving optimal discharge practices in the frail elderly.
C125
Safety profile of high dose statin therapy in geriatric patients with
stroke.
D. Manocha, N. Bansal, Z. El Zammar, S. Brangman. SUNY Upstate
Medical University, Syracuse, NY.
Introduction: Use of high dose statins in patients with stroke has
become a standard clinical practice after the SPARCL study in 2006.
Although the mean age of population in SPARCL study was around
63 years, scientific evidence derived from the same has been extrapolated
to much older patients in clinical practice. Very little data is
available on the magnitude of adverse effects of high dose statin therapy
in geriatric patients. Methods: This single-center retrospective
study was conducted at Upstate Medical University, Syracuse, NY.
The goal was to define the magnitude of side effects of high dose
statins in our selected geriatric study population. We reviewed
records of 120 patients between the ages of 65-89 years to collect demographic,
clinical, laboratory & adverse drug reaction data. Data
were compared between patients on high dose statin therapy (cases)
vs. those on regular doses (controls) using Chi square, Fisher exact
test & Student T test. P value

P OSTER
A BSTRACTS
b) the frequency and number of emergency room visits, hospitalizations,
readmissions, and nursing home placements, c) the presence of
a health care proxy and the formulation of advanced directives, d) the
types and extent of services the patient receives from DOROT and e)
instruments to assess patient satisfaction with overall healthcare and
perception of their quality of life. Data will also be collected on patients
cared for under our house call program, using retrospective
data going back to 2007 (n=251) and prospective data on patients currently
being cared for (n=82).
Results and Conclusion: To date, the collaboration has been involved
in the care of 40 patients. In addition, data is being collected
on all 82 patients currently cared for with our house call program and
retrospectively on about 250 patients who had been cared for by our
house call program since 2007. It is hoped that by comparing the information
obtained on the two groups of patients that we can better
understand the impact of providing a comprehensive care program
offered by agencies like DOROT.
C127
A Qualitative Review of Exercise Interventions to Reduce Falls in
Older Adults.
E. Trieu, 1 V. Shier, 2 D. Ganz. 3,1 1. David Geffen School of Medicine at
UCLA, Los Angeles, CA; 2. RAND, Santa Monica, CA; 3. Greater LA
VAMC, Los Angeles, CA.
Supported By: This project is funded by the Archstone
Foundation/USC Fall Prevention Center of Excellence. DAG is supported
by a VA HSR&D Career Development Award. ET was supported
by the UCLA Medical Student Training in Aging Research
program.
Background
Systematic reviews demonstrate that exercise containing balance
training is particularly effective in reducing falls in communitydwelling
elders. However, the best strategy for implementing a balance
program is unknown.
Methods
Two reviewers independently screened 114 full text articles
from 6 systematic reviews of RCTs to prevent falls. Fourteen RCTs of
exercise programs in a medical setting and involving a balance training
component were selected for further review. We identified related
articles that provided experiential insight into the exercise program
of each included RCT by searching the references in, and articles citing,
the RCT. Two reviewers independently abstracted data from the
14 RCTs and their related articles. Data were analyzed using qualitative
data analysis software.
Results
Exercise programs were heterogeneous across target population
and baseline risk of falling, program approach and setting, and exercise
intensity and duration. Many programs were successful in improving
strength, mobility, and/or endurance, in addition to balance.
Facilitators to uptake of exercise programs reported in at least one
study included involvement of health practitioners in the recruitment
process, supervision of exercise (resulting in reduced feelings of isolation),
and individualized training (resulting in recruitment of a
broader participant group). Studies also reported factors that contributed
towards a lack of success in reducing falls or falls risk factors
including the population being too healthy or lacking balance problems,
lack of supervised exercise, and low adherence due to an unhealthy
population. Authors mentioned the positive effects of group
training on promoting adherence and group cohesion. Convenient locations,
opportunity for social interaction and pleasant environments,
and overall enjoyment were also noted as factors that promote adherence.
Several programs reported patient enjoyment but did not
necessarily show high adherence.
Conclusions
Exercise programs to prevent falls are not “one-size-fits-all”
programs. Because patient adherence is an important aspect of an exercise
program’s success, special consideration to a patient population’s
baseline health measures, needs, and interests improves participant
enjoyment, potentially resulting in greater effectiveness.
C128
The high diagnostic yield of an outpatient geriatric clinic.
F. Moret, H. Jaccard-Ruedin, C. Bula, S. Monod. Service of geriatrics
medicine and geriatric rehabilitation, Epalinges, Switzerland.
Background: Primary care physicians have limited time to perform
comprehensive geriatric assessment. Interdisciplinary outpatient
geriatric clinic might assist primary care physicians in early
recognition and management of geriatric syndromes. The objectives
of this study were 1) to determine characteristics of patients referred
to an outpatient geriatric clinic; 2) to determine the prevalence of
geriatric syndromes in this population; 3) to identify main recommendations
made to primary care physicians.
Method: Database from the outpatient clinic of the service of
geriatric medicine was analyzed. It includes demographic, social,
functional and medical data, as well as recommendations made for
primary care physicians.
Results: Subjects (N=146) were all community-dwelling older
patients (79.1±7.4 years, 56.2% women, 50.7% living alone, 34.9% receiving
home care), referred by a primary care physician, an hospitalist
or a family member (79%, 15% and 6% respectively). Main reasons
for referral were request for comprehensive assessment,
cognitive evaluation, and mobility assessment (41.8%, 28.1%, and
15.8%, respectively). Mean performances at Katz’s Basic ADL and
Lawton’s instrumental ADL were 5.3±1.1 and 4.7±2.8, respectively,
and 54.1% of patients reported a fall over the past year. Overall,
74.7% of patients were newly diagnosed with gait and balance impairment,
71.9% with cognitive impairment, 52.7% with affective disorder,
52.1% with osteoporosis, 43.8% with urinary incontinence,
32.2% with orthostatic hypotension, and 55.5% with polypharmacy
(≥6 different drugs; median 6±3.9, IQR 1-11). A mean number of
12.7±4.2 recommendations was made for each patient. Overall, 87.6
% of patients were given recommendations about fall prevention:
walking aid adaptation (54% of all patients), vitamine D prescription
(53%), home hazards assessment (52%), and exercise prescription
(46%). Half (51.7%) of the patients received a recommendation for
referral to a memory clinic. Treatment modifications were proposed
in 80.8% of patients with polypharmacy (mostly psychotropic drugs
discontinuation).
Conclusion: In this population of elderly outpatients, polypharmacy,
mobility and cognitive impairments were highly prevalent. Outpatient
geriatric consultation is a good opportunity to identify new
geriatric syndromes and to propose interventions aiming at functional
decline prevention.
C129
The Fracture Care and Prevention Program: an integrated model of
care to prevent reoccurrence of minimal trauma fractures.
G. Loza-Diaz, 1 E. Thembani, 1 O. Demontiero, 1,2 A. Sharma, 2
G. Duque. 1,2 1. Ageing Bone Research Program, The University of
Sydney, Penrith, NSW, Australia; 2. Geriatric Medicine, Nepean
Hospital, Penrith, NSW, Australia.
Supported By: Servier, Sanofi-Aventis, Novartis, Nepean Medical
Research Foundation
BACKGROUND: Patients that experience a minimal trauma
fracture are at higher risk of experiencing another fracture. Yet, very
few patients, especially the elderly, are identified and provided with
an appropriate plan to prevent further fractures.
OBJECTIVE: To describe the implementation and evaluation
of an osteoporotic fracture prevention in a geriatric setting.
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PROGRAM STRUCTURE AND PROCESS: The Fracture
Care and Prevention Program is a model of care designed to intervene
when the first minimal trauma fracture occurs. A nurse coordinator
(attached to a geriatrics department) identifies patients with
minimal trauma fractures in hospital wards, rehab department, emergency
department and local health centres. This coordinator provides
patients with educational materials about osteoporosis and fractures,
provides recommendations for vitamin D and calcium supplementation,
encourages exercise and explains the specific treatment for osteoporosis.
Patients are also referred to bone density testing. The patients’
family doctor is informed of the assessment to reiterate the
recommendations provided to the patient, and for referral to a specialist
at the Falls and Fractures Clinic.
PROGRAM OUTCOMES: From January to August 2011, 82
patients were registered with the Fracture Care and Prevention Program.
At follow-up post-discharge from hospital (8 weeks), 51% of
patients were referred to the Falls and Fractures Clinic (13% attended),
32% started gentle exercise, and 40% read the educational
materials provided. The number of patients taking vitamin D increased
from 12% to 40%. The number of BMD tests increased 25%.
In addition, 28% had a discussion with their physician about osteoporosis
and treatments. Finally, the number of prescription for osteoporosis
treatment increased in 32%.
CONCLUSIONS: The Fracture Care and Prevention program
is an effective model of intervention to increase awareness of the importance
of falls and fractures prevention in older persons, not only
to the patients but also to their physicians. This model, run by a nurse
coordinator, is cost effective and easily implemented in a geriatric
setting.
C130
Profiles and Characteristics Associated with Rehospitalization of
Patients in a Sub-Acute Rehabilitation Facility.
H. Guzik, 1 N. Sharma, 1 A. Gupta, 1 N. Arif, 1 C. Nouryan, 1
R. Pekmezaris, 1 M. Lesser, 2 G. Wolf-Klein. 1 1. North Shore-LIJ
Health System, New Hyde Park, NY; 2. Feinstein Institute for Medical
Research, Manhasset, NY.
Background: Reduction of unnecessary rehospitalization of patients
has been identified as an important goal in geriatric medicine.
We studied hospital readmission patterns of patients receiving care at
a 258-bed sub acute rehabilitation facility.
Methods: Retrospective chart review of 100 patients (50 rehospitalized
[RH] and 50 not rehospitalized [NRH] within 60 days of admission),
randomly selected between 1/2011 and 9/2011.
Results: When comparing RH and NRH, demographic analysis
revealed a significant difference with regard to age (80.6 vs 75.7 respectively,
p

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medical assistant. We work closely with all community agencies to
help maintain the patient in the community as long as possible.
Methods: Home visit patients (N=590) were identified by a log
maintained by home visit staff. The patients were linked to hospital
information system data by medical record number to obtain demographic
and hospital encounter information (N=539). Only patients
with identifiable hospital admissions prior to or post 180 days to the
program entry were included in the before and after comparison
(N=387). A comparison group (N=1273) was defined as Medicare patients
with 3 or more inpatient admissions in calendar year 2008 who
were not enrolled in HV program. Primary outcome measures were
ED visits, hospital admissions, and length of stay at 30 and 180 days
pre- and post-home visit enrollment. Secondary measures were patient
days in the HV program and discharge disposition.
Results: Approximately 55% of the HV patients had death as
their primary reason for discharge from our program. Average number
of patient days in the HV program was 285 days.
Patients had worse primary outcome measures prior to enrolling
in the HV program. After entering the HV program, 30 day
ED visits and inpatient admissions were reduced by 26% and 34% respectively.
At the 180 day interval, this effect was still sustained with
ED visits reduced by 9% and inpatient admissions by 28%. When
compared to the non-HV comparison group, the HV outcomes were
favorable as the comparison group had a 55% 180 day readmission
rate. Of note, our case mix index (1.74) was higher than the comparison
group (1.66).
Length of stay for our cohort of patients prior to the HV program
was 8.0 days. After enrollment, LOS was 6.2 days which again
compares favorably to the non-HV comparison group with a LOS of
7.5 days.
Conclusion: A HV program is an effective model of care that reduces
ED visits, readmission rates, and length of stay. Hospital systems
looking to improve their transitions of care process should look
to partner with HV programs to improve similar outcome measures.
The average length of time a patient stays in our program is
roughly 9.5 months. By serving such a frail population, a HV program
can and should be viewed as an outpatient palliative care program.
C133
The Effect of Medication on Brain Size: Polypharmacy is Associated
with Gray Matter Atrophy.
A. Toussi, 1 O. V. Meulenbroek, 2 S. A. Studenski, 1 M. G. Olde
Rikkert. 2 1. University of Pittsburgh School of Medicine, Pittsburgh,
PA; 2. Alzheimer Centre Nijmegen, Radboud University Nijmegen
Medical Centre, Nijmegen, Netherlands.
Supported By: NIH Grant 5 T32 AG 021885-09
Background: Cognitive decline is a frequent problem encountered
in the geriatric population and it is associated with the use of
polypharmacy. In addition, the elderly are more susceptible to adverse
drug reactions, especially neuropsychiatric effects (e.g. delirium)
due to aging changes in the neurochemistry of the brain, pharmacodynamics,
and pharmacokinetics. The combined effect of aging
and polypharmacy may be detrimental to the brain function and
structure. We investigated the burden of polypharmacy on the structure
of the brain, specifically on the amount of gray and white matter,
in a population of patients who were referred to our memory clinic.
Methods: We selected consecutive patients who visited the
Radboud University Nijmegen Medical Centre memory clinic
from 2007 to 2010 database. Baseline variables included demographics,
medication list, and information on relevant co-morbidities.
The level of education was scored by the system of Verhage.
The structural MRI scans were segmented into gray matter (GM),
white matter (WM) and CSF using the VBM toolbox in SPM5, and
volumes were extracted. We calculated the GM and WM fraction
by dividing the GM or WM volume by the intracranial volume
(GM+ WM+CSF). The number of current, regularly-taken medication
with a known systemic effect was counted. Topical, “as
needed”, and supplemental medications (vitamins, minerals, and
herbals) were excluded. We used a linear regression model to investigate
the correlation between GM fraction, WM fraction and
amount of medication, while controlling for age, sex, education and
diagnosis.
Results: We found a significant correlation between polypharmacy
and GM (Pearson r = -0.149, p=0.002). These effects were independent
of sex, age, education and diagnosis. For WM fraction, there
was no correlation.
Discussion: Our results indicate that the more medications a patient
is taking, the more GM atrophy is present. However, further investigation
of the effects of medications on brain atrophy is warranted.
Physicians already should be cognizant of this association
when treating elderly patients.
C134
MOCA & MMSE Comparison in Detection of Cognitive
Impairment & Change in Very Old Age.
A. Mohammed, 1 S. Kabsoun, 1 B. Leonard, 2 W. Nieri. 1,2 1. Geriatric,
Banner Geriatric Fellowship Program, Sun city, AZ; 2. Banner Health
Research Institute, Sun City, AZ.
Background
The Mini Mental State Exam (MMSE) is the most widely used
screening test for dementia. However, research shows that it can underestimate
cognitive impairment, varies within the population by
age & education, and probably has limitations in assessing progressive
cognitive decline. The Montreal Cognitive Assessment (MOCA)
test may be superior to the MMSE in early detection of Alzheimer’s
disease (AD), but little research has been done with it using very old
subjects. We determined the efficacy of the MMSE and MOCA in detecting
early signs of cognitive impairment and change in healthy subjects
70-105 years old. We also determined whether level of physical
activity was related to cognitive performance.
Methods
Subjects were in the longevity project at the Center for Healthy
Aging, BSHRI. They were 70 years old or older with no dementia at
enrollment, and had completed baseline, 2nd and 3rd annual assessments
in cognitive, medical, and psychosocial domains. One hundred
and forty-eight subjects met these criteria and were stratified by age
decade. To assess relative efficacy, MMSE & MOCA scores were plotted
for each subject, and the proportion performing at, below, or
above standard cutoff scores was determined. To assess decline over
1-year, difference scores were calculated separately for the MMSE &
MoCA. Level of activity was measured with the Rapid Assessment of
Physical Activity (RAPA), and scores were correlated with MoCA
performance.
Results
A fair number of healthy 70, 80, 90 and 100 year-old subjects
performed above the cutoffs on both the MMSE & MoCA. With increasing
age, however, an increasing proportion performed below the
MoCA cutoff while scoring above the cutoff for the MMSE, supporting
previous findings of superiority of the MoCA over the MMSE in
the younger old. In the same groups, 1-year change was negligible for
the MMSE, while for the MoCA, scores were on average 1.3 points
lower. Subjects who were more physically active scored higher on the
MoCA, but only for 90- and 100-year olds.
Conclusion
This study suggests that the MoCA is a better instrument for detecting
cognitive impairment compared to MMSE, even in the oldest
old. The MoCA can be a good tool for monitoring cognitive changes
over time, and thus can aid care planning in early dementia. Finally,
increased physical activity may mitigate cognitive decline often associated
with aging.
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C135 Encore Presentation
Wheelchair Wrist Drop among Nursing Home Residents.
A. Komiyama. General Internal Medicine, Kawasaki Municipal Tama
Hospital, Kawasaki, Japan.
Background: In 1982 Hartigan first reported radial neuropathy
in nursing home residents that was associated with the use of a wheelchair
and later termed “wheelchair wrist drop”. Two additional case
reports have been published, bringing the total to 14 patients. Unfortunately,
the most recent study published in 2009 was unaware of previous
ones; thus wheelchair wrist drop appears to remain underrecognized.
Furthermore, although cases of wheelchair wrist drop may be
relatively common and overlooked in nursing homes, neither its frequency
nor demographics of the study population has been documented.
Objectives: To prospectively delineate frequency and contributing
factors of wheelchair wrist drop as well as clinical characteristics
of the study population in a nursing home.
Methods: Subjects were 311 elderly residents, mean age 81.9 and
female 63.7%, admitted to a nursing home from February 2005 to December
2008. During this period of 47 months the residents were subjected
to a comprehensive geriatric assessment at admission and 3-
month intervals and watched for any adverse events. Radial nerve
palsy was diagnosed clinically by the characteristic features including
selective weakness of wrist and finger extensors; precise sensory findings
were difficult to interpret in this population. The residents with
wheelchair wrist drop did not undergo an EMG in consideration of
their overall condition.
Results: Examination of the study population shows moderate
dementia with a mean Mini-Mental State Examination score of
10.6/30 and impaired mobility and dependence with a mean score of
29.6/91 on the motor domain of Functional Impairment Measure; 193
residents (62.1%) routinely used wheelchair. Several months after
admission, five female residents (2.6% of wheelchair users) developed
radial neuropathy, resulting from leaning against the armrest.
The contributing factors appeared to be immobility and lateral body
tilt due to frailty in three and those due to parkinsonism in two. All
but one improved one month later; one markedly frail resident experienced
recurrence with residual weakness. For 23 months from February
2007 no more wrist drop occurred in wheelchair users.
Conclusion: 2.6% of wheelchair users suffered from wrist drop in
the first half of the observation period in a nursing home. Recognition
of wheelchair wrist drop and its risk factors among care staffs could
likely have prevented from further development of this syndrome.
C136
The contribution of executive function and brain volume to gait
speed in older adults with and without cerebral infarction.
B. Manor, V. Novak. Harvard Medical School, Boston, MA.
Background: Gait impairment is common in older adults, especially
following cerebral infarction. The compensatory role of central
locomotor circuits on the control of gait remains unclear. We examined
the dependence upon executive function and non-infarcted regional
brain tissue volumes for the control of gait speed in healthy
older adults and those with right or left-hemisphere middle cerebral
artery (MCA) infarct. Methods: Healthy older adults (n=55,
age=65±8 years) and individuals with right MCA infarct (n=19,
age=65±8 years, 7±6 years post-stroke) or left MCA infarct (n=20,
age=65±8 years, 7±6 years post-stroke) were recruited. Gait speed
was calculated from an indoor walk at preferred speed. Executive
function was measured with the trail making test. Cortical gray matter
volumes within non-infarcted brain regions (i.e., the cerebellum
and occipital lobes) were quantified from anatomical 3T MRIs. Results:The
right and left infarct groups had similar infarct volumes and
time since stroke. Gait speeds were slower (p

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C138
Improvement in Functional Independence Measure (FIM) scores of
dementia patients on a Medical Psychiatric Unit.
C. A. Fabrizio, 1 C. G. Lyketsos, 2 E. S. Oh. 2 1. University of Medicine
and Dentistry of New Jersey- School of Osteopathic Medicine,
Stratford, NJ; 2. Psychiatry, Medicine, Pathology, The Johns Hopkins
University School of Medicine, Baltimore, MD.
Supported By: 2011 MSTAR Program at Johns Hopkins
Background:Physical therapy may be effective for functional recovery
in older patients with dementia, yet research on this topic has
been limited. The goal of this study is to examine the association between
number of physical therapy sessions and improvement in functional
outcomes on an interdisciplinary medical psychiatry unit.
Methods:Retrospective data (1/2008 to 6/2011) were collected
from medical records. Patients were categorized as having movement
disorder (MD, N=8) or “no movement disorder”(NMD,N=27). FIM
scores included transfer (FIM BCW–Bed, Chair, Wheelchair:1-7),
ambulation distance (FIM D–Distance:1-3), and level of independence
in ambulation (FIM DS–Distance Score:1-7). Statistics were
performed using GraphPad Prism and STATA.
Results:Compared to the admission FIM scores, scores in all
three categories significantly improved in both groups with exception
of FIM BCW score in MD (Table 1). Linear regression adjusting for
age, gender, number of physical therapy sessions, comorbidities, medication
and MMSE scores did not change the effect sizes.
Conclusion:Although dementia patients in our medical psychiatry
unit improved in most measures of the FIM, we did not find a specific
association between these outcomes and a number of clinical
variables including the number of physical therapy sessions. Further
analyses are being conducted to investigate the effects of other clinical
variables at this time. However, these effects may also be the result
of the comprehensive care that they receive from geriatricians,
geriatric psychiatrists, therapists, and nurses on the interdisciplinary
team, rather than one specific intervention.
Table 1 Improvements in Functional Independence Measure Scores
at Discharge
C139
Practice effects: A unique cognitive variable?
C. Callister,K.Duff.Neurology, University of Utah, Salt Lake City, UT.
Supported By: AFAR MSTAR Summer 2011 grant; National
Institute on Aging
BACKGROUND:
Practice effects are improvements in cognitive performance due
to repeat testing with the same materials. These improvements are
present in cognitively normal older adults, but mostly absent in patients
with dementia. Practice effects can also predict further decline
in patients with Mild Cognitive Impairment. However, it is unclear
what variables (e.g., demographic, patient characteristic, other cognitive
abilities) moderate practice effects. We hypothesized that practice
effects would be related to age, education, and baseline cognitive
functioning.
METHODS:
268 community-dwelling older adults (mean age=77.3 years,
mean education=15.3 years) participated in this study. During a baseline
visit, demographic information (age, gender, education), patient
characteristics (depression, premorbid IQ, global cognition), and
baseline cognitive measures of memory, executive functioning, and
processing speed were collected. The participants returned a week
later and repeated the same battery of cognitive tests. To quantify
practice effects, 1-week scores were divided by baseline scores. Correlates
of practice effects and demographic, patient characteristic and
other cognitive variables were examined with Pearson correlations
and chi-square tests.
RESULTS:
Practice effects were not significantly related to age, gender, education,
depression, cognitive status, or pre-morbid IQ. Overall,
practice effects were also not related to baseline cognitive performances.
CONCLUSIONS: Practice effects were not related to most demographics,
patient characteristics, and baseline cognitive measures.
This suggests that practice effects may be a unique cognitive variable
that is not confounded by variables that typically influence other cognitive
performances. Overall, this makes the interpretation of practice
effects more straightforward.
C140
Validity of Computer-Based Mental Status Exam Screening in the
Geriatric Population.
C. L. Duncan, T. K. Malmstrom, G. T. Grossberg, J. E. Morley.
Division of Geriatrics - Internal Medicine, Saint Louis University
School of Medicine, St. Louis, MO.
Supported By: Medical Student Training in Aging Research
(MSTAR) program 2011 summer scholarship awarded by American
Federation for Aging Research (AFAR) to Catherine L. Duncan
B.S. (SLU SOM MSII)
Background: Dr. Oz developed a computerized mental status
exam based on the Saint Louis University Mental Status (SLUMS)
Exam and made it readily available on his website
(http://www.doctoroz.com/quiz/memory-quiz). We have examined
the validity of his screen against the SLUMS along with another
computerized version developed by Saint Louis University (SLU)
for the initial screening of cognitive impairment in the geriatric
population.
Methods: The SLUMS exam was administered to 100 participants
recruited from SLU Geriatric Medicine and Geriatric Psychiatry
clinics, followed by one of two randomly chosen computerized
adaptations (50% given the Dr. Oz Memory Quiz and 50% given the
Self-Administered VA-SLUMS Exam) to those scoring ≥ 12/30 on
the SLUMS after a designated duration (minimum t=15 minutes, median
t =65 minutes).
Results: Neither computerized exam showed positive sensitivity
or specificity compared to the paper SLUMS (AUC≤0.5), but positive
correlations were seen between the total scores of both the Self-Administered
VA-SLUMS and the Dr. Oz computerized versions compared
to the paper SLUMS (r=0.726 and r=0.691, respectively). Additionally,
the Self-Administered VA-SLUMS showed a modest
increase in the weighted measures of agreement (κ=0.38) compared
to the Dr. Oz Memory Quiz (κ=0.29).
Conclusions: While neither computerized exam showed positive
sensitivity or specificity compared to the paper SLUMS, positive correlations
were seen between the total scores, with the Self-Administered
VA-SLUMS showing a modest increase in both measure of
agreement and correlation of total scores compared to the Dr. Oz
Memory Quiz. Specific modifications to each computerized exam are
recommended as well as an increase in sample size and in the duration
of wait time between paper and computerized testing. Further
study with implementation of the suggested changes is necessary with
the hope of refining these computerized SLUMS exams to become
valid and useful preliminary screens for cognitive impairment in the
geriatric population.
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C141
Contribution of brain imaging to the understanding of Alzheimer
disease-related gait disorders, a systematic review.
C. Annweiler, 1,2 O. Beauchet, 2 R. Bartha, 3 M. Montero-Odasso. 1 1.
Department of Medicine, Division of Geriatric Medicine, The
University of Western Ontario, London, ON, Canada; 2. Department
of Internal Medicine and Geriatrics, Angers University Hospital,
Angers, France; 3. Center for Functional and Metabolic Mapping,
Robarts Research Institute, London, ON, Canada.
Background. Although Alzheimer disease-related gait disorders
(ADRGD) are common, determining their origin is a goal yet to be
reached. In particular, which brain structures and underlying lesions
are involved in ADRGD remains unknown. Our objective was to systematically
review all published data that examined the associations
between gait disorders and brain imaging in patients with Alzheimer
disease (AD).
Methods. We conducted a Medline and Cochrane Library search
indexed under the MeSH terms “Gait” OR “Gait Disorders, Neurologic”
OR “Walking” combined with “Brain Mapping” OR “Magnetic
Resonance Imaging” OR “Tomography, X-Ray Computed” OR “Tomography,
Emission-Computed, Single-Photon” OR “Positron-Emission
Tomography” OR “Nuclear Medicine” OR “Brain” combined
with “Alzheimer disease” OR “Dementia”.
Results. Of the 465 selected studies, 3 observational studies met
the selection criteria. The number of participants ranged from 2 to 42
community-dwelling AD patients (29% to 100% female). ADRGD
(i.e., shorter stride length) were associated with a high visual score of
white matter lesions, mainly in the medial frontal lobes and basal ganglia.
The nigrostriatal dopamine system was unaffected. Finally,
ADRGD (i.e., shorter stride length and higher stride length variability)
correlated with lower hippocampal volume and function.
Conclusions. ADRGD could be explained by a high burden of
subcortical hyperintensities on the frontal-subcortical circuits together
with hippocampal atrophy and hypometabolism.
C142
Does the Veterans Affairs Saint Louis University Mental Status
(SLUMS) Exam predict the course of cognitive impairment?
D. M. Cruz, 1 C. M. Allen, 1 T. K. Malmstrom, 1 N. Tumosa, 1,2 J. E. Morley
. 1 1. Geriatrics, Saint Louis University, St. Louis, MO; 2. GRECC, St
Louis VAMC Jefferson Barracks Division, Saint Louis, MO.
Supported By: No financial disclosure.
Background: The Veterans Affairs Saint Louis University Mental
Status (SLUMS) exam is a screening tool developed for the detection
of cognitive impairment which showed better sensitivity and
specificity for the detection of both dementia and mild cognitive impairment
(MCI) than the Mini-Mental State Exam (MMSE). This
study explores the SLUMS exam’s potential to identify the clinical
course of MCI and dementia in patients with cognitive impairment
after 7.5-years.
Methods: Patients (N=533) at the Geriatric Research, Education
and Clinical Center at the Veterans Affairs Hospital St. Louis,
MO were screened for cognitive dysfunction in 2003 using both the
SLUMS exam and the MMSE. In 2010 the rates of mortality, institutionalization
and change in SLUMS exam score were evaluated as
outcome measures. In this longitudinal study the associations between
outcome measures, MMSE and SLUMS exam total scores, individual
item scores, and cognitive status were examined using Kaplan-Meier
curves and Cox proportional-hazards regression.
Results: Five hundred thirty three charts were reviewed:
176/533(33%) patients had died and 31/526 (6%) were institutionalized
during the 7.5-year follow-up period. All subjects were male,
with a mean age of 75 years, and most had high school education or
greater (71%). MMSE dementia and SLUMS exam dementia
(p34%) was found among stroke caregivers.
To understand caregiver depression, we investigated depression
risk factors among stroke patients and their caregivers.
Method: In the national telephone survey for stroke caregivers’
experience,we indentified caregivers ofVeterans who had the first-time
stroke during 2000 and 2006. The level of depression was measured by
the 10-item CESD scale.The social support measure was the sum of 12
items. Bivariate analyses identified significant risk factors with depression.
Adjusting for covariates, logistic regression was applied to assess
the relationship between social support and depression; and ordinal repeated
measure analysis was used to test for interaction effects between
social support and race on 10 items of depression scale simultaneously.
Results: Among 261 caregiver-Veteran dyads, there were 62%
whites, 17% blacks, and 21% Puerto Ricans caregivers (mean
age=65). An increased likelihood of being depressed was found in the
following caregivers’ characteristics (p values ranged from

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A BSTRACTS
ever, whether these cognitive impairments are due to effects of surgery,
anesthesia, or perioperative confounders is unknown. In order
to study these associations, appropriate behavioral neuroscience experiments
must be characterized to reliably model the effects of anesthesia
in laboratory animals. The primary objective of this study was
to determine if isoflurane anesthesia was associated with spatial reference
memory deficits in young or aged rats.
METHODS: Eleven 12-week-old and eleven 20-month-old
male Fischer 344 rats were randomly assigned to anesthesia for 2
hours with 1.2% isoflurane or a control group that breathed 30%
oxygen alone. Twenty-four hours following anesthesia, retention
memory was evaluated using a Morris Water Maze (MWM) task.
RESULTS: While there were differences in the performance of
young when compared to aged rats, there were no significant differences
between isoflurane and control groups on any measure of the
MWM performance at either age. These data suggest that isoflurane
anesthesia does not lead to reference memory deficits in young or
aged rats as investigated using a MWM task.
CONCLUSIONS: This study demonstrates that some memory
domains are not impaired following isoflurane anesthesia in young or
aged rats.
C145
Self-reported school performance and risk for Alzheimer’s disease in
older adults.
E. Guh, A. E. Sanders, MD MS. Albert Einstein College of Medicine,
Bronx, NY.
Supported By: Ms. Guh is supported by the Medical Student
Training in Aging Research program of the American Federation
for Aging Research (MSTAR-AFAR).
Dr. Sanders receives salary and research support from the Einstein
CTSA Grant UL1 RR025750 and KL2 RR025749 and TL1
RR025748 from the National Center for Research Resources
(NCRR), a component of the National Institutes of Health (NIH),
and NIH roadmap for Medical Research.
The Einstein Aging Study is funded by the NIH/NIA (P01
AG03949; PI Richard Lipton, MD).
The contents of this manuscript are solely the responsibility of the
authors and do not necessarily represent the official view of the
NCRR or NIH.
Background: Previous research has shown a low level of education
to be a risk factor for Alzheimer’s disease (AD). The Aging, Demographics,
and Memory Study identified self-assessed below-average
school performance as a possible risk factor for AD. We
attempted to replicate these findings in a diverse urban cohort.
Methods: The Einstein Aging Study is a community-based longitudinal
study of aging and cognition in the Bronx, NY. Participants
self-reported previous school performance (A student, B student,
etc.) and were categorized into groups of “above average,” “average,”
“below average,” and those who stated they “did not know.” Reading
level was measured by the WRAT-3 reading subscore. Using ‘average’
performance as the reference group, we used univariate logistic regression
to examine the risk of AD in the ‘above average’ and ‘below
average’ groups. A subsequent nested logistic regression model adjusted
for age, sex, race, years of education, and reading level.
Results: Of the 1,520 participants with data on self-reported
school performance (mean age, 78.2 years; 61% female; 27% black),
67 developed AD. At baseline, 342 (23%) reported ‘above-average’
school performance, 785 (52%) were ‘average,’ 359 (24%) were
‘below-average,’ and 34 (2%) ‘did not know.’ In the univariate model,
participants who had ‘below average’ school performance were 2.2
times more likely to develop AD than those with ‘average’ performance
(odds ratio (OR) 2.2, 95% confidence interval (CI) 1.2-4.1,
p=0.01). A second model that adjusted for age, sex, race, and years of
formal education revealed a similar risk (OR 2.2, 95% CI 1.2-4.3,
p=0.02). It also showed a relationship between years of formal education
and risk for AD (OR 0.9, 95% CI 0.9-1.0, p=0.15). However, additional
adjustment for reading level attenuated the risk and decreased
the statistical significance for ‘below average’ performers
developing AD (OR 1.9, 95% CI 1.0-3.8, p=0.06). The relationship between
years of formal education and risk for AD also was no longer
present (OR 1.0, 95% CI 0.9-1.1, p=0.79). In all models, there was no
significant risk associated with ‘above average’ performance when
compared to ‘average’ performance.
Conclusion: Participants who reported ‘below average’ school
performance had an increased risk in developing AD. We suggest
reading level may be a mediator of the relationship between self-reported
school performance and risk for AD.
C146
Incidence, Predictors and Prognosis of Delirium in a Geriatric
Cardiac Intensive Care Unit.
E. Mossello, L. Pecorella, C. Giulietti, G. Toffanello, F. Caldi,
S. Fumagalli, P. Valoti, M. Cavallini, N. Zaffarana, M. Belladonna,
S. Francini, M. Rimediotti, A. Mello, N. Marchionni, M. Di Bari. Unit
of Gerontology and Geriatric Medicine, Department of Critical Care
Medicine and Surgery, University of Florence, Florence, Italy.
Supported By: Foundation Cassa di Risparmio di Pistoia e Pescia
Background: In patients admitted to an Intensive Care Unit
(ICU), delirium has a prevalence from 20% to 80% and a definite
negative prognostic impact. Few data are available on the specific setting
of Cardiac ICU (CICU). Aims of the study were to: 1) estimate
prevalence and incidence of delirium in a Geriatric CICU, 2) identify
its risk factors, and 3) assess its prognostic impact.
Methods: The presence of delirium was identified with the systematical
application of Confusion Assessment Method-ICU. On admission
pre-morbid disability, dementia (Informant Questionnaire on
Cognitive Decline, IQCODE), multimorbidity (Charlson Index, CI),
and acute physiologic derangement on admission (APACHE II) were
assessed. Invasive procedures were recorded.
Results: Out of 373 patients (mean age 79 years; pre-existing dementia
26%), 18% showed delirium (8% prevalent on admission,
10% incident during hospital stay). In a logistic regression model, independent
predictors of delirium (OR, 95%CI) included age (1.07,
1.02-1.13), APACHE-II (1.10, 1.04-1.16), dementia (2.97, 1.58-5.60),
CI (1.22, 1.05-1.41) and clinical diagnosis [ST-elevation myocardial
infarction (STEMI) (6.40, 2.40-17.07) or respiratory failure (8.49,
1.54-46.85) vs. Non-STEMI]. Predictors of incident delirium were the
same, though dementia had a reduced predictive value. The use of invasive
procedures (arterial and central venous catheter, nasogastric
tube, urinary catheter, intra-aortic balloon counterpulsation, and orotracheal
intubation) was associated with subsequent delirium, independently
of clinical status on admission. Delirium, especially its incident
form, was associated with prolonged hospitalization (p

P OSTER
A BSTRACTS
nal process can present as hip pain, though usually with neurological
and systemic symptoms.
CASE: An 80 year old Caucasian man with a history of sarcoidosis,
pulmonary embolism, and atrial fibrillation on anticoagulation,
was admitted to the hospital with progressive left hip pain. He
had been treated initially with pain medications by his primary physician
for presumed osteoarthritis. His pain worsened over several
months and became associated with left lower extremity swelling, difficulty
walking with left foot drop, and generalized weakness. His
physical exam was remarkable for mildly distended abdomen with
firmness in the left lower quadrant without hepatosplenomegaly, mild
left lower extremity edema, decreased hip range of motion without
pain, and mild weakness with left dorsiflexion. Digital rectal exam
showed bright red blood. His labs revealed leukocytosis of 12,000,
anemia with a hemoglobin of 11, normal platelet count, and
supratherapeutic INR of 6.5. A lower extremity ultrasound revealed
an acute proximal left lower extremity DVT. A large left retroperitoneal
mass involving the iliopsoas muscle and surrounding vasculature
was found on CAT scan of the abdomen and pelvis. He also had
bowel wall thickening in the distal sigmoid colon and at the splenic
flexure. A colonoscopy was performed and showed two separate
masses involving the colon. Biopsies done via both ultrasound guidance
and colonoscopy were positive for Burkitt lymphoma. He received
chemotherapy and was discharged home under hospice care.
DISCUSSION: Burkitt lymphoma is rare in older adults. It usually
occurs in adults less than 35 years of age. It often presents with
abdominal symptoms such as pain, ascites, or gastrointestinal bleeding.
The left hip pain, swelling, and leg weakness in this patient was
atypical and was due to the involvement of the left iliopsoas muscles
and surrounding nerves and vasculature.
CONCLUSION: In an elderly patient with chronic unilateral
hip pain and atypical clinical signs and symptoms such as foot drop,
leg swelling and focal weakness, consider an intra-abdominal or
pelvic infiltrative process.
C149
Pulse wave velocity varies within the cardiac cycle.
A. K. Reddy, 1 C. J. Hartley, 1 G. E. Taffet. 1,2 1. Medicine (CVR),
Baylor College of Medicine, Houston, TX; 2. Medicine (Geriatrics),
Baylor College of Medicine, Houston, TX.
Supported By: NIH
Aortic pulse wave velocity (PWV), an index of arterial stiffness,
is measured using the foot-to-foot (Ff) pulse transit time (PTT) of the
flow velocity waveform at two aortic sites and the separation distance
(Sd) between these sites (PWV=Sd/PTT). It has been shown that
PWV is directly proportional to pressure (Kim et al., J Human Hypertens,
21:141-48, 2007), from a low at end-diastole to a high at endsystole
within each cardiac cycle. But the velocity foot occurs at enddiastolic
pressure and therefore Ff-PWV may underestimate the
overall PWV (and stiffness). PWV can also be determined from aortic
impedance (Imp) as PWV = Zc/ρ, where Zc = average of impedance
moduli from 2nd-10th harmonics (see figure) (Reddy et al., Am
J Physiol HCP, 285:H1464-70, 2003). Since Imp-PWV is determined
from several harmonics we believe that it is a better representation of
vessel stiffness than Ff-PWV.
We determined Imp-PWV (figure) in 5 young (lower dashed
line; 282±10) and 6 old (upper dotted line; 444±59) mice and Ff-PWV
in 3 young (286±14) and 3 old (416±22) mice. PWV determined by
both methods was not significantly different in the young mice because
at young age lower overall PWV may be closer to Ff-PWV. In
the old mice Imp-PWV was higher but was not significant perhaps
due to large variability. Higher values Imp-PWV in old mice may represent
the increase in the magnitude of the higher harmonics caused
by stiffer arteries in old age.
C148
Association of Vitamin D deficiency and In-Hospital Mortality in
Elderly Patients with Heart Failure.
A. Ali, N. Abi Rafeh, A. Abdo, J. Ross, V. Hak, D. P. Seminara,
A. Szerszen. Geriatrics, Staten Island University Hospital, Staten
Island, NY.
Background: Vitamin D deficiency has been implicated in the
pathogenesis of symptomatic heart failure. Low levels of 25-Hydroxyvitamin-D
(25(OH)D) are associated with poor long term prognosis
in heart failure. The relationship of low 25(OH)D levels and in-hospital
mortality in elderly patients admitted with acute heart failure is
not well studied.
Objective: The study aims to assess the association of 25(OH)D
deficiency and in-hospital mortality in elderly population admitted
with heart failure and to determine the association between
25(OH)D levels and Ejection Fraction (EF), Brain Natriuretic Peptide
(BNP), and New York Heart Association (NYHA) functional
classification.
Methods and Results: This was a cross-sectional observational
pilot study. Twenty patients with acute heart failure were recruited in
the study. The mean age of the patients was 84 (65-96) yrs. Subjects
were divided into two groups based on their 25(OH)D levels of less
than 20mg/dl or more than 20mg/dl. There was a trend towards higher
BNP level in the 25(OH)D deficiency group (1946 ± 1531 pg/ml vs.
808 ± 302 pg/ml; p= 0.07). There was no correlation between
25(OH)D levels and EF or NYHA functional class. However, Sixty
two percent of patients died in-hospital in 25(OH)D deficiency group
as compared to none in normal 25(HO)D levels group (p=0.026).
Conclusion: A low 25(OH)D level is associated with high inhospital
mortality in elderly patients admitted with acute heart failure.
The 25(OH)D level may be used as a prognostic maker for inhospital
mortality in elderly patients with heart failure.
C150
Antibiotic Utilization in ICU Patients Requiring Mechanical
Ventilation.
B. Chen, M. Restrepo. School of Medicine, UTHSCSA, San
Antonio, TX.
Supported By: MSTAR program through the National Institute
of Aging
PURPOSE: Infection is a major concern in health care but especially
in the ICU and those on mechanical ventilation. There are limited
data available regarding antibiotic utilization and the impact on
clinical outcomes in the ICU setting, but particularly on patients requiring
mechanical ventilation. We Assess antibiotic utilization and
the impact on clinical outcomes in hospitalized ICU patients who required
mechanical ventilation.
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METHODS: We conducted a retrospective observational cohort
study of VA MICU patients in the year of 2007. We included patients
who were on >18 years and on mechanical ventilators for >24
hrs. We looked into the antibiotic use and microbial culture to ultimately
evaluate the clinical outcomes (length of stay and mortality)
of these patients. [|11|]
RESULTS: We identified 157 ICU patients who required mechanical
ventilation. 95% of the patients received at least one dose of
antibiotic therapy. The most common antibiotics were vancomycin
and pip/tazo and tobramycin. The use of antibiotic was related to positive
microbial cultures (p= 0.04). Adequate therapy is associated
with positive cultures (p

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project, we attempt to understand some of the barriers against the efficacy
of skin cancer prevention strategies.
METHODS
A 26 question survey-based descriptive and prospective study
was performed on 140 Mohs surgery-treated patients at UCSD. Data
was analyzed using percentages and estimated confidence intervals
for population proportions.
RESULTS
51% of participants mentioned their doctor as a source of skin
cancer prevention information. 73% of the 140 study participants
were aware of sunblock as a protective strategy, and 76% of people in
this group report current usage of sunblock. Participants who were
able to name ≥2 preventative strategies had higher self-ratings of utilization
of those strategies than people who could only name 1 preventative
strategy. 43% of the people not using sunblock were unsure
that sunblock actually works, and 52% of them thought it was too
messy and oily. 65% of all participants improved in their self-rating of
utilization of preventative strategies post skin cancer diagnosis.
CONCLUSIONS
The results of our survey study show that the majority of people
who know of successful protective strategies are actually using them,
and an awareness of a larger number of preventative strategies is related
to a higher chance of utilization. However, most of the behavior
improvement occurred after diagnosis of skin cancer, which suggests
that people are not considering their risk of skin cancer as an imminent
threat during early life. Therefore, in order to set up a future
framework to decrease the incidence of skin cancer in the aging population,
we recommend increasing the number of sun safety educational
campaigns as well as encouraging physicians to be more active
at educating patients on skin cancer risk.
C155
Maintaining and Respecting an Older Adults’ Life While It Is
Ending: Challenges Faced by Family Members.
C. R. Van Son, S. Izumi. College of Nursing, Washington State
University, Spokane, WA.
Supported By: American Nurses Foundation
Hospice and Palliative Nurses Association
Background: Efforts towards the improvement of end of life
care must be accelerated to meet the needs of our rapidly aging society.
Older adults with chronic conditions experience a longer trajectory
with acute exacerbations and recovery, with progressive functional
declines occurring over months and years. Palliative care
adaptations are still needed to meet the needs of older adults going
through prolonged and uncertain trajectory at the end of life. A gap
exists between the focus on palliative care by healthcare
providers/systems and the need for maintaining and optimizing daily
life for older adults. The objective of this presentation is to describe
the gap from the family member’s perspective.
Methods: Qualitative descriptive study using semi-structured interviews
with 23 family members of deceased older adults with various
chronic conditions. Secondary analysis of the interview data was
conducted using qualitative thematic analysis approach.
Results: Family members shared the challenges they faced while
they were facilitating the care of older family members who were
dying. Although families were aware of the downward decline, they
still recognized the importance of keeping daily routines to maintain
the quality and function of the older adult’s life. However, once an acknowledgement
of dying was made by the healthcare provider/system,
the palliative care approach was instituted and not always
adapted to optimize function and daily routines of older adults. Families
reported that healthcare providers often: 1) relegated the older
adult to a bedbound status while they were still able to be actively
mobile; 2) failed to inquire about or respond to daily routines that
would enhance daily life; 3) dismissed older adults as being cognitively
impaired when they were not; and 4) neglected to prevent or
address treatable geriatric conditions such as delirium.
Conclusions: End of life for older adults occurs over weeks,
months, and even years. Therefore, palliative care approaches must
consider this longer trajectory and adapt to meet the older adults’
and their family members’ needs.
C156
Impact of financial exploitation on the health of older women.
C. P. Mouton. Dean’s Office, Meharry Medical College, Nashville, TN.
Supported By: National Institutes of Health
Background: Financial abuse (FA) and exploitation is a growing
problem. Nationally, an estimated 12.3 % of elder abuse victims are
victims of FA. However, little is known about the effects of FA on independently
functioning older women.
Objectives: To determine the effect of FA on health status and
quality of life in a cohort of functionally independent older women.
Design: Cross-sectional survey
Setting: The local Observational Study Cohort of the Women’s
Health Initiative in San Antonio, Texas
Participants: Using this cohort, we surveyed over 1200 women,
aged 50-79 years old.
Measurements: We asked these women about their exposure of
FA prior to the survey and currently. Women were also asked about
their health status using the SF-36.
Results: Of the 1271 women surveyed, 2.9% being forced to sign
documents they did not understand, 3.6% were forced to give up
property, 32% had money borrowed, and 2% had finances controlled
against their wishes. Being forced to sign documents was associated
with lower role-physical, pain, general health and physical component
summary scores. Giving up property was associated with lower
role-physical, social functioning, role-emotional, mental health, and
mental component summary scores. Having money borrowed was associated
with lower role-physical, role-emotional, and mental component
summary scores. Having finances controlled was associated with
lower social functioning, role-emotional, and mental component summary
scores.
Conclusion: Experiencing financial abuse is associated with
lower sexual health status and poor quality of life in older women.
C157
Micronutrient Deficiencies in Palliative Care Patients.
C. Petit, A. F. Leone. Palmetto Health - USC School of Medicine,
Columbia, SC.
Background: As health providers attempt to mitigate and ease
discomfort, suffering and pain in the palliative care patient, it becomes
imperative to investigate and treat all factors that might be
contributing to distress. Unconsciously, we tend to assume that nutritional
deficiencies are isolated to populations from third world countries,
those who underwent bariatric weight loss procedures or those
with know malabsorption syndromes. Current studies are proving this
idea to be a myth.
Methods: In an effort to provide comprehensive care, patients
with symptoms suggestive of deficiency states, who were expected to
live for at least one month, underwent a nutritional assessment to
screen for micronutrient deficiencies seen by a single provider of a
Palliative Care Consultant Service. It was the intent to replace any
nutritional paucity. Those who underwent screening, directed by
symptom constellation, underwent analysis of various micronutrients
including Vitamins B1, B2, B3, B6, B12, C, Vitamin D, ascorbic acid,
CoQ10, Zinc, pre-albumin and albumin.
Results: 58 sequential referrals in May and June of this year underwent
chart reviewed. 13 were suspected to have a life expectancy
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of less than 1 month and did not undergo nutritional assessment beyond
protein malnutrition. The remaining underwent targeted evaluation
based on symptom constellation. 82.9% were found to have at
least one identified nutritional deficiency. Of those, 38.2% had a single
nutrient deficiency. 23.5% had two, 32.4% had three and 5.9%
had 4 deficiencies.
Conclusions: Micronutrient deficiencies are more prevalent in
the Palliative care population than previously believed. Appropriate
testing allows targeted, evidence based, replacement which should in
turn ameliorate suffering. All too often palliative care is perceived as
an approach that limits curative care focus, but resolution of deficiencies
seems to establish a bridge of trust between the practitioner, the
patient and the family who perceive the health practitioner to be fully
invested in the care of the patient.
C158
Aging with Disabilities: Comparing symptoms and quality of life
indicators of individuals aging with disabilities to U.S. general
population norms.
D. Amtmann, S. Borson, R. Salem, K. L. Johnson, A. Verrall.
Rehabilitation Medicine, University of Washington, Seattle, WA.
Supported By: The contents of this abstract were developed under a
grant from the Department of Education, NIDRR grant number
H133B080024. However, those contents do not necessarily represent
the policy of the Department of Education, and you should not assume
endorsement by the Federal Government.
Background: Advances in medical care and rehabilitation have
extended the lifespan of people with long-term physical disabilities.
However, quantifying the excess burden of symptoms in persons
aging with disabilities has been hindered by lack of common metrics
across measures and clinical populations. The NIH-funded PROMIS
initiative used modern psychometric methods to develop instruments
that do use a common metric and provide US population
norms for many important domains. The objective of the current
study was to construct profiles of symptoms and QoL indicators in
persons aging with a long-term disability and to compare them to US
population norms.
Methods: PROMIS short forms measuring 7 symptoms or QoL
indicators (fatigue, pain interference with activities, physical and social
function, depression, and sleep and wake disturbance) were completed
by individuals with muscular dystrophy (264), multiple sclerosis
(481), post-polio syndrome (445), and spinal cord injury (323)
(total N=1513) participating in an ongoing longitudinal survey. Individuals
aged 45-94 were included in this analysis. Scores for the overall
sample, by diagnostic group and by age categories, were compared
to the PROMIS US population norms.
Results: Compared to the US general population, individuals
aging with disabilities reported a higher symptom burden and
poorer QoL on 6 of 7 measures (all p

P OSTER
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Methods: Two hundred and four volunteers at McLaren Regional
Medical Center in Flint, Michigan, in May 2011, were
mailed an anonymous survey. The RAND 36–Item Health Survey
(Version 1.0) was used as the instrument for quality of life measurement.
The demographic questions included: gender, age, marital
status, ethnicity, completed level of education and house–hold
income. The responses were collected for eight weeks. We analyzed
demographic variables and compared them between our
mean and those of the general elderly volunteering population,
obtained from the literature. Analysis of quality of life data is
pending.
Results: One hundred and three participants returned completed
surveys, resulting in a 45% response rate. 91% were female,
ages 65 to 94, with the majority (38%) in the 75-84 range. 91% were
Caucasian; 55% were single, as opposed to residing with someone or
married. Majority had either completed the 12th grade (38%) or
some college (35%). 28% had an annual income range in the
$20–34,000, though a significant proportion chose not to provide this
information.
Conclusion: National data tends to group older volunteering
adults into one large category of 65 years and older, however, we
were able to break this group down and revealed the demographic
variables. Additionally, as opposed to the current research which suggests
that those with higher educational and income levels make up
the general volunteering population, our research indicates that it is
those which fall in the middle range on both items who choose to participate
in volunteering activity.
C161
The Relationship Between Body Weight and Quality of Life in
Older Adults with Medicare Supplement Insurance.
K. Hawkins, 1 F. G. Bottone Jr, 1 S. Musich, 1 R. J. Ozminkowski, 1,2
Y. Cheng, 1 R. J. Migliori, 2 C. S. Yeh. 3 1. Advanced Analytics,
OptumInsight, Ann Arbor, MI; 2. UnitedHealth Group Alliances,
Minnetonka, MN; 3. AARP Services, Inc., Washington, DC.
Supported By: UnitedHealth Group and AARP Services, Inc. (ASI).
The objective of this study was to estimate the relative impact
that each body mass index (BMI) category has on health-related
quality of life. A mail survey was sent to 60,000 adults with an
AARP®-branded Medicare Supplement Insurance (i.e. Medigap)
plan provided by UnitedHealthcare Insurance Company (for New
York residents, UnitedHealthcare Insurance Company of New York)
in 10 states. The Medicare Health Outcomes Survey instrument was
used, but renamed the Health Update Survey, for use with a Medigap
sample. Casemix-adjusted comparisons were made between each
BMI category versus those with normal BMI.A total of 22,827 (38%)
eligible sample members responded to the survey. Respondents had
the following BMI categories: 2.2% were underweight, 37.0% were
overweight, 18.5% were obese, 1.9% were morbidly obese, 38.5% had
a normal BMI and 1.9% were missing BMI information. Factors associated
with being underweight or carrying excess body weight were
generally consistent with past reports. Quality of life was assessed
using the average physical component scores (PCS) and mental component
scores (MCS) obtained from the VR-12 health status tool. Respondents’
PCS values were 5.01, 0.16, 3.60 and 9.50 points lower on
average, respectively, for the underweight, overweight, obese and
morbidly obese BMI categories, compared to the normal BMI group.
Respondents’ MCS values were 3.28, +0.52, 0.32 and 1.39 points
lower on average, respectively for the underweight, overweight,
obese and morbidly obese BMI categories, compared to the normal
weight group. The greatest impact on quality of life was on those in
the underweight and morbidly obese categories, with the greater negative
impacts were on the physical rather than mental aspects of quality
of life.
C162
The Responsiveness of Quality of Life Measures in Patients with
Alzheimer’s Disease: Results from the Canadian Alzheimer’s
Disease Quality of Life Study.
G. Naglie, 1,2 D. Hogan, 5 M. Krahn, 3,4 S. Black, 4 M. Freedman, 4
L. Beattie, 6 M. Borrie, 7 A. Byszewski, 8 C. MacKnight, 9 C. Patterson, 10
H. Bergman, 11 J. Irvine, 12 P. Ritvo, 12 D. Streiner, 10 J. Comrie, 12
M. Kowgier, 4 G. Tomlinson. 3,4 1. Baycrest, Toronto, ON, Canada; 2.
Toronto Rehab, Toronto, ON, Canada; 3. Toronto General Research
Institute, Toronto, ON, Canada; 4. University of Toronto, Toronto, ON,
Canada; 5. University of Calgary, Calgary, AB, Canada; 6. University
of British Columbia, Vancouver, BC, Canada; 7. University of Western
Ontario, London, ON, Canada; 8. University of Ottawa, Ottawa, ON,
Canada; 9. Dalhousie University, Halifax, NS, Canada; 10. McMaster
University, Hamilton, ON, Canada; 11. McGill University, Montreal,
QC, Canada; 12. York University, Toronto, ON, Canada.
Supported By: Canadian Institutes of Health Research, Alzheimer
Society of Canada and the University Health Network Geriatric Fund.
Purpose: To assess the responsiveness of a variety of generic and
disease-specific quality of life (QOL) measures in patients with
Alzheimer’s disease (AD).
Methods: We recruited 272 community-living AD patients and
their caregivers from clinics across Canada. Patients with MMSE
scores > 10 rated their QOL using the EQ-5D, Quality of Well-Being
scale, a visual analogue scale and the QOL in AD (QOL-AD) instrument.
Caregivers rated patient’s QOL using these measures as well as
the Health Utilities Index (HUI) and Short-Form-36. QOL and patients’
cognition (AD Assessment Scale-Cognitive), function (Disability
Assessment for Dementia) and neuropsychiatric symptoms
(Neuropsychiatric Inventory and Geriatric Depression Scale) were
assessed at baseline, 6, 12 and 24 months. We evaluated internal responsiveness
using the standardized effect size and the standardized
response mean. We assessed external responsiveness using receiver
operating characteristic (ROC) curves for the QOL measures based
on a decline or no decline in a composite score based on the first principal
component of the core dementia symptoms.
Results: At baseline, patients’ mean age was 82.8, 50.2% were
female and mean MMSE was 20.2. For patient self-ratings, the QOL
measures did not exhibit meaningful responsiveness over time. For
caregiver ratings of patient QOL: the internal responsiveness of the
QOL measures at 12 and 24 months was small (0.12 to 0.28) and small
to moderate (0.22 to 0.59), respectively; the external responsiveness
at 12 and 24 months was greatest for the EQ-5D, QOL-AD and HUI,
with areas under the ROC curves of 0.67 to 0.77.
Conclusions: Over 24 months of follow-up, patient self-ratings of
QOL did not exhibit meaningful responsiveness, while caregiver ratings
of patient QOL with the QOL-AD, HUI and EQ-5D exhibited
moderate responsiveness.
C163
Physical Therapy Interventions Utilizing Dual Task Phenomenon to
Decrease Cognitive-motor Interference in a Person Status-post
Intercerebral Hemorrhage: a Case Report.
A. Tilsley, G. L. Raymond. Physical Therapy, Samuel Merritt
University, Oakland, CA.
BACKGROUND: Cognitive-motor interference (CMI) is a
phenomenon in which the simultaneous performance of a motor and
cognitive task interferes with the performance of one or both tasks.
CMI can occur after a stroke, increasing a person’s risk of falls as they
may be unable to react to unexpected challenges during ambulation.
The objective of this case report is to demonstrate how the theory of
CMI was used to develop interventions aimed at decreasing a patient’s
fall risk.
DESIGN: Case report.
SETTING: Acute rehabilitation in Northern California.
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PARTICIPANT: 57-year-old female with a hemorrhage in the
basal ganglia.
INTERVENTION: Interventions were aimed at addressing balance
and gait. CMI was addressed during functional activities that required
multitasking. Dual task challenges include carrying objects in
her hands, carrying a tray with various items, and talking or answering
questions while ambulating. Dual task challenges progressed along
with gait interventions by utilizing different surfaces and environments.
MEASUREMENTS: Timed Up and Go (TUG), TUG manual,
TUG cognitive, Dynamic Gait Index (DGI).
RESULTS: TUG improved from 14 to 10 seconds, TUG manual
from 15 to 10 seconds, TUG cognitive from 21 to 13 seconds. Dynamic
Gait Index increased from 14 to 21.
CONCLUSION: After using the dual task paradigm to create
interventions focused on decreasing the extent of CMI without deterioration
of either motor or cognitive task, the patient showed improvements
in independence and safety during ambulation and transfers
and decreased risk of falls.
C164 Encore Presentation
Functional Trajectories of Elderly Patients admitted in a Geriatric
Rehabilitation Unit after discharge of acute hospitalization.
E. Martínez, 1,2 J. Sánchez Rodríguez, 1 N. Albiol Tomàs, 1 R. Audi
Ferrer, 1 J. García Navarro. 2 1. Geriatric Department, Hospital de la
Santa Creu, Tortosa, Tarragona, Spain; 2. Grup Sagessa, Reus,
Tarragona, Spain.
Background:The aim of this study is to analyze which factors
evaluated during the Comprehensive Geriatric Assessment(CGA),
performed at acute care by a geriatric team, predict functional trajectories
in elderly patients transferred to a Geriatric Rehabilitation
Unit(GRU).
Methods: Prospective study. All acute hospitalized patients evaluated
(June - December 2010) and transferred to our GRU were included
and followed-up till discharge. Collected data: age, sex, diagnostic
groups (orthopedics, stroke, others); functional status –
activities of daily living (ADLs) previous to acute hospitalization,in
acute care and at discharge (Barthel index,BI). Comorbidity (modified
Charlson Index),dementia,delirium in acute care, length of stay
in acute and rehabilitation units,laboratory data (Hematocrit,Albumin,Total
Proteins, ESR,CRP),polipharmacy and if patient lives
alone.
Statistical Analysis: Characteristics of ability in ADLs patients
groups were compared using t-test to evaluate differences in means
and chi-square test to evaluate differences in percentages; and multivariate
analysis by logistic regression.SPSS v.17 software.
Results: 174 patients evaluated; 12.6 % died; Mean age: 77 years
(±17.5); 48.3% male. Length stay in acute care:12.3 days (± 10.4),
length in GRU: 56 days (± 51.9). Previous BI mean 78.6 (± 22.3);BI in
acute care mean 27.2 (±26.2);BI at discharge 49.2 (± 36.3). Independent
ability to walk: previous: 70.7%, in acute care: 3.4%, at discharge:
37.9%. Patients with dementia: 25.3%,delirium: 25.9%; polipharmacy:
71.3%,living alone 35.6%. Diagnosis groups: Orthopedic
33.5%, stroke 22.9%, cardiovascular and others 32.9%. Modified
Charlson Index: mean 1.8 (±1.2).
In multivariate analysis, factors related to walk independent
were absence of dementia and short lengths of stay in GRU. Dementia,Cardiopathy
and long length of stay in acute care were associated
with poor functional prognosis. The functional decline in acute care
should explain 15% of functional trajectory (Pearson coeff. correlation
0.38).
Conclusions: The probability to walk independent was low in
demented patients with long length of stay in the GRU. The best ability
in ADLs was achieved in patients with a short length of stay in
acute care, with orthopedic diagnosis on admission and no comorbidity
as dementia, delirium and heart disease.
C165
Factors associated with acute care readmissions from a skilled
nursing facility.
R. Y. Blake, K. Fairfield, H. Wierman, R. Marino. Geriatrics, Maine
Medical Center, Portland, ME.
Background:
Readmission from skilled nursing facilities (SNF) to acute care
hospitals is costly, disruptive, and may serve as a marker of poor quality
care. This study was designed to investigate risk factors for readmission
in a single small, suburban skilled nursing facility.
Methods:
We conducted a retrospective chart review of all admissions to a
SNF in Maine within a one year period (N=130). We excluded four
patients with incomplete data (final N=126). Data collected included
patient age, gender, day and month of admission, days from SNF admission
to first physician contact, and admitting primary and secondary
diagnoses. For patients who were readmitted to an acute care facility
within 30 days, we reviewed hospital admission records to
determine primary readmission diagnosis. We used descriptive statistics
(chi square, t-test) for data analyses.
Results:
The mean age of the population was 82 years, with a range of 50-
99. The majority were women (79/126, 63%). The overall 30-day readmission
rate was 13% (17/126). A significantly higher proportion of
men were readmitted vs. women (21% vs. 9%, p=0.05). 63% (12/17)
of readmissions were attributable to patients admitted during the
months of December, January, and March. There was a mean of 1.8
+/- 1.7 days from SNF admission to initial physician contact, and this
was similar for readmitted vs. non-readmitted patients (2.3 +/-1.8 vs.
1.8 +/- 1.7, p=0.35). Specific primary diagnoses associated with the
highest readmission rates included GI bleed (2/5, 40%), pneumonia
(3/9, 33%), CAD (1/3, 33%), UTI (3/10, 30%), and CHF (2/9, 22%).
At the time of acute hospital readmission, top diagnoses were similar,
also including pneumonia (4/17, 24%), CHF (2/17, 12%), and GI
bleed (12%), with the addition of multifactorial delirium (12%). Patients
who were ultimately readmitted had significantly more active
comorbidities (8.0 +/- 2.7) than those were not readmitted (6.3 +/-
2.3), p=0.02.
Conclusions:
In this population, patients at higher risk for readmission include
males, those with a higher number of active comorbidities, and
patients with a primary diagnosis of GI bleed, infection (UTI, pneumonia),
or cardiovascular disorder (CAD, CHF). Closer attention to
these higher risk patients, in conjunction with strict adherence to established
guidelines and standards of care, may help to minimize unnecessary
acute care hospital readmissions in the future.
Poster Session D
Friday, May 4
3:00 pm – 4:30 pm
D1
Amiodarone-induced Rhabdomyolysis.
E. C. Ong, 1 N. Maheshwari, 1 A. Sy, 1 E. Roffe, 2 S. Chaudhari, 1,2
D. Kumari, 2 S. Mushiyev. 1 1. Internal Medicine, Metropolitan Hospital
Center, New York, NY; 2. Geriatric Medicine, Metropolitan Hospital
Center, New York, NY.
Introduction: Rhabdomyolysis is a condition characterized by
muscle necrosis causing release of muscle enzymes into the circulation,
resulting in elevated serum creatinine kinase (CK) levels. It is
rarely caused by Amiodarone. We present a case of an elderly male
with amiodarone-induced rhabdomyolysis.
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Case: A 78 year-old male with history of coronary artery disease,
hypertension and chronic atrial fibrillation was admitted following a
fall without major injury. He presented with a two-month history of
progressive muscle weakness and pain resulting in difficulty in ambulation.
He underwent coronary artery bypass graft two months prior.
Medications included cardizem, digoxin, warfarin, simvastatin, amiodarone.
Physical examination was remarkable for generalized muscle
tenderness and decreased muscle strength of 3-4/5 in all four extremities.
Laboratory tests showed elevated CK of 10,280, aspartate
aminotransferase of 563, alanine aminotransferase of 403, alkaline
phosphatase of 99, normal renal function. Urinalysis showed large
blood with 5-10 red blood cells. Simvastatin was stopped and patient
was started on intravenous hydration. His CK level transiently decreased
to 8,900, but on the third day it increased to 11,600. Intravenous
hydration was continued and bicarbonate drip was started.
Patient’s family later reported that amiodarone was just recently
started after the bypass graft two months prior. Amiodarone was
stopped and the patient’s clinical status steadily improved. By day
seven, his CK level dropped to 700.
Discussion: The severity of rhabdomyolysis ranges from asymptomatic
elevations in serum muscle enzymes to life-threatening cases
with extreme enzyme elevations, electrolyte imbalances and renal
failure. Classic presentation includes myalgia, red to brown urine due
to myoglobinuria, and elevated serum CK levels. Many drugs are
known to cause rhabdomyolysis including statins, colchicine, and cocaine.
Few cases of amiodarone-induced rhabdomyolysis have been
reported. In this case, the patient continued showing worsening CK
levels in spite of stopping the statin. His clinical status and CK level
dramatically improved upon discontinuation of amiodarone. Physicians
must keep in mind that amiodarone can be one of the uncommon
causes of rhabdomyolysis.
D2
Chronic Subdural Hygroma presenting as Dementia.
E. C. Ong, 1 N. Maheshwari, 1 E. Roffe, 2 S. Chaudhari, 1,2 D. Kumari, 2
M. Belal. 1 1. Internal Medicine, Metropolitan Hospital Center, New
York, NY; 2. Geriatric Medicine, Metropolitan Hospital Center, New
York, NY.
Introduction: Chronic subdural hygroma is common among elderly
individuals. It is a lesser-known potentially reversible cause of
dementia. We present a case of an elderly male with chronic subdural
hygroma presenting as dementia.
Case: An 81 year-old male with medical history of mild hypertension
was brought in by his daughter to Geriatric clinic to establish
medical care. Patient was recently seen by psychiatry and neurology
due to insomnia and agitation (especially at night), started on Memantine
and Donepezil for diagnosis of Dementia. Physical examination
was unremarkable except for disorientation to place and time, inability
to do three-item recall, and Mini-mental state examination
score of 17/30. Laboratory tests were normal including thyroid functions,
vitamin B12, and Syphillis IgG. CAT scan of the brain revealed
chronic subdural hygroma overlying the right cerebral convexity with
midline shift, moderate cerebral and cerebellar atrophy. Patient was
referred to neurosurgery clinic, however patient and family refused to
undergo any neurosurgical intervention. Repeat brain CAT scan
showed increase in subdural hygroma with possible subacute and/or
acute component, but patient had no worsening of clinical
signs/symptoms on subsequent clinic follow-ups. Patient will be followed
in neurosurgery, neurology and geriatric clinic with serial brain
CAT scan.
Discussion: Chronic subdural hygroma is a subdural collection
of cerebrospinal fluid (CSF). This results from sudden decrease in
pressure by ventricular shunting leading to leak of CSF from the subarachnoid
space into the subdural space especially in cases with moderate
to severe brain atrophy. Elderly patients are prone to develop
hygromas owing to frequent falls sustaining head trauma, and significant
cerebral atrophy related to old age. Large hygromas may cause
secondary localized mass effects on the adjacent brain parenchyma
causing neurologic symptoms. Global deficits such as disturbances of
consciousness are more common than focal deficits. Brain CAT scan
would show crescent-shaped extra-axial lesions. Surgical evacuation
is recommended if there is evidence of moderate to severe cognitive
impairment or progressive neurologic deterioration. Physicians
should recognize chronic subdural hygroma as a reversible cause of
dementia among the geriatric population.
D3
Actinomyces israelii - A rare cause of prosthetic joint infection in
the elderly.
G. Gulati, S. Gulati, D. Powell. Internal Medicine, The Reading
Hospital and Medical Center, West Reading, PA.
INTRODUCTION: Actinomyces prosthetic joint infections are
extremely rare, described in only half a dozen case reports in medical
literature. Our case describes a patient who presented with new onset
prosthetic joint infection with no identifiable local or systemic source
or trauma.
CASE PRESENTATION: A 72 year old male with a history of
left total hip replacement in 2002 presented to the hospital with a one
month history of night sweats and progressively worsening pain in the
left leg. He denied any fever, trauma or injury to the affected side. On
physical exam, he had a temperature of 38.7 degrees Celsius and a
pulse of 115 per minute. Musculoskeletal examination was significant
for a tender left hip joint at the groin with limited range of motion.
On laboratory work up, he had an ESR of 82mm/sec, CRP of 15
mg/dL and leukocytosis of 31,300/cu mm with 90% neutrophils. CT
scan of the hip revealed an attenuated fluid-filled distended region
anterior to the hip prosthesis and muscular asymmetry suspicious for
an abscess. Surgical arthrotomy of the left hip joint with debridement
was done. On histopathology, the specimen showed granulation tissue
with acute-on-chronic inflammation and grew Actinomyces israelli
on cultures. He was started on ampicillin and later switched to doxycycline
due to a significant allergic reaction to the former for 6 weeks.
He was discharged with instructions for outpatient follow up for prosthesis
removal.
DISCUSSION: Actinomyces israelii, a gram positive anaerobic
bacterium, causes infections involving the oral cervicofacial area,
lungs and abdomen. Involvement of the musculoskeletal system is
rare and attributable to adjacent soft tissue infections, occasionally to
local trauma or hematogenous spread. Late infections of prosthetic
joints have been described in literature as spread from an extra articular
site. Diagnosis is established by bacteriological identification
using sterile cultures showing characteristic appearance and sulfur
granules. Penicillins are the mainstay of treatment, and use of tetracycline
class has been reported in cases of penicillin allergy. A combination
of medical and surgical therapy with consideration for prosthesis
removal needs to be considered. Some experts recommend prolonged
antibiotic courses for better results. Early recognition of this
entity even in the absence of an obvious predisposing cause is required
for early diagnosis and institution of therapy.
D4
Confusion, ataxia and psychosis - amphetamine toxicity in the
elderly.
G. Gulati, S. Gulati. Internal Medicine, The Reading Hospital and
Medical Center, West Reading, PA.
INTRODUCTION: Amphetamine abuse is the primary cause
of emergency visits in 73,400 patients per year in the United States.
Classic presentations include psychosis, agitation and sympathomimetic
signs.
CASE PRESENTATION: A 62 year old male with a past history
of recreational drug abuse presented with acute onset unsteady
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gait, word finding difficulty and erratic speech, with mild confusion
and confabulation. Fixed delusions were also noted, as well as visual
and auditory hallucinations. He and his accompanying family denied
any recent alcohol use. On physical exam, he had a blood pressure of
186/105, and neurological examination revealed hypertonia, positive
Romberg’s test and abnormal heel to toe test as well as incoordination
of movements. He also had some cog wheeling and would fall
backwards on standing, which did not change with eyes being open or
closed. Laboratory evaluation revealed stable CBC with differential,
normal electrolytes, mild transaminitis, a negative blood alcohol level,
negative Lyme test and RPR serology. It was however positive for
amphetamines in the urinary drug screen. The patient was treated
with as needed lorezapam and haloperidol. Over the next day or two
he improved significantly and his problems including ambulatory
dysfunction had resolved.
DISCUSSION: Confusion, ataxia and psychosis are symptoms
common to alcohol withdrawal, drug ingestion and other rarer medical
conditions. Elucidating a cause becomes vital in the elderly where
this triad may be a common presentation. It is important to remember
to obtain a drug screen in a patient where symptoms don’t fit in
and common diagnoses such as alcohol withdrawal seem less likely,
even in extremes of age. Early interventions with atypical antipsychotics
and benzodiazepines are warranted and bring about improvement
in symptoms.
D5
An Interesting Case of Ankle Pain in an Arthritic Older Adult.
I. Sulapas, D. S. Edwards, B. G. Jones. Family & Community Medicine,
Texas Tech University Health Sciences Center, Lubbock, TX.
Supported By: This project has received no funding.
Introduction: Osteochondritis dissecans (OCD) of the talus is
more commonly seen in the adolescent and young male population,
but should be in the differential for ankle pain in an older adult.
History: A 60-year-old Hispanic male presented with complaints
of left ankle pain for the last 3 months. He has a long past medical history
of diabetes (HbA1c 7.0%), coronary artery disease with stents,
hypertension, osteoarthritis, stroke, and peripheral vascular disease.
He is poorly compliant with his medications. The patient stated that
he has never had an evaluation of his left ankle and denied any
trauma to the foot. He is currently wheelchair bound secondary to a
stroke four years ago. An angiogram two months prior to initial visit
showed that his lower legs are well perfused. He described the ankle
pain as sharp, located in the left medial ankle region with swelling,
non-radiating, and pain only when he is bearing any weight. He denied
any tingling sensation to his feet, as well as any locking or catching
of his left ankle. Findings: On physical exam, there was 1+ edema
on the medial portion of left ankle, 2+ pulses on left posterior tibialis
and dorsalis pedis arteries, and brisk capillary refill noted. There was
tenderness on both the tibiotalar joint and the medial malleolus, and
full ankle passive and active range of motion. His sensation was intact,
and 3/5 motor strength. A radiograph of the left ankle revealed a
large subchondral bone defect extending into the articular surface of
the talar dome and joint effusion (Stage IIb). A subsequent MRI
showed a 1.5 cm osteochondral defect of the medial portion of the
talus extending to the articular surface without definite evidence of
collapse.
Discussion: Clinicians should include OCD in the differential diagnosis
for chronic ankle pain in an older adult. OCD is a relative
rare disorder that is characterized by an area of subchondral bone
that undergoes necrosis. The adult form of OCD is commonly seen in
patients from 16 to 50 years of age. Knee joints are most common,
with 75% of cases reported, followed by the elbow (6%), then ankle
4%). The talus supports the axial load during weight-bearing, so it
plays a vital role in ankle motion. Treatment involves immobilization
and observation, however if symptoms persist or grinding or catching
develops, an orthopedic consult is warranted for arthroscopic drilling
versus bone graft.
D6
“Doc, I want to die”: the ethical dilemma of a patient’s right to
refuse life-saving treatment due to a death wish.
J. K. Yuen, 1 K. Covinsky, 1,2 R. Sudore. 2,1 1. Geriatrics, UCSF, San
Francisco, CA; 2. VAMC, San Francisco, CA.
Case: A 64 year-old recently widowed man presented with fever,
weight loss and abdominal pain. CT scan revealed multiple liver abscesses.
Infectious Disease thought that drainage and antibiotics
would be curative and that no treatment would be fatal. The patient
initially consented to drain placement but later refused further drain
manipulation, antibiotics and antidepressants stating, “I have nothing
to live for” and “I want to die.” Psychiatry evaluation revealed that he
had a long history of depression and refusal of medical and psychiatric
treatment. Multiple discussions took place over two weeks between
the patient and his primary team, Palliative Care, and Psychiatry.
All providers agreed that he expressed a clear choice and
understood the risks of his decision. Yet, there were conflicting opinions
regarding his decision-making capacity. Some providers were
deeply disturbed by the patient’s irrational choice and felt that his depression
and passive suicidal ideation rendered him incapable of
making decisions. Others felt that the patient retained valid internal
reasoning as evidenced by his clear and consistent thought process.
The ethics committee deliberated and deferred the capacity determination
to the primary team who felt the patient retained capacity. The
patient opted for comfort care, antibiotics were discontinued, and the
patient was transferred to an inpatient hospice unit.
Discussion: This case highlights the dilemma between the ethical
principles of beneficence and honoring patients’ autonomy to refuse
treatment – in this case, for a curable and otherwise fatal condition in
the setting of depression and a wish to die. A diagnosis of depression
is not sufficient to render someone incapable of decision making. To
have capacity, patients must demonstrate reasoning as defined as consistency
of choice and the ability to weigh the risks, benefits and consequences
of decisions. Disagreement arises over whether the determination
of intact reasoning should be based upon a patient’s
internal values and worldview or whether the external rationality of
the patient’s decision in the context of societal norms should also be
considered. Although the patient in this case made a choice that is
considered highly irrational by many, it was determined that he
demonstrated intact reasoning and the capacity to refuse treatment.
D7
Rapid Onset Hyponatremia After Initiating TMP/SMX and
Citalopram.
J. M. Redding, 1 S. Nichols, 2 S. Hallen. 1 1. Dept. of Geriatrics, Maine
Medical Center, Portland, ME; 2. Dept. of Pharmacy, Maine Medical
Center, Portland, ME.
TMP/SMX-induced hyponatremia, while rare, is a likely underdiagnosed
event. By decreasing aldosterone-mediated sodium reabsorption
in the collecting duct, TMP/SMX, in synergy with other
serum sodium-lowering medications, such as selective serotonin reuptake
inhibitors (SSRIs), may cause severe hyponatremia.
A 79-year-old female was admitted with weakness, confusion,
and a serum sodium of 119mEq/L (140 mEq/L 10 days prior to admission.)
Citalopram and TMP/SMX had been initiated 7 and 3 days
prior, respectively. On exam, the patient appeared euvolemic. Laboratory
data revealed hypotonic hyponatremia (serum osmolality=248mOsm/kg)
with a creatinine clearance of 36ml/min. A head
CT was normal. Both medications were discontinued on admission.
Initial therapy with 0.9% NaCl resulted in a decreased sodium level
of 117mEq/L after 4 hours. A slow infusion of 3% NaCl then increased
her sodium to 129meq/L (12mEq/L in 24hrs). She was transitioned
to a fluid restriction of 1.5L/day and her sodium increased further
to 136mEq/L by hospital day 4, with resolution of her symptoms.
The patient developed severe, rapid onset hyponatremia after
initiating TMP/SMX in addition to citalopram. We hypothesize that
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two synergistic mechanisms caused the hyponatremia. The first was
the syndrome of inappropriate antidiuretic hormone (SIADH) secondary
to citalopram. Her presentation is consistent with SIADH as
evidenced by euvolemia, low serum osmolality, and worsening hyponatremia
with a normal saline challenge. We find support for a second
mechanism from the unusually rapid and severe onset of the
SSRI-induced SIADH. The addition of TMP/SMX may have worsened
the hyponatremia through trimethoprim-mediated aldosterone
antagonism. Consistent with this hypothesis, the patient showed rapid
improvement of her hyponatremia by hospital day 4, when citalopram
was still present in her serum while TMP/SMX was already
eliminated. (Given the patient’s age and renal function, TMP/SMX’s
T½=18hrs and citalopram’s T½=50hrs.)
The potential synergism between TMP/SMX and citalopram, as
observed in this case, merits a warning as a potential drug interaction.
Providers should take care when adding TMP/SMX to a regimen containing
other potentially hyponatremia-inducing medications, particularly
in cases of renal dysfunction.
D8
Missed Diagnosis of Waldenstrom’s Macroglobulinemia and
Systemic Amyloidosis in a Patient Diagnosed as Follicular
Lymphoma.
J. Silvestre, S. Saad. Montefiore Medical Center / Albert Einstein
College of Medicine, Bronx, NY.
Supported By: No financial disclosures
Waldenstrom’s Macroglobulinemia (WM) is a rare lymphoplasmacytoid
malignancy present in 2.5/million/year. Of these, < 5% develop
systemic amyloidosis (AL). We present a case of WM complicated
by AL, erroneously diagnosed as a benign follicular lymphoma.
Cardiac amyloidosis and WM were found on postmortem pathology.
Case: A 79 year old male was transferred from a nursing home
because of fever and hypotension.
His past medical history included hypertension, seizure disorder,
anemia, peptic ulcer disease, Parkinson’s disease. Patient had an excellent
functional and cognitive status until diagnosed with follicular
center lymphoma with M-gammopathy by biopsy 15 months before
presentation. On retrospective analysis, flow cytometry was CD10+,
CD19+, and CD20+. PET CT scan showed minimal involvement of
retroperitoneal lymph nodes but no hepatosplenomegaly. Bone scan
was negative, IgM > 5 g/dL, and beta-2-microglobulin was elevated.
He had received one month of rituximab. Soon afterwards, he developed
diverticular perforation requiring colostomy. Later, a delayed
colostomy reversal surgery was complicated by sepsis and acute kidney
injury, needing dialysis. Subsequent clinical course worsened with
functional decline and multiple admissions due to urinary tract infections,
C. difficile diarrhea, and health care associated pneumonia.
Hospital Course: On the Emergency Department, the patient
was hypotensive and unresponsive. Laboratory data showed pyuria,
leukocytosis, and anemia. Electrocardiogram showed normal sinus
rhythm. Chest X-ray showed mild congestive heart failure. Prior
echocardiogram showed normal function but left ventricular hypertrophy.
The patient was fluid resuscitated and treated with broad
spectrum antibiotics for presumed sepsis. Later he defervesced and
stabilized, however his heart failure worsened. His overall prognosis
remained poor. Palliative care was instituted and he expired 12 days
after admission.
On postmortem pathology, extensive systemic amyloidosis was
found and significant cardiac involvement was reported. Lymphoplasmacytoid
cells were identified, suggestive of WM.
Discussion -
When patients with lymphoma and gammopathy develop symptoms
of heart failure, AL should be suspected since it drastically reduces
the survival. Expression of CD10 and CD23 may be found in 10
to 20% of cases and should not exclude WM. Coexistence of WM and
AL carry a grim prognosis.
D9
Topical clindamycin phosphate use for chest wall follicultis
complicated by severe Clostridium difficle infection.
J. Palla, 1 S. M. Imam, 1,2 S. B. Johnson. 3,4 1. Geriatrics, Edward Hines
VA Hospital, Hines, IL; 2. Internal Medicine, Loyola university
Hospital, Maywood, IL; 3. Infectious Disease, Edward Hines VA
Hospital, Hines, IL; 4. Infectious Disease, Loyola university Hospital,
Maywood, IL.
Back ground: Topical application of clindamycin is not a well
recognized risk for Clostridium difficile infection (CDI) but the association
has been reported. We report a rare case of severe CDI following
topical clindamycin phosphate use.
Case report: A 62 year old male resident of a nursing home was
transferred to the emergency room with fever, hypotension and
tachycardia. He had history of Hartmann’s Colostomy done 4 months
ago for recurrent diverticulitis followed by severe CDI. No history of
exposure to antibiotics in the past 4 months or any other symptoms
were elicited. Medication review did show 1% clindamycin phosphate
ointment prescribed 3 weeks ago for chest wall folliculitis.
Physical exam was non-contributory. Initial workup showed leukocytosis
and a normal chest x-ray. Although bacterial sepsis was suspected
initially, he developed loose colostomy output shortly after
presentation and the white blood count increased to 23000 per cc 3 .
Oral vancomycin treatment was started for suspected CDI and the diagnosis
was confirmed by stool C.difficile toxin assay. The leukocytosis
and loose colostomy output improved within 48 hrs. He was transferred
back to the nursing home, where the clindamycin ointment was
identified as a possible trigger for the colitis and was discontinued.
Discussion: Twenty cases of topical clindamycin related diarrhea
and two case reports of proven CDI were published from 1978 to
1986. Pharmacokinetic and pharmacodynamic studies after topical
clindamycin application have shown detectable serum concentrations
and presumptive effects on intestinal flora. Animal studies have
shown that the lethal dose applied topically to hamsters was similar to
doses given to humans for treatment of acne. It is important to recognize
this potential side effect of topical administration of clindamycin
and use it cautiously, particularly in patients at high risk for CDI.
D10
Uncommon causes of intractable hallucinations in the demented
elderly.
K. Alagiakrishnan. Medicine, University of Alberta, Edmonton, AB,
Canada.
Introduction: Hallucinations are false sensory perceptions or experiences
that a person sees, hears, smells or feels something but do
not exist. It can be the result of the brain changes in dementia or as a
result of medical problems. In this report, three uncommon causes of
hallucinations in dementia patients are presented.
Case reports:
Case 1:
A 75 year old female came for cognitive assessment. She had
cognitive decline for the past two years. For the past four months, patient
smelled sour gas (olfactory hallucinations) in the basement and
it was thought to be due to confusion, which was secondary to dementia.
A short course of antipsychotics did not help with the symptom.
On one occasion, patient called the police for this problem. At
that time a neurologist saw the patient in the ER and was sent home
with a suspicion of query small stroke. During our assessment, we
found no history of epilepsy or psychiatric disorders. There was no evidence
of delirium or no neurological deficits were seen. MRI of the
head showed large infiltrating mass involving both cerebral hemispheres
and the differential diagnosis was an astrocytoma or possible
lymphoma.
Case 2:
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An 80 year old woman, with a known history of dementia for
the past five years, came for assessment of visual hallucinations (seeing
a man through her bedroom window daily for the past nine
months). No history of vision problems or psychiatric disorders.
Cholinesterase inhibitor and antipsychotic treatment did not help
with the visual hallucinations. A CT head taken at that time compared
with the previous CT scan taken before one year showed an
occipital lobe infarct, which might be contributing to these visual
hallucinations.
Case 3:
An 84 year old male with a known history of dementia for the
past 3 years came with a history of buzzing sound in the head (auditory
hallucinations) for the past 5 months. Antipsychotic management
did not help with the problem. A complete assessment including
CT scan did not show any acute findings, except decreased hearing in
both ears. Patient was sent to an audiologist and with the help of
hearing aids, patient’s symptom got better.
Conclusion:
Psychotic behaviors may pose more challenges than cognitive
decline for the demented patients as well as their caregivers. When
demented patients present with intractable hallucinations, not responding
to medical management, rare and unusual causes of hallucinations
should be considered.
D11
Effect of language in cognitive testing of a bilingual older adult.
K. Berg, 1 S. Mejnartowicz, 1 B. Olmedo, 1 L. Walke. 1,2 1. Yale School of
Medicine, New Haven, CT; 2. VA Connecticut, West Haven, CT.
Supported By: The authors have no financial disclosures to report
Objective: Recognize potential language bias in cognitive testing
of bilingual older adults
Case: An 80-year-old Hispanic veteran was brought to the geriatrics
consult clinic for a cognitive assessment. He graduated high
school in Puerto Rico and had worked in English speaking settings in
the United States for over 60 years. During the initial visit, he scored
18/30 on the English language Mini-Mental State Examination with
deficits in orientation (-8), recall (-3) and constructional praxis (-1).
Three months later we administered the Saint Louis University Mental
Status in English to better evaluate executive function. He scored
13/30 with deficits in story comprehension (-6), recall (-4), orientation
(-2), animal generation (-2), reverse digit span (-1), and clock drawing
(-2) and was started on a cholinesterase inhibitor. At his 6-month
visit, we repeated both tests in Spanish. Using the validated Spanish
MMSE his score improved from 18/30 to 21/30 with changes in orientation
(+2) and constructional praxis (+1). An on-site certified translator
converted the SLUMS into Spanish making two cultural
changes to the content: the characters “Jack and Jill” were changed to
“Maria and Jose” and instead of a stockbroker, Maria was described
as a businesswoman who owned a factory. On the Spanish version of
the SLUMS, the patient’s score improved from 13/30 to 22/30 with the
greatest changes in story comprehension (+4), clock drawing (+2), animal
generation (+1), recall (+1) and attention (+1).
Discussion: The 9-point difference on the SLUMS and 3-point
difference on the MMSE illustrate several understudied issues regarding
cognitive testing and among bilingual older adults. First, the
effect of language may be more pronounced in tests of executive dysfunction,
language generation and comprehension, which are core
domains of cognition. Second, little is known about the effect of bilingualism
on the aging brain or if there is a differential impact of cognitive
deficits on the languages spoken by bilingual older adults, and
these areas merit research. Lastly, because testing in the patient’s
non-native language may misrepresent cognitive deficits, clinicians
should attempt to administer language appropriate cognitive tests before
making diagnostic and therapeutic decisions.
D12
Acute Encephalopathy as a complication of Small Bowel
Obstruction.
K. P. McIntosh, C. Rommesser, T. Caprio. Medicine, University of
Rochester School of Medicine & Dentistry, Rochester, NY.
Supported By: HRSA GTPD Grant #D01HP08792
Background:
We present a case of acute encephalopathy seen in a patient
with a small bowel obstruction. The gastrointestinal tract has been
classically seen as the main source of circulating and excretion of ammonia.
This small molecule crosses the blood-brain barrier and is absorbed
and metabolized by the astrocytes, a population of cells in the
brain that constitutes 30% of the cerebral cortex. It is hypothesized to
be a minor contributor in the cascade leading to encephalopathy associated
with acute illness.
Case Presentation:
A 74 year old female nursing home resident with a history of f
incisional and umbilical hernia repair was acutely admitted to the
hospital with abdominal pain, nausea, and bilious vomiting and subsequently
found to have a complete small bowel obstruction on CT
scan. During her hospital course as the patient’s obstruction was
medically managed via decompression, she ultimately developed significantly
elevated ammonia levels, diffuse encephalopathy, and ultimately
developed status epileptic. Her ammonia level at the time of
her coma presentation was 193 mcg/dL. Her status epilepticus resolved
with antiepileptic medications and with resolution of her small
bowel obstruction she was treated with lactulose to help mitigate additional
production of toxic ammonium metabolites. She improved
significantly with concurrent rapid resolution of her elevated ammonia
levels.
Discussion:
This case presents a unique presentation that shows an uncommon
but likely complication of having an acute small bowel obstruction.
Traditionally focus has been on hepatic impairments in clearance
of ammonia containing metabolites as the primary cause of
encephalopathy. However, it is necessary to be mindful of the significant
role the small bowel plays in eliminating and producing toxic
levels of ammonia. This case also illustrated the challenge of trying to
reduce ammonia products with laxative in the setting of an immotile
bowel due to the obstruction. The question of whether surgical correction
a small bowel obstruction would have lessened the risk of encephalopathy
is also a question that needs to be addressed in this setting.
There needs to be a timeline developed of how long to pursue
the medical management that addresses correcting the obstruction
while simultaneously attempting to mitigate the toxin production
contributing to a worsening encephalopathy.
D13
When a Good Story Gives the Wrong Impression: An Atypical
Presentation of Complete Heart Block.
K. James, I. Kopits. Department of Medicine-Section of Geriatrics,
Boston University Medical Center , Boston, MA.
Introduction: Syncope is a common clinical event in geriatric
medicine and increases three-fold in patients over 80 years of age.
The ability to risk stratify patients to outpatient versus inpatient management
is critically important.
Case Report: An 89 year old man with a history of diverticular
bleeds, hypertension and an MI 15 years prior, presented for evaluation
of nausea and dry heaves. His symptoms began suddenly and persisted
episodically throughout the day. He was unable to take any
food or medications by mouth and developed mild diffuse abdominal
pain. He denied dizziness, palpitations or chest pain and had no postural
changes in blood pressure or pulse. In clinic he began belching
loudly. He then became pale and diaphoretic followed shortly by loss
of postural tone. He was unresponsive for approximately 10 seconds
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then awoke spontaneously and continued to wretch. His mental status
was at baseline and he reported feeling well as he was taken to the ED
for further evaluation. EKG was notable for first degree AV block
(PR interval 224ms, unchanged from prior). Results of a CBC, serum
chemistries, Echocardiogram (done one month prior), and abdominal
CT scan were normal. He was able to eat and drink and had no further
syncopal episodes during 8 hours of observation in the ED. Our
clinical impression was reflex mediated vasovagal syncope secondary
to significant upper gastrointestinal distress. Despite this benign explanation
of his syncope, the ED physician admitted him to a telemetry
bed. Hours later he displayed multiple episodes of complete heart
block (CHB), with one episode resulting in loss of consciousness followed
by vomiting.A temporary pacing wire was placed followed by a
permanent pacemaker the next day. He experienced complete resolution
of his GI symptoms following pacemaker implantation.
Conclusion: Current practice guidelines emphasize the preeminence
of an accurate history in determining the etiology of syncope.
This patient’s atypical presentation of CHB mimicked reflex mediated
vasovagal syncope. His age and remote history of MI led to his
admission, though it seems likely that many physicians would have
discharged this patient. This case demonstrates the importance of
maintaining a high index of suspicion for atypical presentations of arrhythmic
syncope in very elderly patients with cardiac risk factors.
D14 Encore Presentation
A fatal case of treatment resistant C. difficile colitis.
K. S. Malik, M. Reisner ( AGS-F ). internal medicine, jersey city medical
center, Jersey City, NJ.
Introduction: C.diff colitis is frequently associated with previous
antibiotic use especially in the elderly population and those with recent
exposure to hospitals, nursing homes and daycare centers. The
“National Prevalence Study of C.Diff in U.S. Healthcare Facilities”
indicates that 13 out of every 1,000 inpatients were either infected or
colonized with C.Diff. Mortality rate as high as 25% in elderly patients
who are frail and immuno-compromised.
Recurrence occurs in approximately 25 percent of cases. Oral
vancomycin is the preferred therapy for severe or refractory cases.
Combination of oral vancomycin and intravenous metronidazole for
patients of C. diff with ileus is shown to be very effective. Efficacy of
this treatment in geriatric population is still questionable.
We present a treatment resistant case of C.diff colitis.
Case Description: Ms L was a 95 year old female with a history
of dementia and recent appendectomy who presented with C.diff colitis
to the hospital. Her colitis resolved after 10 days course of
Metronidazole.
Approximately 4 weeks later Ms. L developed watery diarrhea,
five to six times a day associated with weight loss. There were no
symptoms of nausea, vomiting, abdominal pain, fever, chills or rash.
Upon arrival in ER, she was thermodynamically stable, Normal
physical exam with leukocytosis of 16. Patient was admitted and
Metronidazole restarted.
Stool for C.diff toxin was positive. Within 48 hours, her condition
deteriorated. WBC rose from 16 to 50 and progressed to septic shock.
Ms L was transferred to MICU and aggressive intravenous fluid therapy
with vasopressors and oral vancomycin was added to the regimen.
Subsequently she developed diffuse abdominal tenderness.
WBC further increased to 112 with lactic acidosis of 11. Despite the
classic presentation of C.Diff, leukocytosis of 112 prompted an evaluation
for acute leukemia, and a flow cytometry was done which was
normal.
CAT scan of the abdomen revealed diffuse pseudomembranous
colitis; developed multiorgan failure, ARDS and deceased within 96
hours of admission.
Conclusion:
C. diff colitis is associated with significant mortality in the geriatrics
patients. Extensive leukocytosis is associated with poor prognosis.
Decreased immunity and multiple co morbidities are responsible
for this increased incidence in the elderly population. The clinical syndrome
of chronic C. diff and the best treatment options in this population
group needs to be further investigated.
D15
Diabetes is Associated with Functional Impairments in HIV+ Older
Adults.
K. Shah, 1 T. N. Hilton, 2 A. E. Luque, 1 W. J. Hall. 1 1. Medicine,
University of Rochester, Rochester, NY; 2. Physical therapy, Ithaca
College, Rochester, NY.
Supported By: This abstract was supported in part by the University
of Rochester Developmental Center for AIDS Research (NIH
P30AI078498)and John A Hartford Foundation Center for
Excellence in Geriatric Medicine and Training.
BACKGROUND: The prevalence of glucose intolerance and
diabetes in HIV+ patients has increased dramatically following the
widespread use of highly active antiretroviral therapy and the improved
survival rate in this population. The risk is further exacerbated
as this population ages. Although it is known that HIV+ patients
are at increased risk of frailty, little is known regarding the
impact of diabetes on physical function in HIV+ older adults (HOA).
PURPOSE: To explore the nature of functional impairment in HOA
with glucose intolerance status as measured by having diabetes.
METHODS: Twenty HOA (mean age=60 y; 30% female) participated
in a case-control study at an urban HIV clinic. Ten HOA with
diabetes were matched to ten HOA controls without diabetes on age,
gender and BMI. Subjective and objective measures of functional status
were evaluated using the Physical Performance Test (PPT),
graded treadmill test, isokinetic dynamometer, gait speed, balance
and functional status questionnaires (FSQ). Body composition was
evaluated using DXA. Muscle quality was evaluated by determining
the ratio of leg strength to leg lean mass. RESULTS: The two groups
were comparable in duration of HIV, CD4 count and viral load. Compared
with matched controls, the case patients had lower scores in
PPT, peak aerobic power, and FSQ (p

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agent has been rarely described in female residents of long-term care
facilities.
Case
74 year old woman with moderate dementia admitted from
home because of need for increased supervision. The patient developed
more frequent episodes of urinary incontinence and she was
treated for two urinary tract infections. About nine months after admission,
a urogynecology nurse practitioner recommended a regimen
of treatment including tamsulosin. In addition geriatrics staff reviewed
the case and recommended stopping nortriptyline, which the
patient was taking for depression. The tamsulosin was well-tolerated,
and the patient had decreased daytime incontinence and the patient
felt she was able to void more easily.
Discussion:
Tamsulosin (“Flomax”) is an alpha-blocker, thought to function
at the bladder neck, leading to improved urine flow. Its use is controversial
in women: there are few high quality studies involving women
and many geriatricians have concerns about the potential side effects
(e.g. orthostatic hypotension, increased congestive heart failure incidence).
Tamsulosin has been recommended by some urologists in
certain women with functional or anatomical bladder outlet obstruction,
but its use has been rarely described in older women in nursing
facilities.
Conclusion:
In this case, tamsulosin was used as part of a multidisciplinary
intervention lead by a urogynecology nurse practitioner involving a
search for causes, behavioral modifications, and medication adjustment.
While this woman’s symptoms improved on tamsulosin, and the
medication was well-tolerated, its role in the care of women with
functional and anatomical obstruction remains controversial, and
there is little good evidence demonstrating its benefits. Further research
is needed to determine which women will most benefit from
its use.
D17
Breast implant herniation masquerading coronary heart disease in
an elderly woman.
L. C. Andrade, 1 M. Raji, 1 J. G. Alamo. 2 1. Internal Medicine/
Geriatrics, UTMB, Galveston, TX; 2. None, Pearland, TX.
INTRODUCTION: Breast Implant complications and symptoms
of coronary heart disease are rarely considered to have features
in common. This report describes a case of a 69 year old Caucasian female
with past medical history relevant for hyperlipidemia and overweigh,
who presented with symptoms resembling coronary heart disease.
Results of the physical examination were relatively benign. A
Dobutamine Stress Test showed normal Ejection Fraction of 55%
and was negative for inducible ischemic and wall motion abnormality.
The patient had a Mammogram which showed bilateral
silicone/saline implants and herniation medially of the left implant.
She subsequently underwent bilateral breast implant removal with
no complications.
By this case presentation we want to discuss the evidence linking
late breast implant complications with associated coronary symptoms.
DISCUSSION: This case report illustrates that breast implant
complications can present with atypical symptoms in the elderly
which can mimic coronary heart disease. The elderly represent the
fastest-growing segment of the American population and one that
had breast implants inserted when younger. Breast reconstruction
has also become a standard part of the care for female patients with
breast cancer, the incidence of which increases with age. It is especially
important not to confuse angina-like symptoms related to herniating
breast implants with those related to heart disease. Heart disease
is the number one killer of women. However, like our patient, if
the stress and other cardiac tests are negative, breast implant herniations
should be considered as part of the differential diagnosis of
chest pain in older women with implant.
CONCLUSIONS: Our patient with chest pain secondary to herniated
breast implant presented with several misleading features of
coronary syndrome. Negative workup with regard to coronary artery
disease prompted us to look for integrity of the breast implants, which
led to the correct diagnosis and guided the patient’s intervention.
Late complications of breast implants should be a consideration on
the differential diagnosis in patients with a history of breast implants
presenting with chest pain. However, coronary heart disease work up
should always be considered and cardiac causes ruled out first, prior
to assuming the problem is solely due to the breast implant or some
other non-cardiac problems.
D18
Insidious TB Meningitis in the Elderly.
M. Chelagiri, A. Date, J. Shimonov, D. Asnis, A. Vela, D. Dave,
H. Sharma, J. Campanova. Geriatrics Division, Flushing Hospital
Medical Center, Flushing, NY.
Introduction : Tuberculosis (TB) is a major global public health
issue. Although pulmonary TB has declined in the last decade in US,
the number of central nervous system (CNS)TB has remained the
same. It accounts for 6% of all extra-pulmonary infection and 1% of
all cases of TB diagnosed in the US. CNS TB includes: meningitis, tuberculoma
and abscess. In the elderly, CNS TB can be subtle; leading
to death in weeks if untreated.
Case Report: 66 y/o healthy Asian Indian male, presented with
progressive malaise, weakness, intermittent headache, high grade
fevers, chills and productive cough for 12 days. Recent immigrant denies
sick contacts. CT Chest revealed bilateral diffuse nodular inflammatory
lesions consistent with miliary pattern. PPD and HIV were
negative; quantiferon was positive. Sputum AFB x 3 were negative.
Pleural biopsy showed necrotizing granulomas with AFB stain positive.
RIPE was prescribed for miliary TB. The neurological status deteriorated
with progressive malaise, headache, seizures, and confusion.
CT Head revealed hydrocephalus. He was started on keppra,
corticosteroids and intubated. Ventriculostomy drain was placed to
relieve intracranial pressure. CSF analysis: low glucose, elevated protein,
lymphocytic pleocytosis. AFB stain negative. MTB by PCR negative
but AFB cultures in broth grew Mycobacterium tuberculosis by
DNA probe. MRI brain confirmed meningeal disease and hydrocephalus.
Subsequently, he was extubated and mental status improved,
although residual neurological sequelae remained.
Discussion: The BMRC classification is useful for prognosis and
therapy: Stage 1-Lasts 2-3 weeks, malaise, lassitude, fever, anorexia,
headache and personality change, Stage 2–Meningeal irritation, protracted
headache, vomiting and cranial nerve palsies, and Stage 3-
Clouding of sensorium, stupor, coma, seizures and hemiparesis. Risk
factors are immigration from TB prevalent areas, crowded living,
HIV, drug resistance. The worst prognostic factor for TB meningitis is
the level of consciousness during the time treatment commenced.
Conclusion: The most important determinant for the development
of CNS TB has always been age. CNS TB is often not diagnosed
promptly due to the nonspecific and subtle clinical features. Geriatricians
must consider reactivation of TB in patients presenting with
neurological symptoms from endemic regions. Early recognition and
timely treatment is critical to prevent mortality and morbidity.
D19
Avoiding snap judgments: decreased oral intake resulting in
admission to a geropsychiatric unit.
M. Bednarczyk, 1 J. Chang, 2 M. Gorbien, 1 J. C. Olson, 1 M. J. Leiding. 1
1. Geriatrics, Rush University Medical Center, Chicago, IL; 2. Family
Medicine, Mt. Sinai Hospital, Chicago, IL.
Background: Decreased oral intake and weight loss are common
symptoms in the elderly, frequently attributed to depression,
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cancer, non malignant GI disorders, and medication side effects. In a
quarter of patients, no identifiable cause is found. However, somatic
diseases may be mislabeled as a psychiatric disorder because specific
organic symptoms may be overlooked or misinterpreted by physicians,
psychiatrists, or by the patients themselves.
Design/Methods: Case Reports of three patients admitted in a
Geriatric Psychiatry Unit at RUMC
Results:
Patient #1: 95 y.o. female with decreased hearing and visual acuity,
GERD admitted following suicide attempt by ingesting a bottle of
Advil, complaining of regurgitation, cough and dysphagia. Videofluoroscopic
swallow study showed large air filled esophagus and lack of
peristaltic movement concerning for Zenker’s diverticulum. Patient
declined further work up, her symptoms were managed conservatively.
Patient #2: 74 y.o. female with HTN, DM2 presented with weakness,
weight loss, sore throat, recurrent emesis for 2 months. She expressed
paranoid thoughts of “aliens in her stomach.” Her family believed
she was anorexic. She was diagnosed with gastric
adenocarcinoma compressing the esophagus, necessitating G- tube
and esophageal stent placement.
Patient #3: 80 y.o. female nursing home resident with weight loss,
depression, complaining of food sticking in her chest. Although a barium
swallow was concerning for an esophageal stricture, EGD was
negative. Ultimately, her symptoms resolved as her depression was
treated.
Relevance: Unintentional weight loss may lead to significant
morbidity and mortality in elderly patients if left untreated. Although
this is frequently attributed to an underlying psychiatric disorder,
these diagnoses require absence of somatic disease. Two of these patients
had a somatic cause for their illness, while in the last patient
medical work up was necessary to verify a psychiatric cause of her decline.
As geriatricians, we are taught to not overlook psychosocial
causes of these symptoms. Nevertheless, a careful medical investigation
to exclude a possible somatic disease mimicking a psychiatric disorder
in elderly patients is essential.
D20
A Suspicious Case of Syncope: Can Factitious Disorder Occur in
Persons with Dementia?
M. Grammas, A. Donahue, M. Drickamer. Yale University School of
Medicine, New Haven, CT.
CASE: An 88-year-old man with a history of atrial fibrillation,
dementia and depression presented with frequent episodes of loss of
consciousness. He had several prior negative evaluations. Patient was
OX3 and had a normal physical exam. He had mild, asymptomatic
postural BP changes. CXR, head CT, ECG, echocardiogram and labs
were normal. He scored 24/30 on MMSE with deficits in short-term
recall and visual-spatial domains. His clock drawing showed perfect
planning and ordering of numbers but incorrect hand placement.
During the hospitalization, he had several episodes of loss of
consciousness, some while supine, others when arising to stand. Vital
signs, telemetry review, pacemaker interrogation, and continuous
video EEG monitoring revealed no explanation.After emerging from
one episode, the patient remarked, “You know I am faking all of this.
I like to see you people come around.” Psychiatry consult stated that
due to his dementia, he did not have the capacity to feign an illness.
DISCUSSION: Transient loss of consciousness is not an uncommon
presenting symptom among older adults. The most common
causes are orthostasis, carotid hypersensitivity and cardiac abnormalities.
Nonsyncopal causes include seizures, metabolic, intoxication
and psychogenic. History and physical reveals the diagnosis in approximately
half of cases. Imaging, cardiac and neurologic evaluations
should be performed as indicated. While the spectrum of
feigned medical illnesses are diagnoses of exclusion, they should also
be considered when symptoms persist despite adequate evaluation.
Simulated diseases arise from either unconscious or conscious behaviors.
Among the conscious simulated diseases is factitious disorder,
the intentional production of symptoms for a primary gain, to achieve
the sick role. It is estimated that factitious disorder may account for
as many as 5% of all physician visits with neurologic symptoms being
among the most common. There is scant literature on whether factitious
disorders occur in patients with dementia. Based on fMRI studies,
the act of deception is associated with increased activity in prefrontal
and anterior cingulate cortices, areas involved in executive
function. Our patient, independent of ADLs and some IADLs and
able to follow multiple step instructions, demonstrated a number of
behaviors supporting executive function sufficient to consciously
feign symptoms of illness.
D21
An unexpected death over 3000 miles from home: the importance of
advance care planning.
M. Koya. Internal Medicine, University of Washington, Seattle, WA.
Case: A 66-year-old woman walked in with her husband to the
emergency department complaining of dyspnea. Within an hour of arriving,
the patient became hypoxemic and hypotensive requiring intubation
and initiation of vasoactive agents. Workup revealed severe
biventricular failure with an atrial septal defect (ASD) and a large
right to left shunt. The patient was admitted to the cardiac intensive
care unit (CICU). The husband stated to the on-call resident that they
were visiting from New York, and her only past medical history was a
remote history of breast cancer. They had never discussed advanced
care planning. Efforts were made to contact her primary oncologist to
obtain records; however this was unsuccessful. The husband asked the
resident to “do whatever is necessary” and the patient underwent
intra-aortic balloon pump and Swan-Ganz catheter placement. When
she still did not improve, the team prepared for an ASD repair, but
the patient was too unstable to leave the CICU. With the team’s recommendation,
the husband and other family members who telephoned
from New York agreed to withdraw care and the patient died
immediately.
After her death, medical records from her oncologist revealed
that the patient was diagnosed with Stage II breast cancer over 10
years ago and was status post chemotherapy. She was then lost to follow-up.
Recently, she was discovered to have metastatic disease and
heart failure with a cardiac shunt. Although she was prescribed cardiac
medications, the patient declined to take them. She had never informed
her husband about her cardiac condition.
Discussion: This case illustrates the importance of advance care
planning. The patient was more than 3000 miles away from her home,
became critically ill very rapidly, and had not discussed her medical
conditions or her wishes with her legal next of kin, her husband. Advance
care planning helps ensure that patients have their wishes followed
in the event they are unable to make their own decision at time
of acute illness. In a study of adults 60 years or age or older, subjects
who had living wills were more likely to want and receive limited care
or comfort care than all care possible(1). Given her history of noncompliance
with medical recommendations, there is a strong possibility
that the patient would not have wished for many of the interventions
that were administered. (1) Silverira et al. N Engl J Med. 2010
Apr 1;362(13):1211-8
D22
Not Your Ordinary Syncopal Event: A Case of Aortocaval Fistula.
M. Wirt, L. Cox-Vance. UPMC, Pittsburgh, PA.
Syncope, a common presenting symptom, challenges providers
to determine the underlying cause and any increased risk for death.
Abdominal aortic aneurysm (AAA) rupture and related complications
can be missed if not considered in the patient presenting with
syncope.
A 76 yo man with hypertension, coronary artery disease and
atrial fibrillation presented to the emergency room after a syncopal
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episode. He was alert and coherent but noted to be diaphoretic,
tachycardic and hypotensive with an irregular pulse. EKG revealed
supraventricular tachycardia which converted to sinus tachycardia
with IV adenosine. His hypotension remained refractory to normal
saline boluses and a norepinephrine infusion was added with resultant
blood pressure stabilization. Initial laboratory evaluation revealed
normal electrolytes, hematocrit of 40%, WBC 14.8 x 10^9 /L,
Troponin I 0.10ng/ml and INR 1.4. A repeat EKG showed atrial fibrillation
with diffuse ST depression. Chest x-ray was without acute
changes. The patient was transferred to the intensive care unit (ICU)
with preliminary diagnoses of hypotension, elevated troponin and
atrial fibrillation.
During initial ICU assessment, a pulsatile abdominal mass was
noted. Urgent CT angiography revealed an 8.7 X 8 cm infrarenal
AAA with contrast leaking into the right common iliac vein and inferior
vena cava. The patient underwent emergent open repair of the
ruptured AAA and aortocaval fistula with grafting of the right iliac
and left common femoral arteries. The bowel was noted to be dusky
necessitating urgent left hemicolectomy and sigmoidectomy.
The patient returned to the intensive care unit where he remained
intubated but responsive. He continued to require pressor
support and required massive blood product transfusion. Within several
hours, evidence of ongoing bowel ischemia was noted with discussion
of further debridement of the bowel. The patient’s family declined
further aggressive care and the patient died approximately 30
hours after the initial syncopal event.
This case illustrates the importance of careful differential diagnosis
and thorough physical examination in the evaluation of patients
presenting with syncope. AAA rupture, with or without the rare complication
of aortocaval fistula, must be considered in the syncope differential
as the rapidity of diagnosis and surgical intervention significantly
impacts survival.
D23
Dementia and “Delirium” Due to Whole Brain Radiation in a
Cancer Survivor.
M. Elarabi, M. Brennan. Baystate Medical Center, Springfield, MA.
Introduction
Radiation therapy (RT) is important in treating CNS tumors.
Sufficient doses of RT eradicate neoplasms but will inexorably damage
normal tissue. Controversy persists around the impact of RT on
the adult brain. The authors report a case of a patient with recurrent
admissions for “delirium” that proved to be due to ongoing radiation
induced damage.
Case
A 67 year old man had a craniopharyngioma resection and RT
25 years ago; he had hypopituitarism, stroke, and dementia and was
admitted twice in a month with profound stupor and excessive daytime
sleepiness. On the first occasion he was intubated for airway protection.
The geriatrics team was asked to assess his delirium. His physical
examination was only remarkable for gait ataxia. His MMSE was
28/30; a Geriatric Depression Scale was negative but a urinalysis was
positive. An MRI revealed atrophy, old lacunar infarcts and chronic
white matter changes suggesting small vessel ischemia. A video EEG
revealed mild to moderate diffuse cerebral dysfunction. A
polysomnogram showed mild OSA and an irregular sleep cycle. His
cognitive impairment, hypersomnolence and loss of circadian rhythm
proved to be due to a damaged hypothalamic pituitary axis as a result
of his tumor and RT induced brain injury.
Discussion
There are 3 types of radiation injury: acute, early delayed and
late delayed. Late delayed injury is irreversible, occurs 6 months to
many years later and primarily damages the white matter causing atrophy,
leukoencephalopathy, neurocognitive decline and hypothalamic-pituitary
and endocrine dysfunction. The proposed etiology is
vascular and likely results from damage to capillary endothelial cells,
increased microvascular permeability and impaired blood brain barrier
integrity leading to ischemia. Analyzing the impact of RT is confounded
by injury from cerebrovascular disease, baseline impairments
in cognition and multifactorial interactions of tumor, surgery,
chemotherapy and steroids.
Conclusion
Tools to measure and identify radiation effects are underdeveloped.
Long term studies that carefully assess baseline cognition and
changes over time are critically needed or the eventual result of high
dose RT may be a demented, bedridden patient who is cancer free.
With more aggressive forms of RT and improved survival rates, geriatricians
will be seeing increasing numbers of elders with RT induced
cognitive injury. Geriatricians must learn to recognize and manage
the resulting deficits.
D24
Severe Consequence of Acquired Diaphragmatic Hernia After
Reconstructive Surgery for Chest Wound Dehiscence After
Coronary Artery Bypass Surgery.
M. Izhar, 1,2 A. Gupta, 1,2 F. Aziz, 1,2 R. J. Beyth, 1,3 M. K. Bautista. 1,2 1.
GRECC, NF/SGVHS, Gainesville, FL; 2. Dept of Aging and
Geriatrics, University of Florida, Gainesville, FL; 3. Dept of Medicine,
University of Florida, Gainesville, FL.
Introduction: Diaphragmatic hernia is a rare surgical complication
of reconstructive surgery for wound dehiscence after coronary
artery bypass surgery (CABG). This case illustrates anterior chest
wall hernia, a severe consequence of diaphragmatic hernia in an older
patient after CABG.
Case: A 70 year old man had CABG in 2007 which was complicated
by sternal wound dehiscence after severe coughing. Six days
after CABG, he underwent sternal debridement, omental transposition
and secondary closure of the mediastinum. Three weeks later, he
developed diaphragmatic hernia with the small bowel displaced into
the anterior mediastinum. He also developed anterior chest wall hernia
which grew over time to the size of 6x8 cm. In 2011 he was hospitalized
for acute cholecytitis. Two days after undergoing percutaneous
cholecystostomy tube placement, he developed acute abdomen. Exploratory
laparotomy revealed the cholecystostomy tube traversing
through the small bowel. The cholecytectomy tube was removed and
the small bowel was resected. Over the next 10 days, his anterior chest
wall hernia enlarged significantly to the size of 20x16 cm. CT scan of
chest revealed a large diaphragmatic hernia with the small bowel extending
up to the clavicles. He was not felt to be a surgical candidate
due to lack of acute respiratory distress and his significantly altered
anatomy. He was treated conservatively with indefinite use of the
chest binder and discharged home.
Discussion: Diaphragmatic hernia is a rare but recognized complication
after cardiothoracic surgery. Its published rates range from
2.7 % to 11.7%. During surgery, the omentum is transposed either
through an incision in the anterior diaphragm or through the upper
end of the laparotomy incision and a subcutaneous tunnel. The omentum
can reach the suprasternal notch, thereby allowing the reconstruction
of an extensive defect. In this case the surgical incision in
the anterior diaphragm may have been too large resulting in the gastrointestinal
herniation into the chest wall. Future studies are needed
to evaluate the risks and benefits of surgery such as this among older
adults who may have a high risk for post-operative complications
after CABG.
D25
The role of PC-MRI in the differential diagnosis between
Alzheimer’s disease and NPH.
J. Zmudka. Amiens University Hospital, Amiens, France.
Introduction:
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The diagnosis of Alzheimer’s disease (AD) and normal pressure
hydrocephalus (NPH), as several neurodegenerative diseases, mainly
based on clinical examination, neuropsychological assessment and
conventional imaging, remains difficult.
The aim of this study is to demonstrate the role of Phase-contrast
magnetic resonance imaging (PC-MRI) in the assessment of
cerebral flows, and in consequence in the differential diagnosis between
AD and NPH.
Materials and methods:
Our population consisted of 20 AD patients (mean age: 80 ± 5
years) and 13 NPH (mean age: 70 ± 6 years). Patients were categorized
during a special consultation by a neuropsychologist and a geriatrician.
All the patients underwent cerebral MRI using a 3T-scanner including
PC-MRI imaging for CSF and blood flows quantification.
They were compared with a population (n = 12) of age-matched
healthy elderly (HE) (mean age: 71 ± 9 years) with normal neurological
and neuropsychological screening results (MMSE).
PC-MRI acquisition was then performed in addition of classical
morphological sequences. The PC-MRI sections were positioned at
the cervical level to investigate cerebral vascular input flows from internal
carotids and vertebral vessels. PC-MRI was also performed at
the aqueductal and cervical levels to measure the CSF flows. Afterwards,
PC-MRI images were analyzed to calculate global arterial flow
curves during cardiac cycle (cc). NPH, MA, HE populations were
compared.
Results:
There was no statistical difference of the mean arterial CBF between
the 3 groups (in ml/min): MA (495 ± 84), NPH (450 ± 129) and
HE (509 ± 108).
Cervical CSF flow analysis showed also similar values for all
3 groups (in μl/cc): MA (530 ± 210), NPH (455 ± 133) and HE
(457 ± 154).
In contrast, NPH presented significantly the highest aqueductal
CSF stroke volume (167 μl/cc ± 89) compared to AD (50 ± 30) and
HE (34 ± 17) (P < 0, 05).
Conclusion:
CSF flows quantification can be helpful for aetiological and differential
diagnosis between AD and NPH, especially in case of enlargement
of lateral ventricles.
D26
The First Intervention Study in Elder Self-Neglect: A Randomized
Clinical Trial to Improve Vitamin D Levels.
J. Burnett, 1,4 A. E. Hochschild, 1,4 S. M. Smith, 2,4 A. L. Stotts, 1,4
P. M. Diamond, 3,4 C. B. Dyer. 1,4 1. Internal Medicine, UT Health,
Houston, TX; 2. National Aeronautics and Space Administration
(NASA), Houston, TX; 3. Health Promotoin and Behavioral Sciences,
UT, School of Public Health, Houston, TX; 4. Texas Elder Abuse and
Mistreatment Institute (TEAM), Houston, TX.
Supported By: The National Institute on Aging. Grant # 1R21
AG033261-01A1
Background: Despite high mortality rates, elder self-neglect is
characterized by refusal of medical and social interventions. To date
there have been no tested clinical interventions in elders who selfneglect.
Previous TEAM Institute research has shown significantly
low vitamin D levels in this population. This study aimed to determine
the feasibility of a clinical intervention. Replacement of vitamin
D was chosen because of its ease of administration and favorable
safety profile. Methods: A randomized clinical trial using directly observed
therapy of vitamin D was conducted using 50 elders, >65 years
of age, with Adult Protective Services (APS) validated self-neglect. A
staggered intervention with waiting controls was used to maximize
statistical power. One-third (n=17) of the group was administered
50,000 IU vitamin D2 (ergocalciferol) monthly and the remainder
(n=33) were administered 400 IU monthly. Serum 25-OH vitamin D
was assessed at baseline and 5-months. Results: 69% agreed to participate
in the study and of those n=40 (80%) remained at 5-months. At
baseline, 12% (n=7) were deficient in vitamin D (

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D28
Interactive video dance and cognition: baseline data.
J. Jovancevic- Misic, S. A. Studenski, Y. Zheng, S. Perera. University
of Pittsburgh, Pittsburgh, PA.
Supported By: The research reported in this abstract was supported
by NIH- Claude D Pepper Older Americans Independence Center
Grant, P30 AG024827, and by T32 grant (AG21885).
Purpose: Though some evidence exists that physical exercise has
the potential to affect cognitive function, the majority of evidence relates
to the cognitive effects of fitness training. There is evidence that
video games may induce cognitive improvement and generalize to
daily function, but mostly do not involve physical exercise. Little is
known of how combining these two types of training might impact
cognition, or the role of participants’ cognitive status on their success.
The purpose of this study is to examine the role of visual attention in
learning to process visual info in interactive video dance. Relative
value of participants’ previous experience with video games and
some types of leisure activities in predicting their performance on the
video dance was also investigated.
Methods: This is a cross sectional analysis of the baseline data
from a RCT Adherence and health effects of video dance exercise
and brisk walking in postmenopausal women. We focus on the baseline
data of the interactive video dance group. Participants were 46
overweight, sedantary women aged 50-65. Repeatable Battery for the
Assessment of Neuropsychological Status (RBANS) test, the Useful
Field of View (UFOV) test and Leisure activity questionnaire were
administered at baseline. Participants’ previous experience with
video games, and ability to master the basics of interactive video
based dance on the first day was noted.
Results: We analyzed the association between two cognitive domains
(attention and visuo-spatial) as measured by RBANS and attention
deployment and visuo-spatial skills (UFOV). All domains
were correlated (Table 1).
Performance on cognitive tests as predictors of success in finishing
video dance lessons the first day was analyzed. The test of divided
attention (UFOV) and RBANS (attention) score tended to have an
impact, though only RBANS effect was significant (p=0.03). Previous
experience with dance and video games was found to have no effect
on the success of video dance performance.
Conclusions: Baseline data indicates that UFOV reflects some
RBANS factors and as such may be related to early success with
learning video dance. Further it would appear that no prior experience
playing video games or dancing is necessary for mastering this
new skill.
D30 Encore Presentation
Skeletal muscle sampling in elderly research participants with
chronic disease.
M. F. Lyles, J. L. Demons, K. M. Murphy, B. J. Nicklas. Internal
Medicine, Wake Forest School of Medicine, Winston Salem, NC.
Supported By: Claude Pepper Older Americans Independence
Center (1P30 AG21332, WFU General Clinical Research Center
(M01-RR07122), National Institute on Aging (R37 AG018915)
Deficits in skeletal muscle metabolism and function are major
contributors to development of disability in older adults. The conduct
of in vitro experiments of muscle metabolism and function is important
for advancing understanding of aging-related disability progression.
Percutaneous muscle biopsy techniques are widely utilized in
studies of young and/or healthy persons, but are underutilized in the
elderly, especially those with chronic illness, who are at the highest
risk of becoming disabled. The goal of this project was to determine
the feasibility, safety and tissue yield of muscle biopsies performed in
older adults with common chronic diseases enrolled in several clinical
trials. A total of 324 biopsies were performed in research participants
with COPD, CHF, osteoarthritis or obesity, who were enrolled in clinical
trials of weight loss and/or exercise training. Only minor modifications
in safety procedures, such as adjustment of table position,
were needed for biopsy performance in these patients. The average
tissue yield of for all biopsies was 157±90 mg. Participants in which
muscle was obtained (81%) were compared to those in which only
adipose tissue was obtained (19%; Table 1). Successful acquisition of
skeletal muscle was more challenging in women and in more obese
participants. The return rate for post-intervention biopsy was >90%.
Percutaneous muscle biopsy is a feasible, safe and acceptable procedure
in older adults with chronic diseases and provides a tool to understanding
the development of disability in this group.
Characteristics of participants with and without muscle tissue yield
*Average yield = 157±90 mg
D31 Encore Presentation
Extended-release memantine (28 mg, once daily) and sustained
cognitive improvement: Post hoc responder analysis from a
randomized trial in patients with moderate to severe Alzheimer’s
disease.
M. Tocco, 1 S. Hendrix, 2 M. L. Miller, 3 V. Pejovic, 3 S. M. Graham. 1 1.
Forest Research Institute, Jersey City, NJ; 2. Pentara Corporation,
Salt Lake City, UT; 3. Prescott Medical Communications Group,
Chicago, IL.
Supported By: Supported by Forest Laboratories, Inc.
Background: Alzheimer’s disease (AD) trials routinely report
mean score differences between treatment groups; however, it is also
important to compare percentages of patients who respond to treatment.
An extended-release (ER) formulation of memantine (28 mg,
once daily) was recently approved in the US based on a 24-week, randomized,
placebo-controlled trial (NCT00322153) in patients with
moderate to severe AD concurrently taking a cholinesterase inhibitor.
Memantine ER-treated patients significantly outperformed
placebo-treated patients on several outcome measures, including the
Severe Impairment Battery (SIB), an instrument for assessing cognition
in severely demented patients. In this post hoc analysis, we determined
the percentages of patients who achieved a positive response
on the SIB and maintained it throughout the trial.
Methods: Five SIB response levels to double-blind treatment
were selected (improvements of ≥0, ≥5, ≥10, ≥15, and ≥20 points), corresponding
to 0, 0.5, 1.0, 1.5, and 2.0 standard deviations of the observed
baseline-to-endpoint score change. Numbers of patients (observed
cases) in each group who attained such responses at Weeks 4,
8, 12, or 18 and maintained them through Week 24 (Endpoint) were
compared using Fisher’s exact test, without correcting for multiple
comparisons.
Results: The mean (± SD) Baseline SIB score for the intent-totreat
population (N=661) was 76.1 ± 18.4. A total of 523 patients (memantine
ER, 261; placebo, 262) had available SIB data at all visits.
Significantly more patients in the memantine ER group than the
placebo group maintained Week 8 SIB responses of ≥5 points (26.1%
vs 17.0%; P=0.014) and ≥10 points (14.6% vs 7.6%; P=0.012) through
Endpoint. Similar differences in response maintenance were observed
for responses attained at Week 12 (≥5 points: 28.5% vs 19.9%,
P=0.025; ≥10 points: 16.3% vs 8.2%, P=0.005; ≥15 points: 9.5% vs
4.1%, P=0.015) and Week 18 (≥10 points: 18.8% vs 10.0%, P=0.004;
≥15 points: 10.9% vs 4.5%, P=0.006). No other significant betweengroup
differences were observed.
Conclusions: In this post hoc analysis, memantine ER was associated
with cognitive improvement attained after 8-18 weeks and sustained
through study endpoint.
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D32
Comparison of Three Screening Tools to Predict Hospital
Readmission and Mortality in Older Adults.
M. Deschodt, 1,2 J. Flamaing, 2 N. Wellens, 1 S. Boonen, 2 P. Moons, 1
K. Milisen. 1,2 1. Center for Health Services and Nursing Research,
Katholieke Universiteit Leuven, Leuven, Belgium; 2. Department of
Geriatric Medicine, University Hospitals Leuven, Leuven, Belgium.
Purpose: To compare the diagnostic characteristics of the Identification
of Seniors At Risk (ISAR), the Flemish version of the Triage
Risk Screening Tool (TRST), and the Variable Indicative of Placement
Risk (VIP) to predict hospital readmission, alone or in combination
with mortality, in hospitalized patients aged 75 years or older.
Methods: Multicenter prospective cohort study with 30 days follow-up
in 25 general hospitals in Belgium. Baseline data were gathered
within 72 hours of admission. Readmission was defined as an unplanned
hospital stay of at least 24 hours. Information was gathered
by a nurse through patient or proxy interview at admission and
through phone-call at follow-up. Eight hundred and sixty-eight questionnaires
with complete screening were returned. Data of hospital
readmission was available for 72.6% (n=630) of the patients. Besides
analyses in surviving patients only (n=588), combined endpoint
analyses (readmitted or dead) were performed.
Results: Respectively 12.2% (n=72/588) and 6.7% (n=42/630) of
the patients were readmitted or died within 30 days after hospital discharge.
Sensitivity and NPV to predict readmission was high for
ISAR cut off ≥2 (86% and 90%, resp.), TRST cut off ≥2 (71% and
86%, resp.) and VIP cut off ≥1 (60% and 89%, resp.). Increasing the
cut off score with one point had a positive effect on the specificity, but
at the expense of the sensitivity for all three screening tools (69% for
ISAR, 60% for VIP and 40.4% for TRST). Results of the combined
endpoint analyses are shown in the table.
Conclusion: All screening instruments showed good sensitivity
and NPV, the two major characteristics for good screening tools, but
hospital readmission alone or in combination with mortality in older
patients seemed to be most accurately predicted by using the ISAR
cut off ≥3. False positives could be filtered out according to the clinical
expert opinion of a care team.
D33
Increased risk of hospital admission in Patients 65 years and older
presenting to the emergency department.
M. S. Radeos, I. Kariolis, A. Wasserman, K. Joshi, Z. Huang.
Emergency Medicine, New York Hospital Queens, Flushing, NY.
Background: US Emergency department (ED) visits by those 65
years and older account for an estimated 17.5 million visits, or approximately
15% of all visits. About 10.6 million of these are by those
75 years and older.
Objective: We sought to determine factors increase the risk of
hospital admission among adults aged 65 years and older who present
to the ED.
Methods: Research associate (RA) administered a survey to a
convenience sample of adults 65 years and older presenting to a
Level I trauma center. We collected demographic and clinical variables.
We present data as percentages and medians with interquartile
range (IQR). We tested the
univariate association with admission using t-test. Kruskal-Wallis,
chi-square and fisher exact test as appropiate. We ran logistic regression
models with 95% confidence intervals (CI).
Results: We enrolled 1,329 subjects between 1/2010 and 11/2011.
376 (28%) were age 65-74 and 953 (72%) were 75 and older. 59%
were female, and 80% had either Medicare or Medicare plus a supplement.
Race/ethnicity was 61% White, 12% Black, 11% Latino, and
13% Asian. 15% had limited English proficiency. 56% of patients
were admitted. 90% of patients lived independently. 92% had a PMD
or regular health care provider (HCP). In a logistic model that included
age categorory (65-74 versus 75+) sex, race, mode of arrival,
living independently and prior visit to and ED or urgent care center
within the previous week, only the previous ED or urgent care visit in
the previous week was statistically significant, [OR 1.63, 95% CI
[1.08, 2.44) P=0.019]
Conclusion: Older patients who present to the ED have a very
high admission rate suggesting a high acuity. Those who return to the
ED within a week of ED or urgent care visit are at increased risk of
admission to the hospital. This finding underestimates the true acuity,
as many patients receive acute care and may be safely discharged
to home. Future research should focus on interventions in this high
risk group.
D34
Psychiatric Emergencies in the Suburbs: An EMS Response to the
Distressed Senior.
J. J. Bernick, 1,2 D. Dalbey, 2 M. Lester. 2 1. Internal Medicine, San
Jacinto Methodist Hospital, Baytown, TX; 2. Emergency Medical
Service, Health Department, City of Baytown, TX.
Background: When confronted with the confused and agitated
senior patient appreciation of their history and immediate medical
status supply essential insight for patient stabilization. Geriatric patients
with various chronic conditions, multiple medications, and limited
functional reserve display increased susceptibility to psychiatric
problems. The EMS frequently provides the initial evaluation of the
distressed patient manifesting behavioral disorders. This study objective
proposed to review and convey an awareness of the initial assessment
of seniors with diverse psychiatric emergencies.
Methods: This investigation examined the records of a suburban
EMS in Harris County, Texas during a 46 month period commencing
in January, 2008. The field encounters of community residing patients
at least 60 years old receiving evaluation for psychiatric emergencies
were analyzed. The EMS team recorded patient’s primary symptoms,
history and physical findings, procedures performed, and response to
their initial treatment. Event chronology considered the decision to
transport the patient to the hospital.
Results: During the study period, 206 geriatric patients obtained
evaluation for psychiatric emergencies accounting for 11% of psychiatric
calls. Anxiety disorders were the most common diagnosis presenting
in (64)seniors (31% of calls) and the majority required hospital
transport. The EMS treated patients (33) for both drug overdose
and medication withdrawal. The presence of suicidal ideations(13%
of calls), psychotic behavior(12%), and delirium(12%) affected a significant
proportion of seniors requiring EMS care. The EMS attended
an unexpected number of patients (8) threatening a weapon assault.
Approximately 35% of patients receiving EMS triage acknowledged
previous psychiatric disorders.
Conclusion: The appearance of psychiatric symptoms in geriatric
patients develops with dementia,adverse medication reactions,and family
disputes. However, diminishing functional capacity creates an opportunity
for behavioral issues to arise without prior warning. Caregivers
often rely upon the EMS as the initial responder to meet their crisis.
Health professionals early recognition and treatment of senior’s psychiatric
issues enhances support to caregivers, promotes accurate physician
treatment, and improves coordination of care among the health team.
D35
Emergency Department Prescribing and Continuity.
L. Ragsdale, 1 C. Horney, 2 K. Schmader, 2 S. N. Hastings. 2 1. Surgery,
Duke University, Durham, NC; 2. Medicine, Duke University,
Durham, NC.
Supported By: This research was conducted while Dr. Hastings was
supported by a VA HSR&D Career Development Award (RCD
06-019).
Background
S198
AGS 2012 ANNUAL MEETING

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More than ½ of all older patients treated and released from the
emergency department(ED) receive one or more prescriptions. The
goals of this study were to describe medication prescribing and continuity
of care for older patients treated and released from the ED.
Methods
We examined health system records of 308 patients ≥ 65 years old
treated and released from an urban academic ED with 77,000 annual
visits. Patients were excluded if they did not have at least one PCP visit
in the 12 months preceding the index ED visit. Data were collected
using a standardized chart abstraction tool. Medications were categorized
according to the VA Medication Classification System, and continuity
measures (1) ED contact with PCP; (2) ED visit acknowledgement
by PCP; and (3) discharge drug documentation by PCP were
based on Acute Care of the Elderly (ACOVE) Quality Indicators.
Results
Of 308 patients, 163 (53%) were prescribed at least one medication
(total 260 drugs); 23.3% were prescribed 2 medications and 8%
were prescribed ≥ 3. Overall, 89.2% of prescriptions were new medications
for the patient. The most commonly prescribed drug class
was central nervous system (CNS) medications (32.3%); 86.9% of
these were opioid containing. Other commonly prescribed drug
classes were antimicrobials (21.9%) and gastrointestinal medications
(11.9%). Common indications for medications included non-urinary
infections (17.3%), musculoskeletal pain (17.3%) and trauma
(16.5%). The majority of prescriptions were written for a time limited
course (91.1%); 46.6% had a specified schedule and 53.4% were as
needed (prn). Of the scheduled drugs, the median days supply was 7
(mode 7). Among prn drugs, the median days supply was 5 (mode 3).
The ED provider note documented communication with patients’
outpatient provider in 14.5% of visits (2.2% PCP; 12.3% specialist).
Overall, 72.4% of patients had a PCP follow-up within 90 days of
their ED visit. The PCP note acknowledged the ED visit in 46.1% of
patients. Among patients prescribed medications in the ED (n=163),
the PCP note acknowledged the new medications in 25.4% of cases.
Conclusions
ED providers frequently prescribe new CNS and antimicrobial
medications for older patients treated and released from the ED.
Lack of communication between providers in the care for this patient
population was common. Further research is needed to determine
how best to improve communication between the ED and PCPs.
D36
Vitamin D deficiency is associated with fall-related risk factors in
home-bound older adults.
J. L. Demons, 1 J. A. Tooze, 1 B. R. Davis, 1 R. Shertzer-Skinner, 1
L. Kearsley, 2 R. Gottlieb, 2 J. D. Williamson, 1 D. K. Houston. 1 1. Sticht
Center on Aging, Wake Forest University School of Medicine,
Winston-Salem, NC; 2. Senior Services, Inc, Winston-Salem, NC.
Supported By: Supported by the Wake Forest Translational
Science Institute, Center for Integrative Medicine and Pepper
Center (P30-AG21332)
Background: Falls in the elderly are known to be costly to both
the function of seniors and the medical system. Risk factors for falls
that can be intervened upon, such as vitamin D deficiency, are sought
by physicians. Older home-bound persons eligible to receive meals
from a home meal delivery program (Meals on Wheels (MOW)) are
at high risk for vitamin D deficiency due to the very nature of being
home-bound and inability to provide their own nutrition. They are
likely also at higher risk for falls considering their inability to move
about in the community. We assessed several aspects of falls and fallrelated
risk factors to determine if they were associated with vitamin
D levels in MOW participants.
Methods: 25-hydroxyvitamin D levels were assessed in seventytwo
seniors being served by MOW in Forsyth Co, NC as part of baseline
assessments for a vitamin D intervention study (mean age 77.3
yrs; 76% women, 76% black). History of falls in the prior year and the
seriousness of any fall that occurred were obtained by recall. Fear of
falling and the Pepper Assessment Tool for Disability (PAT-D) were
also obtained.
Results: Vitamin D insufficiency (10-

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D38
The burden of comorbid conditions and symptoms affecting quality
of life in nursing home patients with dementia.
J. M. Checchi, D. Peterson, J. Tjia. Geriatrics, University of
Massachusetts Medical School, Worcester, MA.
Supported By: This study was funded by a grant from the Agency
for Healthcare Quality and Research.
Background: While over 50% of nursing home (NH) residents
in the US have dementia, the burden of comorbid conditions and
symptoms affecting quality of life in this population is understudied.
Further, comorbidity and symptom burden differences by severity of
dementia remain unclear. The study aim is to describe differences in
the prevalence of comorbidites and bothersome symptoms in a
large, population-based sample of NH residents with differing stages
of dementia.
Methods: Data from the first full assessment of the Minimum
Data Set (MDS) was used to identify a population of NH residents
with dementia (Alzheimer’s type or other causes) from 5 states (PA,
MA, CA, FL, MN) in 2008-2009. We used the Cognitive Performance
Scale (CPS) to identify residents with mild-to-moderate (CPS 1-4)
and advanced dementia (CPS 5-6), and to compare differences in the
prevalence of comorbidites and bothersome symptoms (including
pain, eating difficulties, and conditions indicative of potentially druginduced
syndromes [e.g. dehydration, delusions, vertigo, syncope, unsteady
gait, and vomiting]) using a χ2 test.
Results: The study sample included 271,589 residents with mildmoderate
dementia and 96,346 with advanced dementia (total
n=367,935). The 10 most frequently reported comorbid conditions
were hypertension (70.6%), osteoporosis (31.6%), arthritis (31.0%),
anemia (29.7%), diabetes (27.3%), congestive heart failure (20.6%),
hypothyroidism (20.4%), cerebrovascular accident [CVA] (19.2%),
arrhythmia (18.6%), and COPD (17.2%). Residents with mild-moderate
dementia had a higher incidence of each of these comorbidities
except CVA (p

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patients transferred from acute care hospital to a GRU. The poorest
prognosis is showed in hypoalbuminemic patients with delirium and
the best in orthopaedic diagnosis group patients.
D41
Symptom Burden in Frail Hemodialysis Patients.
K. Christianer, 1 R. Shengelia, 1 B. M. Eiss, 1 J. E. Roberts, 1 M. C. Reid, 1
R. D. Adelman, 1 N. Berman. 1,2 1. Weill Cornell Medical College, New
York, NY; 2. Rogosin Institute, New York, NY.
Supported By: Supported by the Henry Adelman Fund for Medical
Student Education in Geriatrics and the Jewish Foundation for the
Education of Women
Background: In 2008, there were 110,000 incident cases of
ESRD, of which the fastest growing group are patients ages 65+.
Many ESRD patients are placed on aggressive hemodialysis (HD)
treatment, regardless of their comorbidities. Patients with ESRD experience
high symptom burden, even when compared with other
chronic, debilitating conditions, and HD itself can be associated with
side effects (e.g. excess blood volume removal causing fatigue). This
project investigated which symptoms are deemed most burdensome
by HD patients and whether some symptoms may be related to HD
treatment.
Method: Participants were recruited from two outpatient dialysis
clinics in New York City. All patients were receiving HD and categorized
as “frail” (i.e. ineligible for transplant) by their treating
nephrologist. Other eligibility criteria included fluency in English and
intact cognition. Participants were interviewed using the Dialysis
Symptom Index (DSI) and the MOS SF-36. Chart reviews identified
comorbidity using the Charlson Comorbidity Index (CCI).
Results: Of the 31 participants enrolled as of 12/1/11, the mean
age is 71 (range 44-89); 39% are female and the mean CCI Score is 6.4
(range 1-15). Patients reported a mean of 14 symptoms of the 30 that
were asked. Symptoms with high prevalence were Feeling Tired or
Lack of Energy (90%), Dry Skin (70%), Trouble Staying Asleep
(65%), and Nausea (48%). Results of Worrying (61%) and Feeling
Sad (58%) within the past week suggest high rates of depression.
When asked which symptoms were felt to be HD treatment related,
the most common responses were Feeling Tired or a Lack of Energy
(93%), Muscle Cramps (90%), Feeling Anxious (77%) and Lightheadedness
(67%).
Our sample demonstrated higher symptom burden when compared
with a general HD population 1 , with double-digit differences in
prevalence of 20 symptoms, the most prominent being Feeling Sad
(58% vs. 30%), Dry Skin (70% vs. 42%) and Dyspnea (48% vs. 21%).
Conclusion: Frail ESRD patients receiving HD experience immense
symptom burden, even when compared to the general HD
population, and patients attributed many symptoms to HD itself.
Many of the symptoms may be reduced by modifying treatment (e.g.
reducing the time spent in HD).These pilot data support future efforts
to investigate palliative care interventions in this target population.
References:
1 Abdel-Kader K, et al. Clin J Am Soc Nephrol 2009;4:1057-64
D42
Characteristics and Economic Burden of Elderly Patients with
Hospital-Acquired Clostridium-difficile in a Managed Care Setting.
M. E. Strauss, 1 R. Quimbo, 2 S. Palli, 2 J. Singer. 2 1. MESTRA
Consulting, Inc.,White Plains, NY; 2. HealthCore, Inc.,Wilmington, DE.
Supported By: Optimer Pharmaceuticals, Inc.
BACKGROUND: Hospital-acquired C. difficile associated disease
(CDAD) results in an estimated $1.3 billion in excess costs in the
US. Elderly individuals ≥65 are at especially high risk of CDAD and
its recurrence due to diminished immune response, multiple comorbidities,
and increased exposure to health care facilities. This study describes
the incremental economic burden of CDAD in hospitalized
patients ≥65 from a managed care perspective. METHODS: Hospitalized
patients ≥65 years of age with a 12 month pre-index eligibility
between 1/1/2005 and 10/31/2010 were identified within the Health-
Core Integrated Research Database (HIRD SM ). Cases with an inpatient
diagnosis of CDAD (ICD 008.45) were matched to hospitalized
controls without CDAD on a 1:3 match ratio based on: age±10, gender,
and baseline/in-hospital comorbidities. Mean length of stay
(LOS) and costs were calculated using multivariate GLM with a
gamma distribution. Covariates were determined from univariate
analysis of baseline characteristics. RESULTS: 10933 CDAD patients
were matched to 32799 controls. While age (mean 80 (±7.9)), gender
(62% female), and major comorbidity groups were well balanced,
post-match disparities persisted (p

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rate was 21.9% for community dwellers and 34.4% for nursing home
residents. Readmission rates for specific diagnoses among community-dwelling
and nursing home patients were, respectively: 19% and
43% for CHF, 12.8% and 22.5% for pneumonia, 13.6% and 35% for
UTI, and 23.5% and 28% for GI bleed.
Conclusions: Nursing home patients have a higher rate of readmission
and in-hospital mortality than community-dwelling patients.
Readmission rates for major diagnoses were uniformly higher for
nursing home patients than for community dwellers.
D44 Encore Presentation
High Blood Pressure is Associated with Mortality only in Faster
Walking Elderly Adults.
M. Odden, 1,2 C. A. Peralta, 2 M. Haan, 3 K. Covinsky. 2 1. Public
Health, Oregon State University, Corvallis, OR; 2. Medicine,
University of California, San Francisco, San Francisco, CA; 3.
Epidemiology and Biostatistics, University of California, San
Francisco, San Francisco, CA.
Supported By: Dr. Odden was supported by a Ruth L. Kirschstein
National Research Service Award (T32HP19025).
Background: The association between high blood pressure (BP)
and risk of death varies by age and appears to be attenuated in some
elderly adults. Walking speed is an excellent measure of functional
status and may identify which elders may be most at risk for the adverse
consequences of hypertension. We aimed to determine if the association
between BP and mortality differed by walking speed in elderly
adults.
Methods: The study population included 2,340 persons ≥ 65
years, with measured BP, in the National Health and Nutrition Examination
Survey (NHANES) waves 1999-2000 and 2001-2002. Mortality
data was linked to death certificate data in the National Death
Index. Walking speed was measured over a 20-foot walk; 243 (8%)
did not complete the walk for various safety and logistical reasons.
Participants with walking speed above the mean (2.7 ft/sec) were
classified as faster walkers. Potential confounders included age, sex,
race, survey year, lifestyle and physiologic factors, chronic health conditions,
and antihypertensive use.
Results: There were 589 deaths recorded through December
31st, 2006. Among faster walkers, those with elevated systolic BP
(≥140 mmHg) had a higher mortality rate compared to those with
systolic BP

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A BSTRACTS
pare; (3) to get a sense of patient’s goals of care. Common reasons not
to discuss included: (1) respect for patient’s cultural values; (2) patient’s
lack of mental capacity to understand implications of prognosis;
(3) difficulty estimating prognosis with non-specific disease/comorbidity.
11 clinicians were not willing to discuss 5-year prognosis
because they felt that they could not accurately prognosticate on that
time frame and they did not think it would be useful for patients to
receive uncertain information. All clinicians were willing to discuss
prognosis with patients who have less than 1 year to live because it
helps patients make critical decisions about their end of life care.
CONCLUSIONS: Clinicians balance individual patient factors
when deciding to discuss prognosis with their frail older patients. Clinicians
identified a lack of accurate prognostic information as a barrier
to discussing long-term prognosis with frail elders.
D47
Assessment of Advanced Care Planning Documentation for Patients
Discharged to Hospice Care.
M. E. Young, 1 E. Hurwitz, 2 S. H. Chao, 1 V. Parker, 1 W. Suen. 1 1.
Geriatrics, Boston University, Boston, MA; 2. Internal Medicine,
Boston University, Boston, MA.
Background: Three components of advanced care planning
(ACP) include choosing a health care agent, determining resuscitation
wishes and delineating goals of care. During transitions of care,
these three wishes should be documented in one place where the receiving
providers can easily access the information. Methods: We performed
an assessment of ACP documentation at our hospital. From
2005-2010, 289 patients, 65 years of age and older, were discharged
from Boston Medical Center to hospice care. Of these patients, fifty
randomly selected discharge summaries were reviewed to look for
the presence of the three defined components of ACP. If the ACP elements
were not documented in the discharge summary, we searched
the entire medical record for the location of documentation. Results:
The majority (n=43) of the charts we reviewed did not include all
three components of ACP in the discharge summary. When examining
the entire medical record, we found at least one ACP element
missing in 42% (n=21) of the charts. The discharge summary author
most commonly missed documenting the health care agent. Patients
with a documented palliative care consultation had more complete
documentation of ACP than those without a palliative care consultation.
Conclusions: Documentation of ACP is poor at the time of discharge.
A palliative care consultation is associated with more complete
documentation of ACP. We plan to implement an educational
and technological intervention to encourage clearer and more complete
documentation of ACP.
D48
Assessing the wish to die in elderly people.
S. Monod, 1 E. Rochat, 2,1 C. Bula, 1 A. Durst, 1 B. Spencer. 3 1. Service of
geriatric medicine, University of Lausanne Medical Center, Epalinges,
Switzerland; 2. Chaplaincy Service, University of Lausanne Medical
Center, Lausanne, Switzerland; 3. Institute of Social and Preventive
Medicine, University of Lausanne, Lausanne, Switzerland.
Background: The wish to die has mainly been studied in terminally-ill
young adults. In elderly persons, factors associated with the
wish to die are likely to differ from those observed in younger people.
Since the most frequently used scale -“The Schedule of Attitudes Toward
Hastened Death” (SAHD, Rosenfeld et al., 2000)- was previously
used in terminally ill cancer or AIDS patients, its use in elderly
people suffering from multiple comorbidities is problematic. The objectives
of this study were 1) to adapt the SAHD for use in elderly
people, 2) to develop a new instrument to assess patients’ attitudes towards
death 3) to test the relevance/acceptability of these instruments.
Methods:An adapted version of the SAHD to the elderly population
(SAHD-OLD) was obtained by analyzing all items of the instrument
in an interdisciplinary group of experts in geriatric care.
Items were modified according to their relevance in elderly population.
An instrument to assess patients’ attitudes towards death was
built on previous qualitative work performed by Schroepfer. These 2
instruments were subjected to cognitive testing in a convenience sample
of 11 community-dwelling people (median age = 82 years; range
76-91).
Results: The SAHD-OLD was obtained by modifying those
items addressing palliative care issues (eg. irreversible consequences
of stopping treatment) and systematically replacing “illness/disease”
by “health problems”. We expressed in statements the 6 categories
identified by Schroepfer, and created instructions asking respondents
to describe their current attitude towards death (Adapted
Schroepfer). During cognitive testing, our sample assessed the
SAHD-OLD and the Adapted Schroepfer as relevant for elderly
people. Respondents judged these 2 instruments acceptable and appreciated
the direct manner in which they addressed end of life issues.
The opportunity to speak openly on this topic was welcomed.
Conclusions: The SAHD-OLD and the Adapted Schroepfer
seem promising instruments to assess the wish to die in elderly people
suffering from multiple comorbidities. Preliminary results show good
comprehension, high relevance and acceptability. Psychometric properties
of the SAHD-OLD are currently being tested in a large sample
of patients.
D49
ROS-Induced NADPH Oxidase Changes and the Aging Heart.
M. E. DuMond. 1,2 1. Pathology, University of Washington, Seattle, WA;
2. Stony Brook University, Stony Brook, NY.
Supported By: MSTAR
The aim of this work was to investigate the effects of increased
Reactive Oxygen Species (ROS) on the levels of NADPH Oxidase 4
(Nox4) and Nox4D in heart tissue. Nox4 is expressed in cardiomyocyte
mitochondria, and its splice variant Nox4D localizes to the nucleus.
Both are ROS generators suspected to be involved in redox signaling.
Cellular damage incurred by chronic ROS overproduction is
the causative agent of an alarming number of diseases and is the underlying
culprit of aging. Understanding the redox signaling that mediates
cellular changes induced by ROS is an important step in intervening
in disease and aging. Potential mechanisms for the antioxidant
effects of the mitochondrial-acting SS31 peptide (Szeto, H, 2006)
were also investigated in this study. SS31 peptide has been shown to
reduce the damaging effects of ROS in mitochondria and elsewhere
in the cell, but its mechanism of action in mitochondria is currently
unknown. In this study, wildtype mice were treated with Angiotensin
II (AngII) using osmotic minipumps for drug delivery. AngII simulates
aging and heart failure by inducing ROS-mediated tissue
changes. Animals were treated with AngII, AngII + SS31 peptide, or
saline. The heart tissue was collected at three timepoints: 3 day, 1
week, and 4 weeks. The results were then evaluated by Western Blot
and protein quantification, comparing treatment to saline controls.
Nox4 was shown to be transiently decreased in AngII + SS31 peptidetreated
mice early in treatment, but after 4 weeks of treatment, Nox4
levels were elevated in both the AngII and AngII + SS31 peptide
mice, suggesting that the rescuing antioxidant effects of SS31 peptide
are eventually overcome by continuous ROS stimulation in response
to AngII. These data suggest that there may be a critical window
where the effects of increased ROS production are reversible, but
over-induction of redox signaling for a prolonged period of time may
result in a state of cellular immunity to the effects of SS31 peptide
and intervening antioxidants. The roles of Nox4 and Nox4D in redox
signaling are obfuscated by the apparent opposing early and late effects.
However, one hypothesis to be further investigated is that a
shift from one Nox4 splice variant to the other in response to increased
ROS is a modulator of redox signaling, and this may be interrupted
by SS31 peptide action.
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D50
A Pilot Study of Teaching Medical Interns to Compute Number-
Needed to Treat (NNT) and Outcome Assessment.
H. Cheng. Medicine, University of Virginia, Charlottesville, VA.
Supported By: HRSA: Geriatric Academic Career Award
Background: Communicating drug benefits is an important
process in patient-centered decision making. Relative risk reduction
(RRR) is usually reported in drug trials and is favorably used by patients
and providers despite RRR is misleading. NNT, a better way to
measure the drug effect size and potentially help patients and
providers to make decision, is less reported, more difficult to be understood
and less favorably used by patients and providers. Therefore,
training medical interns to learn computing NNT can be very
important.
Methodology: A new 4 week mandatory geriatric EBM curriculum
was offered for all medical interns, which was described previously
(A57: 2009 AGS). Teaching computing NNT was the part of this
EBM curriculum and briefly summarized in the following. 1. Needs
assessment by pretest. Medical interns answered yes or no to the
question, “I know how to compute NNT” and then asked to compute
NNT based on a drug trial. 2. Computing NNT using another drug
trial was taught to interns in a didactic lecture. 3. Interns practiced
computing NNT using another drug trial and were asked to apply
NNT in their required 2 geriatric presentations. 4. Outcomes were assessed
by repeating pretest and computing NNT from a drug trial.
McNemar test was used to compare the pre and post test of competence
in computing NNT. κ was used to measure agreement between
self-perceived competence and actual performance. 0.05 was chosen
as statistical significance. SPSS was used for data analysis.
Results: About half of 165 medical interns from 2007 to 2010
completed pre and post-test. Improvement of self-perceived competence
in computing NNT was much bigger than actual performance.
There was slight agreement between self-perceived competence and
actual performance (Table). 32% (28/87) interns overestimated their
competence.
Conclusions: The EBM curriculum improved the medical intern’s
competence in computing NNT. However, actual performance
test should be used to assess the teaching outcome.
Perceived competence and actual performance on computing number-needed
to treat (NNT)
*pretest versus post-test either in self-perceived competence or actual
performance
** Agreement between self-perceived and actual performance in
pre-test phase
D51
Will Learners Rate the Curriculum Differently When the Course
Instructor Did the Evaluation? A Pilot Study of a New Geriatric
Evidence-based Medicine (EBM) Curriculum.
H. Cheng. Medicine, University of Virginia, Charlottesville, VA.
Supported By: Geriatric Academic Career Award
Background: There are different ways to evaluate a curriculum.
Online evaluation or anonymous evaluation by the instructor or an
evaluator has been used. However, it is unknown which way is accurate.
The learners might say good things and might be falsely rated
the curriculum when the course instructor does the evaluation. Consequently,
this will have a negative effect on improving the curriculum.
In this pilot study, I hypothesized that the medical interns might
falsely rate a new geriatric EBM curriculum when the course instructor
(Author) does the evaluation compared to the evaluation done by
another person.
Methodology: A new 4 week geriatric EBM curriculum was provided
for all medical interns during the mandatory geriatric rotation,
which was described previously (A57: 2009 AGS). At the end of rotation,
each intern was asked to anonymously rate the educational
value of the EBM curriculum done by the course instructor. The educational
value of the curriculum was assessed with Likert scales (1-5)
ranged from extremely valuable (5), very valuable (4), somewhat
valuable (3), and minimally valuable (2) to not at all valuable (1). Another
person who was not aware of this study did the same anonymous
evaluation at the end of the rotation. Chi-square was used to
test significance of two evaluations with SPSS (p

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derstanding the patient’s medical history, baseline cognitive and
physical functionality, home medications, and social situation.
Conclusion:
CIR served as a useful tool to assess interns’ learning in a geriatrics
rotation. Interns appear to be gaining knowledge and skills in
keys areas of Geriatrics and are able to articulate how they would
use these knowledge and skills in the future to better care for elderly
patients.
D53
WWAMI Residency Graduates’ Self-reported Preparedness and
Practice Before and After Implementation of a Family Medicine
Residency Continuity Nursing Home Requirement.
J. Raetz, J. Osborn, P. Ford, N. Stevens. Family Medicine, University of
Washington, Seattle, WA.
Background:
Current GME programs will not produce enough geriatricians
to meet the needs of the aging population. Primary care physicians
must receive adequate training to fill this gap. In 2005 the Accreditation
Council for Graduate Medical Education revised the requirements
for family medicine residency training programs to include a
two year continuity nursing home experience. Residents must care
for at least two nursing home patients over a minimum of 24 consecutive
months. The WWAMI Network consists of 18 family medicine
residencies in Washington, Wyoming, Alaska, Montana, and Idaho.
The WWAMII region routinely surveys graduates from the residency
network to characterize preparedness and practice. We examined this
survey data to see if any measurable change could be seen in graduate
preparedness and practice after implementation of the new nursing
home continuity requirement.
Methods:
We examined responses to the questions, “prepared for practice?”
(5 point likert scale) and, “part of my practice?” (yes/no) under
the section, “care of adults: nursing home” for graduates between the
years 1997 and 2009. We then compared responses of physicians who
graduated in 2007 or later with those who graduated prior to 2007.
Results:
Overall self-reported preparedness for nursing home practice
was good and improved slightly after implementation of the ACGME
requirement for a nursing home continuity experience. 795 graduates
between 1997 and 2006 reported level of preparedness for nursing
home care on the five point likert scale (average 3.51). 243 graduates
between 2007 and 2009 reported level of preparedness for nursing
home care on the five point likert scale (average 3.81). Practice in
nursing homes decreased in the same time period. Of the 738 responses
of graduates between 1997 and 2006, 46.39% practiced in
nursing homes. Of the 233 responses of graduates between 2007 and
2009, 28.01% practiced in nursing homes.
Conclusions:
A two year continuity nursing home experience in residency is
associated with improvement in self-reported preparedness to practice
in nursing homes. However, in the same time period fewer graduates
are practicing in nursing homes. More research is needed to identify
factors that increase the number of physicians practicing in
nursing homes to better serve our aging population.
D54
Preferences, Availability, And Quality Of Interactive Teaching
Materials Used By Geriatric Educators.
J. D. Schlaudecker, 1 S. Talebreza, 2 W. Suen, 3 K. Anderson. 2 1.
Geriatrics, University of Cincinnati, Cincinnati, OH; 2. Geriatrics,
University of Utah, Salt Lake City, UT; 3. Geriatrics, Boston
University, Boston, MA.
Supported By: Reynolds Foundation
GACA
Background:
The use of an interactive educational format has been shown to
improve integration of learned material. However few studies have
evaluated if geriatric educators are actually embracing this philosophy,
utilizing interactive teaching techniques in educational venues,
and which techniques are more commonly used.
Methods:
A cross-sectional sampling, using a 26-question Internet ‘Survey
Monkey’ survey, of geriatric educators contacted through American
Geriatrics Society listservs was performed. Participant demographics
and attitudes towards use of interactive educational modalities such
as video clips, games, role-play, and creative writing were assessed
during a two-week period in November 2011. Data was analyzed
across response categories.
Results:
141 physicians responded. 64% had a CAQ in Geriatric Medicine.
43% were past/present GACA recipients. 42% spent between ¼
and ½ of time teaching a broad array of learners. 99% agreed with the
statement: “I believe that trainees prefer interactive educational activities.”
Results demonstrated a very high preference for interactive
educational formats, but a much lower rating of quantity and quality
of available resources. For example: 95% agreed with the statement:
“I believe video clips may capture the trainees attention better than
traditional lecture format”, but 63% felt the videos currently available
were of insufficient quantity and quality, and 31% had created
their own video materials. We will also present differences between
GACA awardees, geriatricians, and different academic ranks in use of
interactive educational techniques.
Conclusion:
Educators in graduate medical education routinely utilize a variety
of interactive teaching techniques in diverse teaching settings,
yet the majority of educators felt the number of interactive resources
available were insufficient to meet their teaching needs. Promoting
online educational resource sites, such as POGOe, and encouraging
educators to submit interactive teaching material to these sites may
facilitate the increased use of more effective interactive teaching
techniques.
D55
A Training Model to Strengthen Team-based Primary Care for
Older Rural Veterans.
J. L. Howe, 1,2 J. L. Griffith. 1,2 1. Geriatrics and Palliative Medicine,
Mount Sinai School of Medicine, New York, NY; 2. GRECC, James J.
Peter VAMC, Bronx, NY.
There is a severe shortage of healthcare professionals and interdisciplinary
teams trained to provide services for the growing population
of older Americans. Forty percent of Veterans live in rural areas
and require specialized geriatrics care, but rural practitioners are
often not equipped with the knowledge and team training needed to
serve complex healthcare needs. The Rural Interdisciplinary Team
Training (RITT) Program, a component of the VHA Office of Rural
Health Geriatric Scholars Program, strengthens interprofessional
teams to better serve older adults at rural VA Community Based
Outpatient Clinics (CBOCs) through a multi-modal educational intervention.
Potential RITT training sites are identified through Scholars
who participate in the educational program which includes attendance
at an intensive geriatrics course and a quality improvement
project. CBOC staff participate in team-based training to enhance
communication, leadership, collaboration, conflict resolution, and
problem solving skills in the care of older Veterans. Piloted in 2011,
the RITT Program trained a total of 68 providers from five separate
teams in rural clinics located in NYS, AZ, CA, WI and AR. The validated
Team Development Measure is disseminated 30 days before
and 30 days after the training intervention in order to assess team cohesion,
communication, roles, and goals. For the RITT in WI, there
was an average increase of 15.4% on practitioners’ self-rated levels of
team development. Practitioners also complete a form 30 days after
the training asking what changes are made in their practice as a result
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of the education intervention. In WI, team members made changes in
their practice by convening with the team, discussing options, and
slowing down. The main barrier to implementation of the project is
not enough support, time constraints, and staff absences. In 2012,
RITT will be implemented at 10 additional sites with more clinical
geriatric teaching content. In conclusion, RITT led to team-based
practice changes in rural clinics and reinforced the other educational
activities of the Geriatric Scholars Program. It also had a “spill over”
effect by taking team training “on the road” to rural clinics where the
Scholars’ colleagues did not have the opportunity to participate.
D56
G-FACTS - Point of Care Geriatric Resources with a Basic
Science Twist.
E. H. Duthie, 1 J. Rehm, 2 K. Denson, 1 S. Denson, 1 B. Wessel, 1
D. Brown, 2 D. Simpson, 2 G. Colloborrative. 2 1. Medicine, Medical
College of Wisconsin, Milwaukee, WI; 2. Academic Affairs
Educational Services, Medical College of Wisconsin, Milwaukee, WI.
Supported By: Reynolds Foundation; Health Services Resources
Administration Geriatric Education Center; Department of
Veterans Affairs; MCW Injury Research Center
Introduction:
Geriatrics related clinical training of residents and fellows continues
to be in the crosshairs of competing forces ranging from new
duty hour limitations and required ACGME/RRC topics to escalating
clinical productivity expectations for teachers. Trainees now expect
immediate access to point of care clinical resources to inform assessment,
diagnosis and management decisions. Currently an array of
e-based clinical resources are available but these resources often omit
the underlying basic sciences to inform action and are highly variable
in quality, level of evidence-based guidance and technology accessibility
(e.g., instant search, access, down load ).
Methods:
Since 2000, Medical College of Wisconsin has successfully provided
just-in time, point-of-care instruction through its End of
Life/Palliative Care Resource Center (EPERC) Fast Fasts. These
concise, practical, peer-reviewed, and evidence-based summaries on
key topics have demonstrated an increase in intern medical knowledge
and self-reported preparedness in symptom management skills.
Adopting this model for geriatrics a blueprint of relevant topics was
identified by a multi-specialty work group and agreement regarding
format/layout to meet our criterion for point of care actional intelligence
emerging from the sciences underlying medicine. Authored by
multi-specialty team including medical students, residents, fellows
and faculty, the fast facts cross specialties.
Results:
An interactive, searchable website houses the geriatric fast facts
(Geriatrics Fast Facts) indexed by common geriatrics topics, ACGME
competencies, organ system, and diseases. Fast facts are keyed as assessment,
etiology, diagnosis, and/or management focused. Download
time is seamless as file sizes and layout adapt to web or mobile devices.
Examples of Geriatrics Fast Facts include rib fractures, pharmacologic
aspects of drug clearance in elderly patient with reduced function,
gait and balance assessment, and hypertension with positive
reviews from faculty and residents alike.
Discussion:
Geriatrics Fast Facts address the“mobile access now”point-of-care
needs of trainees and faculty alike.The incorporation of the sciences underlying
geriatrics provides a unique and added value for residency/fellowship
programs seeking to fulfill ACGME RRC requirements.
D57
Confusion about Delirium.
J. Defillo Draiby, M. Drickamer. Geriatrics, Yale School of Medicine,
New Haven, CT.
Delirium is an important clinical syndrome in the elderly and
is related to increased mortality and hospital length of stay, long
term functional and cognitive decline and institutionalization. Despite
being responsible for higher mortality rates than sepsis or
myocardial infarction, delirium is often not diagnosed or improperly
addressed. We evaluated resident’s level of knowledge and
confidence in regards to delirium in order to inform future formative
interventions.
Methods: A web-based questionnaire was given to third year
medical residents. Chief Residents emailed all residents with information
on the nature of the survey with a brief explanation of the importance
of delirium. The 15 questions were designed to elicit basic
knowledge in diagnosis, predisposing and precipitating factors; prevalence,
prevention, management, attitudes and beliefs. The responses
were tabulated in tables and interpreted by consensus.
Results: 30 0f 45 residents completed the survey. 72 % had never
used a delirium assessment tool. 50 % did not feel they have a good
working knowledge of the diagnosis of delirium. 49% thought they
did not have adequate training in delirium with only 33% feeling
comfortable managing it. Half thought delirium is under-recognized
in the emergency department. 77% of resident thought that staffing
constraints augment the need for restraints. 1/3 of our participants
would use a high dose haloperidol or benzodiazepine to control hyperactive
delirium. Delirium features was described as altered level
of consciousness and fluctuating in 67% of the respondent. The predisposing
factors most frequently recognized were age (27%) and
baseline cognitive status (27%). Of precipitating factors, acute illness
was the most recognized (77%) followed by medications (67%) and
environment (60%).
Conclusion: The study illustrates the deficits of third year medical
residents in regards to delirium. They expressed concern about
the adequacy of their baseline knowledge and most were unaware of
any validated instrument to diagnose delirium. Half felt that they did
not have enough training in delirium and only 1/3 of the residents felt
confident in managing delirium. This lack of confidence is accompanied
by lack of awareness of predisposing and precipitating factors of
delirium all of which impact the care of the hospitalized elderly. The
study is important in creating future educational interventions to solidify
Geriatric teaching in our institution.
D58
Living the Life of an Older Adult Resident in a Nursing Home:
Applying Learning by Living© Methods.
K. F. Janes, 1 M. R. Gugliucci. 2 1. School of Social Work, University of
Maine, Orono, ME; 2. College of Osteopathic Medicine, University of
New England, Biddeford, ME.
Supported By: Lakewood Continue Care Center
University of New England College of Osteopathic Medicine
Background: Only three percent of social work students choose
a career in the aging field and yet between 8,000 and 10,000 people
are turning 65/day. There is a critical need for social workers to be
trained in gerontology. This study determined if Learning by Living©
research protocols could be applied to enhance learning for an MSW
student about aging.
Methods: A qualitative ethnographic/biographic research design
was applied, whereby a social work student volunteered to live as an
elder resident in a nursing home for 12 days, 24/7, complete with medical
diagnoses and “standard” procedures of care (toileting, transferring,
bathing, feeding, etc). Qualitative data (field notes) included
subjective and objective reporting of observations and experiences.
Field notes were analyzed applying content analysis, thematic categorization
and coding using manual analysis methods, and QSR N-Vivo
Research Software.
Results: Data stages included: Pre-admission; daily life; the
“Ahaa” moment; and discharge. Themes included: Frustration, de-
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pendence, depression, social dynamics; dignity, and friendships.
Learning outcomes from living the life of an older nursing home resident
included increased understanding and knowledge about patient/resident
resilience, cross-generational relationships, verbal/ nonverbal
communication skills and thorough professional development.
These insights far exceed what is taught in the classroom.
Conclusions: This life altering experience strengthened the student’s
knowledge, compassion, and empathy for the aging population.
Living as an older adult, aided in acquiring effective communication
skills, confidence to relate with nursing home residents as individuals,
and has advanced learning regarding the intricate levels of family dynamics
in relation to professional caregivers.
D59
Development of an Interdisciplinary Curriculum in Frailty.
K. Thompson, M. Huisingh-Scheetz, L. Mailliard, P. Rush. Section of
Geriatrics and Palliative Medicine, University of Chicago, Chicago, IL.
Supported By: Health Resources and Service Administration,
Geriatric Academic Career Award
Background:
Frailty is a geriatric syndrome characterized by exhaustion,
weakness, weight loss, slow gait speed, and low activity. Identifying
frailty improves prognostication and decision-making in older
adults. Internal medicine (IM) resident education on frailty and interdisciplinary
(ID) teams, a vital component of care for frail patients,
is limited.
Methods
An ID curriculum in frailty was created using Kern et al.’s approach
to curriculum development. Problem identification and needs
assessment was performed, including: 1.) Meeting with the IM residency
program director to assess curricular content and gaps. 2.)
Group meetings with residents to assess pre-curriculum exposure to
frailty and ID teams. Goals and objectives for curriculum were based
on needs assessment. Educational strategies were developed to reflect
goals and objectives. Curriculum was implemented for IM residents
and other learners. Evaluation and feedback from learners was
collected.
Results:
Needs Assessment: IM residents received no exposure to frailty
in their formal curriculum and had minimal opportunity to work with
an ID team.
Objectives: After participation, IM residents will be able to:
1.) Define frailty, identify frail patients; 2.) Perform functional
and cognitive assessment; 3.) Appreciate importance of ID care
for frail patients; 4.) Appreciate relevance of frailty to future
practice.
Educational Strategies: Didactic lecture, observed clinical experience
and ID team experience with feedback, pre/post-testing.
Implementation: From July 1 to December 31, 2011, 22 learners
completed curriculum: 17 IM residents, 1 PM&R resident, 2 social
work interns, 1 physical therapist, 1 medical student.
Evaluation and Feedback: Learner satisfaction survey results
centered on awareness of frailty as a geriatric syndrome and appreciation
of ID care. Representative quotes include: “I had never heard of
frailty. Now I not only know what frailty is, I have completed a frailty
evaluation,” and “I really enjoyed participating in the [ID] team
meeting. I learned about a lot of options for patients that I never
knew existed.”
Conclusions
This ID Curriculum in Frailty is an innovative forum for residents
to learn about frailty and practice ID care. Results suggest that
satisfaction with this educational experience is high. Future work will
quantify improvements in knowledge, skills, and attitudes, and expand
evaluation to other learners.
D60
ASSESSING 5 GERIATRIC DRIVEN BASIC SCIENCE
CONCEPTS IN GME.
K. Denson, 1,2 D. Steven, 1,2 E. H. Duthie, 1,2 D. Braza, 4,2 S. Gehl, 3,2
B. Vasudev, 1,2 T. Webb, 5,2 A. Witt, 3,2 D. Brown, 2 J. Rehm, 2 B. Wessel, 1,2
D. Simpson, 2,3 G. Colloborative. 2 1. Medicine, Medical College of
Wisconsin, Milwaukee, WI; 2. Educational Services Academic Affairs,
Medical College of Wisconsin, Milwaukee, WI; 3. Family and
Community Medicine, Medical College of Wisconsin, Milwaukee, WI;
4. Physical Medicine and Rehabilitation, Medical College of
Wisconsin, Milwaukee, WI; 5. Surgery, Medical College of Wisconsin,
Milwaukee, WI.
Supported By: Reynolds Foundation; Health Services Resources
Administration Geriatric Education Center; Department of
Veterans Affairs
Purpose/Objective:
Geriatric quality care requires that residents/fellows solutions
are based on strong basic science underpinnings. We were unable to
identify reliable or valid clinically-oriented, basic science-related
knowledge assessment tools. In response, we created an examination,
to assess underlying basic science concepts/themes linked to clinically
oriented conditions.
Method:
We identified five basic science geriatrics concepts: impaired
homeostasis; connective tissue changes; post-mitotic tissue predilection
for age changes; cellular replication and control of mitotic
processes; and immunosenescence. We then developed a test blueprint
with two dimensions: five “cross-cutting” geriatric related basic
science themes and 13 common geriatric conditions/diseases/illnesses.
We then generated 26 multiple choice questions (MCQ’s) as 13-
item pairs: the first question assessed the clinical condition/disease/illness
and the second question in the pair assessed the associated underlying
basic science. The examination was piloted using third-year
medical students (N=68). Using item statistics selected questions
were revised. The examination was then administered to
residents/fellows in family medicine, general surgery, nephrology, and
physical medicine and rehabilitation.
Results:
Fifty (50) residents/fellows completed the examination. Average
time to complete was < 25 minutes. Mean performance was 57.7%
correct (range 34% - 77%). There was no significant difference between
clinical and basic science items scores (p > .05) nor were there
significant differences between specialties. The overall exam reliability
is in moderate range (> .71).
Conclusions:
A paired clinical and underlying science MCQ type examination
provides a reliable assessment of residents’ and fellows’ knowledge of
clinical geriatric medicine content in relationship to five underlying
basic science associated geriatric concepts. The no differences finding
between specialties or by item type (clinical versus basic science)
adds further evidence to support examination generalizability across
specialties.
D61
A Three-Year Competency-Based Geriatrics Curriculum for
Internal Medicine Residents.
K. Callahan, K. B. Feiereisel, J. Williamson, F. S. Watkins,
H. H. Atkinson. Wake Forest University School of Medicine, Winston-
Salem, NC.
Background: Graduate medical educators struggle to meet the
Accreditation Council for Graduate Medical Education (ACGME)
competencies; geriatricians have a unique opportunity to infuse
geriatrics content while helping to meet ACGME requirements. We
describe a 3-year geriatrics curriculum that incorporates ACGME
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and geriatrics competencies for Internal Medicine (IM) residents
and engages residents in self-reflection and quality improvement activities.
Methods: Along with IM residency leaders, a curriculum was
developed in 2008 employing spaced learning in geriatrics across
three years. Interns complete an Ambulatory Geriatrics Experience
(AGE): nursing home, primary care, consultations, house calls
and palliative care. PGY-2 residents staff the Acute Care for the
Elderly (ACE) unit; they also conduct a chart audit and patient
survey on their own ambulatory panel through the ABIM Practice
Improvement Module for the Care of the Vulnerable Elderly
(CoVE PIM). In the capstone activity, PGY-3 residents utilize
clinic site-based aggregate CoVE PIM data to reflect on their performance
gaps in quality of care for older adults. Each site develops
a clinic-specific QI intervention targeting systemic, sustainable
improvement.
Results: As of spring 2011, 84 residents completed AGE, 56 completed
ACE, and 28 completed the CoVE PIM. Interns’ satisfaction
score averages 6.9 out of 9 and PGY-2 residents rank the ACE unit
6.75 out of 9 (satisfactory-superior). Residents expressed confidence
in “assessing functional status” with a “more complete approach to
patient care”. Comparison of CoVE PIM quality measures between
the 2006 and 2010 cohorts yielded no significant difference in patient
satisfaction or physician communication scores. Screening practices
for cognitive impairment (2% to 19%) and falls (8% to 30%) improved
at one resident clinic (p=0.01), but not the other.
Conclusions: A 3-year residency curriculum in geriatrics that
meets all ACGME and geriatrics competencies was well received by
residents, who feel they learn key elements of geriatrics. The CoVE
PIM prepares residents for independent self-reflective practice and
supports the institutional QI mission. After one CoVE PIM cycle, residents’
screening behaviors improved in one of two clinics; future
measures will assess the impact of this continued curriculum on
learner knowledge, patient QOC and satisfaction with care.
D62
ICE: Introducing First-Year Medical Residents to
Interprofessional Teams.
K. D. Sheppard, C. R. Ford, K. Foley, L. Mitchell, C. Harada,
A. Rothrock, P. Sawyer, C. S. Ritchie. University of Alabama at
Birmingham, Birmingham, AL.
Introduction:
Interprofessional education (IPE) occurs “when students from
two or more professions learn about, from, and with each other to enable
effective collaboration and improved health outcomes”. The
IPE Collaborative Expert Panel identified core competencies for IPE
which is the foundation of the Interprofessional Clinical Experience
(ICE) at UAB. The ICE was developed to educate trainees from multiple
healthcare professions on the importance of interprofessional
team meetings for effective patient care. The experience’s objectives
include: introducing trainees to other healthcare professions; participating
in an interprofessional team meeting; and providing trainees
with the opportunity to develop a patient-centered care plan. This
study describes the differences between first year medical residents’
attitudes and those of other disciplines’ trainees.
Methods:
Six disciplines participate in ICE: dentistry, medicine, nutrition,
occupational therapy (OT), optometry, and social work. Each discipline
sends 1-2 trainees to interview an identified nursing home resident
over a 1-week period. Trainees then convene for a preceptor-led
team meeting to present findings and assemble a patient care plan.
Trainees complete a 10-item survey which assesses the trainees’ interpretation
of the various team roles and the need for effective communication.
Results:
Preliminary results over seven sessions have shown that medical
residents highly ranked the importance of the roles of medicine, nursing,
OT, physical therapy and social work as 4.57/5 for older adult
healthcare. Other disciplines differed by listing nutrition and pharmacy
as highly important as well as medicine, nursing, and OT. Both
medical residents and other trainees highly valued interprofessional
team meetings and interprofessional care as well as the importance
of effective communication with older adults and healthcare professionals.
Conclusion:
Both medical residents and other trainees value interprofessional
team meetings. The medical residents have differing interpretations
of the roles of healthcare professionals. This presentation will
delineate the difference in the residents’ attitudes versus the other
participating disciplines towards interprofessional teams and the
need for effective communication.
D63
Medical student geriatric education and mentorship: the Student-
Senior Connection Project.
L. K. Byerly, 1 K. Anderson, 1 J. Zelaya, 1 A. Dworkin, 1 M. Anthony, 1
H. McNett, 1 S. Devarajan. 1,2 1. School of Medicine, Oregon Health &
Science University, Portland, OR; 2. Family Medicine, Oregon Health
& Science University, Portland, OR.
Background: Geriatrics focusing on healthy seniors is an underrepresented
topic in medical school education. An elective focusing
on the relationship between medical students and community
dwelling independently living seniors has never been offered at Oregon
Health & Science University School of Medicine (OHSU
SOM), and the Student-Senior Connection Project (SSCP) was created
to pair OHSU medical students and senior “mentors” from the
community with the goal of fostering relationships and learning
partnerships.
Methods: First and second year OHSU SOM students (n=11;
30.2±6 years, 55% female, 82% White) voluntarily participated in
the yearlong program in which they were randomly paired with a
mentor (n=15; 84.5±9 years, 66% female, 100% White) at a local
continuing care retirement community (CCRC). Over the course
of 8 months, mentors and students met for 6 afternoon sessions
that included formal didactic instruction and informal mentoring.
A variety of professionals lectured on topics including: Quality of
Life, Exercise, Perceptions of Aging, Transitions of Care, Nutrition,
and Death & Dying. Students also took part in CCRC events.
At the end of the program, students completed reflective feedback
forms.
Results: Program completion was 100%. Feedback showed
the “Perceptions of Aging” session was both the most important
and interesting topic for students’ medical education, and (60%)
of students were affirmed in the prospect of including geriatrics in
their primary care practices or amongst their specialty choices.
Student reflections demonstrated several overarching themes: a
deeper understanding of aging well, appreciation of exposure to
an active retirement community, and the value of student-mentor
relationships.
Conclusions: This program was a unique elective experience for
OHSU medical students and the first of its kind for medical students
in the Northwest. The pilot year of the program demonstrated the
utility of introducing students to a group of lively, older adults. Students
expressed a strongly positive view of aging upon program completion.
As the students spent time in their mentors’ community, they
formed meaningful relationships as well as an appreciation of the
strengths and talents of a population that is not well-represented in
their medical school education.
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D64
Hospice and Palliative Medicine Toolkit of Assessment Methods.
L. J. Morrison, 1,2 E. Carey, 3 E. Chittenden, 4,5 S. Block. 4,6 1. Baylor
College of Medicine, Houston, TX; 2. The Methodist Hospital,
Houston, TX; 3. Mayo Clinic, Rochester, MN; 4. Harvard Medical
School, Boston, MA; 5. Massachusetts General Hospital, Boston, MA;
6. Dana Farber Cancer Institute, Boston, MA.
Supported By: Dr. Morrison’s work was supported by funds from
the Division of State, Community, and Public Health, Bureau of
Health Professions (BHPr), Health Resources and Services
Administration (HRSA), Department of Health and Human
Services (DHHS), under grants K01 HP 00077 and K01 HP 00117,
Geriatric Academic Career Award. The information or content and
conclusions are those of the author and should not be construed as
the official position or policy of, nor should any endorsements be inferred
by the BHPr, HRSA, DHHS or the U.S. Government.
Background: Hospice and Palliative Medicine (HPM) was recognized
as an ACGME subspecialty in 2006. As existing fellowship
programs transitioned to the ACGME framework, the HPM Competencies
Project Workgroup defined competencies and measureable
outcomes in line with the ACGME Outcome Project (1). The final
step was to develop an assessment toolkit to guide HPM fellow evaluation.
Methods: The Workgroup reviewed candidate assessment tools
organized by ACGME competency domain from within and outside
the field. This included known unpublished tools, published tools, and
tools from evaluation websites. HPM educators were invited to submit
tools in a call to the field. In reviewing instruments, the Workgroup
used characteristics of a good instrument (1,2) and developed
criteria to inform HPM-specific tool selection.
Results: Sixty-four tools were identified, but most had very poor
fit with criteria. Very few were specific to HPM. Many key HPM subcompetencies
were not evaluable with the instruments. Most importantly,
tool validation was lacking. We identified, by consensus, the
two best assessment methods for each ACGME competency domain
and 18 instruments for inclusion in the Toolkit. Ten were newly created
by the Workgroup and eight were adapted from existing tools.
The Workgroup developed the Master Assessment Table. This new
tool lists the most important, representative subcompetencies for
each ACGME competency per Workgroup consensus. These are considered
exemplar skills that will reflect broader mastery of the entire
competency domain. Recommended assessment methods are also indicated.
Conclusions: The Toolkit of Assessment Methods provides guidance
to HPM fellowship directors and faculty in assessing competency-based
performance for fellows. Psychometric evaluation is
needed. New tools are also needed to address competency areas not
covered by existing tools. Despite these limitations, the Toolkit has
the potential for broad application and can be used flexibly to guide
assessment of learners by ACGME competency domain across levels,
disciplines, and fields.
References:
1. ACGME Outcome Project Web site. Available at:
www.acgme.org/Outcome. Accessed December 5, 2011.
2. Epstein RM. Assessment in medical education. N Engl J Med.
2007;356:387-396.
D65
Training health professionals to screen, manage and report age
related driving disorders (ARDDs).
L. Hill, 1 J. Rybar, 1 T. Styer, 1 R. Coimbra, 2 K. Patrick. 1 1. Family and
Preventive Medicine, UCSD, San Diego, CA; 2. Surgery, University of
California, San Diego, San Diego, CA.
Supported By: State of California Office of Traffic Safety
Background: Older adults have a higher prevalence of health
and functional impairments that interfere with their ability to drive
safely. If left unaddressed, these problems pose a risk of driving-related
injury, not only to the individuals themselves, but also to their
families and to others who share the road with them. Physicians and
other health professionals receive little training on research and management
of ARDDs. Research suggests that the topic is often avoided
by both parties, and that physicians are not aware of the AMA guidelines,
posted online since 2003, or the mandated reporting required in
some states. The purpose of this report is to describe the results of a
professional training curriculum addressing this issue.
Methods: The curriculum was developed and administered over
the last 4 years to 1202 health professionals. The training was developed
and modified from the American Medical Association (AMA)
2003 guidelines for physicians (http://www.nhtsa.dot.gov/people/injury/olddrive/OlderDriversPlan).
Training was provided in a variety
of formats, from in-office seminars to grand rounds. The interactive
program included pocket guides, case studies, resources and videos.
Results: Confidence in the ability to screen seniors increased
from 17% to 72%. The change from baseline screening to intent to
screen increased from 27% to 55%. Ninety one percent of participants
agreed or strongly agreed that they had a better understanding
of California’s mandated reporting laws post training. Ninety two
percent of participants post training agreed or strongly agreed that
they had a better understanding of the medical conditions and medications
that may impair older adults’ ability to drive safely.
Attitudes on California’s mandated reporting laws for lapses of
consciousness (LOC) were favorable, though baseline comprehensive
of the laws was low. While California is one of only 9 states that
mandates LOC reporting (including dementia), physicians felt supported
by the laws.
Conclusions: Physicians responded favorably to training on
ARDDs and mandated reporting, with increases in understanding
and intent to change behavior.
D66
An Innovative Approach to Teaching Delirium Using Standardized
Patients.
L. Wilson, E. Roberts, A. Caprio, G. Winzelberg, J. Busby-Whitehead.
UNC Chapel Hill, Chapel Hill, NC.
Supported By: Supported by: The Donald W. Reynolds Foundation
BACKGROUND: Delirium is a serious, under-diagnosed medical
condition that affects up to 1/3 of hospitalized elders. Physicians
from specialties outside of Geriatrics need the skill set to prevent, diagnose,
evaluate, and treat delirium. Attending physicians in specialty
fields may have the opportunity to teach their learners about delirium,
but they may not have the knowledge base for this task. PUR-
POSE: To develop an innovative curriculum using standardized patients
(SPs) for specialty faculty learners (FLs) in order to solidify
their knowledge and increase their confidence in teaching about
delirium. METHODS: FLs designated as Reynolds Specialty Faculty
Scholars on the UNC-CH Donald W. Reynolds Foundation grant,
“Next Steps in Physicians’ Training in Geriatrics,” participated in this
workshop. Small groups of FLs rotated through 3 different stations of
delirious SPs. Prior to “seeing” each patient, the FLs reviewed the
“chart,” learning the SP’s past medical history, recent labs and vitals,
and medication administration record. Using this information, they
determined a pretest probability that the SP would have delirium and
identified predisposing and precipitating factors for this condition.
One FL in each group interviewed the patient using the Confusion
Assessment Method to diagnose delirium while being observed by
others in the group and a consulting Geriatrician. A family member
of the SP answered questions to provide information about the SP’s
baseline functional status and risk factors for delirium. After the interview,
the FLs developed a management plan and identified a oneminute
teaching point from the case to instruct learners about delirium.
The consulting Geriatrician provided feedback and made
recommendations. OUTCOMES: Eighteen FLs from Hematology-
Oncology, Physical Medicine and Rehabilitation, Trauma and Critical
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Care Surgery, Emergency Medicine, Hospital Medicine, and the Office
of Graduate Medical Education completed the workshop. Feedback
was overwhelmingly positive. These high level academic leaders
in their specialty fields all acknowledged that the direct hands on
learning session enhanced their skills for recognizing and diagnosing
delirium as well as gave them the tools for teaching others. CON-
CLUSION: This curriculum provides an active learning environment
with SPs to teach FLs about delirium. These sessions may be replicated
in other settings and with other disciplines.
D67
Simulation Fosters Interprofessional Skills among Nursing,
Pharmacy and Medical Students.
L. C. Hutchison, 1,3 P. S. Ragsdale, 2 S. N. Berryman, 2 T. J. Bilbruck. 4 1.
College of Pharmacy, University of Arkansas for Medical Sciences,
Little Rock, AR; 2. College of Nursing, UAMS, Little Rock, AR; 3.
Donald W. Reynolds Institute on Aging, UAMS, Little Rock, AR; 4.
College of Medicine, UAMS, Little Rock, AR.
Background: Opportunities to learn effective team skills in the
entry-level curricula are sparse. We integrated human patient simulators
into an interprofessional education experience to train nursing,
pharmacy and medical students interprofessional skills in their geriatric
curricula.
Methods: Two unfolding cases provide simulations for nursing
students (N4s) in their geriatric course. N4s alternatively perform assessments
on the simulated patient or watch via remote camera. Following
this, pharmacy (P4s) and medicine (M4s) students join the N4s
for a simulated staff meeting. N4s present their findings and assessment,
answering questions from the other disciplines. The staff meeting
ends with a delineated plan of care for the patient. The case unfolds
with the patient’s arrival at the simulated emergency
department. N4s perform initial assessment of the simulated patient
and are joined by the P4s and M4s to continue assessment and implementation
of a new plan of care. The simulation ends with initiation
of antibiotics for treatment. At the conclusion of the simulation students
meet to discuss what went well and what could be improved.
Results: 69 students participated in 6 sessions of 9-13 students.
There were 53 N4s, 7 P4s, 3 post-graduate year 1 pharmacy residents
and 6 M4s.Student evaluations of the experience are shown in the table.
Conclusions: Combining high-fidelity simulations of geriatric
patients with interprofessional interactions was well-received by students
from nursing, pharmacy and medicine. This process allows students
from multiple professions to learn and practice different team
skills prior to beginning their professional practice.
D68
Hazards of Hospitalization: A Novel Geriatrics Curriculum for
Internal Medicine Interns.
L. Martinez, M. T. Heflin. Department of Medicine, Division of
Geriatrics, Duke University, Durham, NC.
Introduction: Older hospitalized adults are susceptible to complications,
termed “hazards of hospitalization” (HOH), which are associated
with poor patient outcomes including increased mortality.
Despite these adverse outcomes, house staff knowledge about their
patient’s risk factors for developing HOH is lacking. The goal of this
novel curriculum is to improve Internal Medicine (IM) intern knowledge
and skills about HOH in elderly inpatients in order to ultimately
improve patient care and patient outcomes.
Methods: We implemented this curriculum at our institution for
IM interns rotating on the Geriatrics Inpatient Consult service. Instructional
content and references are posted online and a pocketcard
is provided for review on 10 hazards (delirium, pressure ulcers,
urinary issues, functional decline, falls, polypharmacy,
dehydration/malnutrition, infection, depression, and goals of care).
For each patient the intern follows on the consult service, a topic
checklist is completed by the intern and reviewed by the Geriatrics
attending and/or fellow to ensure all HOH have been discussed. They
are also directly observed performing the Confusion Assessment
Method (CAM). Knowledge and self-efficacy towards HOH are
measured in pre- and post-tests (knowledge) and pre- and post- self
efficacy surveys (5 point Likert scale: 1= No confidence to 5=Completely
confident).
Results: To date, 8 learners have completed the curriculum. All
demonstrated increased confidence in their ability to manage HOH
after completion of the curriculum, with the most dramatic increases
seen in delirium (pre 2.50 to post 4.00), urinary issues (2.10 to 3.60),
and functional decline (2.00 to 3.75). Interns are able to more accurately
define HOH as well as identify the correct components of the
CAM. Prior to the rotation, all interns either strongly disagreed (5/8)
or disagreed (3/8) that they felt confident in performing the CAM
compared to afterwards in which all either agreed (1/8) or strongly
agreed (7/8).
Conclusion: Implementation of this curriculum has demonstrated
improvement in intern knowledge and self-efficacy regarding
HOH. While a relatively small number of interns have participated to
date, we anticipate reaching up to 38 by the end of the current academic
year. Next steps include measuring application of these principles
through review of documentation of HOH in older adults cared
for by interns in future inpatient rotations.
D69
Incorporating Evidence-Based Medicine in a Geriatric Medicine
Clerkship.
M. van Zuilen, 1 J. C. Palacios, 1,2 M. J. Mintzer. 1,2 1. University of
Miami Miller School of Medicine, Miami, FL; 2. GRECC, VA Health
Care System, Miami, FL.
INTRODUCTION:
As part of a 4-week geriatric medicine clerkship, students at the
UMMSM complete an evidence-based medicine assignment on a
clinical question arising during rounds in the medical, psychological,
social, economic, or functional domains. This paper presents the structure
and components of this assignment, student performance data,
and feedback from students.
METHODS:
During the clerkship orientation, students receive an overview
of the EBM assignment with sample PICO questions from several
domains. They are instructed to frame a clinical question for one of
their patients, search for the best evidence, critically appraise the validity
and clinical relevance of the evidence, and apply it to their patient.
Students submit a structured critical appraisal of topic form and
deliver a 10-minute slide presentation to their peers and course faculty,
followed by a brief Q&A and feedback session. To promote
group participation, student peers ask questions before faculty members
comment and provide feedback. An 8-item evaluation form is
used to rate students’ performance with 5 scorable categories (unsatisfactory
– excellent) for each item. Although we evaluate the basic
EBM skills (framing a question and conducting a search), emphasis is
placed on the critical appraisal and the discussion of patient specific
factors (risks, values, preferences) in applying the evidence.
RESULTS:
Since 2010, 203 students have completed the EBM assignment.
Although most clinical questions pertained to the medical domain,
students have also addressed issues in the psychological, social, economic
and functional domains. The overall quality of the presentations
has been high (average score is 89.8; range is 68-100). The main
contributors to poor performance are formulating a question that is
not clinically meaningful and failing to address patient specific fac-
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tors. Student feedback indicates they recognize the value of enhancing
their EBM skills, but that they find the assignment time consuming
and the presentation difficult to deliver effectively in 10-minutes.
DISCUSSION:
The EBM assignment in our clerkship builds on prior course
work and paper-based EBM exercises in the pre-clinical years. Students
are able to effectively deliver a clinically meaningful presentation
in a relatively short amount of time. This approach can be easily
adapted by other programs seeking to incorporate EBM into their
curricula.
D70 Encore Presentation
Hearing impairment in the elderly – unheard of in basic and further
nursing education.
M. Decker-Maruska, 2 M. Lerch. 1 1. Geriatric Dept., Protestant
Hospital Bethanien, Iserlohn, Germany; 2. Geriatric Depart., St.
Barbara Hospital, Attendorn, Germany.
Introduction: With nearly 1 million dementia patients, focus on
the special demands of these patients in nursing education grows.
Compared to its high prevalence (approx. 13 Million) hearing impairment
patients are still not recognized in all stages of nursing education.In
the current education, still centred on the anatomy and physiology
of the ear, rarely featuring the basic concept of a hearing aid,
the auditive sensory loss and its consequences is often not an issue,
neither in basic nor in further education.
Methods: After developing a practice oriented educational concept
for the care of hearing impaired geriatric patients, the authors interviewed
105 certified nursing staff from different fields of care (35
from a geriatric ward, a nursing home, a normal hospital ward) with a
minimum working experience between one and four years with a
standardized questionnaire (prevalence, detection, problem recognition
and focus in formal education) before and 3 month after a 2 day
training in specialized care for hearing impaired elderly patients.
Results: In all fields the perceived prevalence grew after the
training workshop (36%=> 67%). The ability to recognize a patient
with a hearing impairment increased significantly in the nursing
home and geriatric sub-group. Especially the ability to evaluate required
repetitions and frequent misunderstandings as signs of hearing
impairment picked up (23%=> 52%). We found a difference between
staff from nursing homes and the geriatric ward opposed to
staff from the normal ward in addressing the major care problems in
hearing impaired elderly patients. Nursing home and geriatric ward
staff recognized the time requirements of handicap-oriented communication
as the core problem, where as the normal ward staff put their
emphasis on technical aids.
Evaluating how much effort was spent on the teaching of sensory
deficiencies overall and on hearing impairment and the conceptual
requirements linked to it in education, especially the staff from
the geriatric wards and the normal wards saw the urgent need for further
nursing education in that particular field.
Conclusion:
To improve the quality of the care process our interviews revealed
the need for more practice-oriented educational concepts developing
competence in recognition, handicap-oriented communication,
and the handling of technical aids required by the auditory
impaired elderly.
D71
Teaching Safe Transitions of Care: An Interdisciplinary Case Based
Approach.
R. K. Miller, E. Goren, C. Whitehouse, A. Norris, J. S. Myers.
Medicine, University of Pennsylvania, Philadelphia, PA.
Background:
Coordinating transitions of care at hospital discharge is essential
to achieve safe, high quality, patient-centered care. The requisite
knowledge and skills in how to execute such a transition are not traditionally
taught to medical trainees. In our experience when they are
taught, they rarely take advantage of the expertise of the interdisciplinary
teams which coordinate these transitions. We sought to design,
implement, and assess an interdisciplinary-led, case-based curriculum
in safe hospital discharge transitions for internal medicine
interns.
Methods:
The curriculum included a brief lecture and case-based session.
The 15 minute lecture reviewed key concepts in hospital discharge
transitions, introduced the interdisciplinary care team roles, and provided
a brief introduction to upcoming small group session. The 40
minute case-based session was conducted with small groups of 6-8 interns..
Each group included a physician moderator, social worker,
clinical pharmacist, and a home care nurse. Two cases were presented,
highlighting the roles of each professional, and emphasizing key high
risk discharge issues.
Results:
Fifty-six interns participated in the curriculum and completed a
satisfacation survey using a 5 point LIkert scale. 24 (42.8%) agreed
and 31 (55.3%) strongly agreed that the session enhanced their ability
to identify threats to a safe hospital discharge. 33 (58.9%) agreed
and 23 (41%) strongly agreed that, after attending the session, they
felt more confident in understanding the roles of other health care
professionals who participate in the discharge process. 8 (14.2%)
agreed and 48 (85.7%) strongly agreed that they believe that the use
of other healthcare professionals to teach this topic was effective.
Conclusion: An interdisciplinary curriculum on teaching safe
transitions of care was well received by internal medicine interns and
resulted in increased confidence in knowledge of discharge transitions,
ability to identify threats to a safe hospital discharge, and the
roles of the physician and other healthcare professionals in the discharge
process. Future directions include expanding the curriculum
to include other residency programs and developing other novel ways
to incorporate interdisciplinary teaching into graduate medical education
training.
D72
Internal Medicine Resident Senior Community Service Learning
Experience.
R. K. Miller, G. True, J. Groce-Martin, J. C. Johnson. Medicine,
University of Pennsylvania, Philadelphia, PA.
Supported By: Donald W. Reynolds Foundation
Background: We developed, piloted, and evaluated a program to
provide a service-learning and community-based, interactive experience
focused on Geriatric Medicine and ACGME core competencies
to medical residents. Service-based learning promotes core competencies
by enriching learners’ experiences, promoting understanding
of community resources and cultural norms, providing help to service
agencies and communities, and developing leadership and professional
skills.
Methods: We developed and piloted a service-based community
learning program with 20 Internal Medicine residents of the University
of Pennsylvania. The program, which consisted of a half-day
morning session, was embedded in a local senior center or senior
housing facility. A community outreach coordinator of the Division of
Geriatrics orchestrated program implementation, assisted in site selection,
and facilitated communication between the project leader
and key contacts at each site. At the site, residents toured the facility,
learned about the mission and activities of the site, and gave a supervised
presentation or “brown-bag” review for the seniors on a Geriatrics
topic. A ten-minute presentation on local senior resources
ended the experience.
Results:
Resident evaluation of the community based learning and service
experience was administered electronically via an IRB-approved
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survey using the internal medicine evaluation system. Of 19 evaluations
received, 84% (16) of the internal medicine residents found the
tour of the facility informative; 42% (8) of the residents agreed or
strongly agreed that the service they performed expanded their
knowledge of senior health issues; 68% (13) of the residents agreed
or strongly agreed that this interaction with the seniors helped them
learn more about communicating with older patients. Themes from
open-ended questions included increased knowledge in senior community
resources and facilities, enjoyment of interactions and learning
from seniors outside a hospital setting.
Conclusion:
Overall, this pilot program of service-based community learning
provided residents with insight into the lived environment and
community resources available to seniors while increasing awareness
of the importance of effective communication with seniors. Future
directions include having all trainees perform an aging presentation,
expansion of topics, and obtaining evaluations from the seniors at
the sites.
D73
Pilot Formative Hybrid Simulation for Sub Interns.
S. McGee, 1 W. Gammon, 1 M. Keough, 1 C. Burnham, 1 S. Chimienti, 1
M. Yazdani, 1 J. Gallagher, 1 J. Reidy, 1 M. Zanetti, 1 A. Fabiny, 2
J. Gordon, 2 J. Gurwitz, 1 M. Pugnaire. 1 1. OEA, UMMS, Worcester,
MA; 2. Harvard Medical School, Boston, MA.
Supported By: A University of Massachusetts Medical School
(UMMS) initiative supported by the Donald W. Reynolds
Foundation
Background/Method: Building on the work of our Reynolds
partners at Harvard Medical School, this Pilot Formative Hybrid
Simulation OSCE experience was developed to incorporate more
formative clerkship experiences within the new UMMS curriculum.
This simulation, which utilizes both standardized patients and a mannequin,
involves a case of an elderly patient presenting to the ED in
respiratory distress with end stage COPD who no longer wishes life
prolonging interventions such as bipap or intubation. Students work
in teams of two: one student assesses the patient in the ED and then
completes a hand-off to the second student who assesses the patient
in the ICU . Students are assessed on their ability to conduct a focused
interview, develop an appropriate differential diagnosis and
identify the goals of care. The experience concludes with students debriefing
with 2 faculty, a geriatrician and a hospitalist or palliative
care specialist.
Methods: Medical sub interns at one UMMS clinical site participate
in this experience as part of the required 4 week medical sub internship.
Students complete an evaluation immediately following the
debriefing session.
Results: Fifty-eight sub-interns have participated in the experience
to date. Preliminary analysis of a small sample of learners
(n=10) demonstrated that: 1) 100% felt that the session was “presented
in a way that helped me integrate knowledge, ideas and skills
with other disciplines” and; 2) 90% found it “useful to debrief and review
[their] own performance.” Selected responses from students regarding
the strength of this experience included, “Challenging experience.
Worthwhile to see these kind of scenarios in a consequence free
environment” and “…practicing end of life discussions in a ‘safer’ setting
than the hospital”.
Conclusions: Sub-interns viewed the Pilot Formative Hybrid
Simulation OSCE experience as valuable. Preliminary data suggest
that they valued the opportunity to practice interviewing skills and
medical decision making at the end-of -life in the safe environment of
the UMMS Simulation Center.
AAMC Geriatric Competencies: #19 Assess and provide initial
management of pain and non-pain symptoms based on patient’s goals
of care
D74
Faculty Development Program for Non Geriatricians: Evaluation of
Gait and Fall Risk, Function and Cognition.
S. McGee, J. Gurwitz, C. Burnham, M. Keough, S. Pasquale,
B. L. Robuccio, M. Pugnaire. OEA, UMMS, Worcester, MA.
Supported By: A University of Massachusetts Medical School
(UMMS) initiative supported by the Donald W. Reynolds
Foundation
Background: As part of the UMMS Donald W Reynolds funded
initiative at UMMS a 60 min interactive faculty development program
was developed and piloted for a diverse group of faculty serving
as mentors/advisors to UMMS medical students. This program included
the Competency Certification in Gait and Fall Risk
Evaluation© workshop materials presented at the 2010 AGS Annual
meeting as well as commonly used functional and cognitive assessment
tools.
Methods: Faculty completed surveys rating their knowledge of
the importance and components of gait and fall risk assessment, functional
and cognitive assessment, and their confidence in performing
these assessments prior to and immediately following the faculty development
workshop. Self-selected into two groups, faculty attended
two sequential workshop presentations: Gait and Fall Risk Assessment,
and Functional Assessment and the Mini-Cog.
Results: Thirteen faculty attendees represented multiple specialties
and subspecialties including psychiatry, pediatrics, radiation oncology
and gynecology. Overall, faculty reported significantly increased
knowledge specific to the importance of performing gait and
fall risk assessment, and their confidence to do so, as a result of the
workshop session. Eighty-five percent of those in attendance reported
the session to be valuable to both their clinical and teaching
responsibilities.
Conclusions: A brief faculty development program for a diverse
group of faculty serving as medical student mentors/advisors was very
well received, and improved their knowledge and confidence in performing
commonly used assessment tools for older adults.
AAMC Geriatric Competencies: #7 Perform and interpret a
cognitive assessment, #9 Assess and describe baseline and current
functional abilities and #12 Ask about falls and watch a patient rise
from a chair and walk then record and interpret the findings.
D75
Frailty and Body Mass Index in Community Dwelling
Octogenarians, Nonagenarians and Centenarians.
J. Ceimo, 1 N. Bravo, 1 B. Leonard, 1 T. Minani, 1 K. O’Connor, 1
L. Evans, 1 D. Coon, 2 W. Nieri. 1 1. Center for Healthy Aging, BSHRI,
Sun City, AZ; 2. College of Nursing and Health Innovation, ASU,
Phoenix, AZ.
Background: Research in frailty has attempted to determine
both a consensual diagnosis and its component parts. Prior studies
show frailty associated with extremes of BMI (U-shaped curve). Not
everyone with BMIs < 20 or > 30 is frail. We propose that stable BMI
through mid- and late adult life (age 50 and up) may identify a subset
> 80 years in whom outlying BMIs were a less significant contributor
to frailty.
Methods: This cross-sectional study on community dwelling 80+
year olds is part of a larger longitudinal study on healthy aging (O’-
Connor et al, 2009). Participants lived in Arizona, were interviewed in
person, and had an MMSE >17.
Height/weight was taken from the initial and second annual
exams (year three). Height/weight data at age 50 was based on participants’
recall. Body Mass Index (BMI) was divided into four categories:
1) < 20, 2) 20-25, 3) 26-30, and 4) > 30. Frailty was determined
from 34 selected deficits associated with physiologic decline and increased
mortality.An individual’s total points divided by total number
of deficits yielded a Frailty Index (FI) from 0.0 to 1.0; higher scores in-
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dicated greater frailty. Descriptive and non-parametric statistical
analysis was performed using SPSS software and Mann Whitney U.
Results: 202 subjects living independently (62% female, mean
age 92) were included. 61 were octogenarians, 69 nonagenarians, and
10 centenarians. Initial mean BMI ranged from 25.2 in octogenarians
to 22.4 in centenarians with no significant drift between years one and
three. Correlated to BMI at age 50, those with < one SD were less
likely to be frail or were less frail. We confirmed prior observations
that strength training correlated with decreased frailty across all ages.
A U shaped curve correlating frailty/BMI held true for subjects up to
age 89. BMI flattened after age 90, suggesting the impact of BMI on
frailty is less.
Conclusions: Frailty correlates with advancing age; BMI does
not. Much effort is spent to obtain/maintain normal BMIs in the elderly.
Our study identifies a subset of elders with outlying BMIs in
whom BMI is not a significant contributor to frailty. Prolonged activity
at a stable BMI may produce physical conditioning that is beneficial.
Avoidance of frailty in this group should stress continued activity
over caloric manipulation.
D76
Orthostatic Hypotension, its risk factors, and the need for its
measurements in the hospital.
J. Chohan, K. Samtani, E. Baum, S. Snyder, N. Kayani, L. Benedict,
S. Hazelet. Post Acute and Senior Services, Summa Health System,
Akron, OH.
Objectives: To investigate the correlation between falls and orthostatic
hypotension (OH) and to examine the benefits of measuring
orthostatic vital signs on admitted patients at high risk for a fall. Design:
Cross-sectional study. Measurements: Patients at high risk included
those: > 65 years old who have fallen in the last 2 months or
had an admitting diagnosis of a fall, syncope, or pre-syncope. Blood
Pressure (BP) was measured in the supine position and after 2 minutes
of sitting and 2 minutes of standing within 24 hours of admission.
Orthostatic hypotension was defined as 20-mmHg decline in Systolic
BP and/or a 10-mmHg decline in diastolic BP from a supine to sitting,
or sitting to
standing position. Results: While 200 people qualified for the
study, only 99 people had orthostatic vital signs measured and of
those 30 people were orthostatic positive. Only five of the 30 were
non-community dwelling patients. 84% of patients had documented
hypertension, 37% had documented heart failure, 23% had anemia
(HgB90) on admission. Of
those who were orthostatic positive, only 1 had a documented fall
while hospitalized. Conclusion: We saw no correlation between falls
and OH, however, anti-hypertensive medications were held on admission
for OH positive patients and a thorough medication reconciliation
was done on discharge through interdisciplinary communication
and physician notification. These results suggest that orthostatic
vital signs should be measured on patients who are at high risk for a
fall to improve their in-patient admission and discharge medication
assessment.
D77
A comparison of different target criteria for geriatric care.
J. van Kempen, 1 H. Schers, 2 R. Melis, 1 M. Olde Rikkert. 1 1.
Department of Geriatric Medicine, Radboud University Nijmegen
Medical Centre, Nijmegen, Netherlands; 2. Department of Primary
Care, Radboud University Nijmegen Medical Centre, Nijmegen,
Netherlands.
Background: There are several instruments for the identification
of frail elderly. None of these aims to identify frail elderly in primary
care to select them for integrated care. Therefore, we developed a
pragmatic identification method, the Easycare-TOS (Two-step Older
people Screening). It optimally uses information that is readily available
to the family physician and takes health and psychosocial aspects
into account. We studied how frail elderly identified with Easycare-
TOS scored on other criteria for geriatric care: disability, multimorbidity
and Fried Frailty criteria.
Methods: Elderly from 4 health centers were included (n=591,
mean age 77 (SD5), 56% women). They were screened with Easycare-TOS.
Additional data were collected for determining multimorbidity
(CIRS-G score ≥2 on ≥2 items), disability (KATZ15 ≥4) and
Fried frailty criteria. We compared the results on the different criteria
in our study population using a Venn diagram.
Results: Figure 1 shows the Venn diagram. The group frail according
to just Easycare-TOS (n=139) had a mean CIRS-G score of
10 (SD4) compared to 14 (SD4) in the group frail according to Fried
(n=58).There was no difference in psychosocial status.The group with
comorbidity and no frailty (n=222) had a mean CIRS-G of 9 (SD3).
Conclusion: Elderly who were frail according to Fried were
more physical frail than elderly who were frail according to Easycare-
TOS solely. Elderly with merely comorbidity had least physical problems.
Follow-up data should show whether Easycare-TOS is able to
identify elderly who will benefit from integrated care.
D78
Fall Stop...MOVE STRONG program to reduce fall risk among
community dwelling older adults.
J. Prager, J. Kardachi, C. Carlucci, S. M. Bradley. Geriatrics, Mount
Sinai Hospital, New York, NY.
Background: Falls is a leading cause of injury and death in older
adults. Approximately, one third of community-dwelling people over
65 years of age fall each year resulting in a significant source of morbidity
and mortality, an important threat to patient safety. Exercise
programs have been shown to reduce rate of falls. The Fall
Stop…MOVE STRONG program is an exercise and education based
fall prevention program. The core content of the program includes a
graduated individualized exercise program, which targets strengthening,
coordination, flexibility, and balance with concurrent education
about personal and environmental fall risk factors and safety strategies
lasting 75 minutes each session. The purpose of this study is to
evaluate if Fall Stop…MOVE STRONG decrease fall risk in community
dwelling older patients.
Methods: Fall Stop...MOVE STRONG if offered over a 12 week
period three times a year in an urban geriatric academic practice. Patients
were approached for participation and consent was obtained.
The measures of functional assessment, falls risk, and fear of falling
were obtained before and after falls prevention program including
The Functional Reach Test, The Four Square Step Test, The Timed Up
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& Go Test, and The Modified Fall Efficacy Scale. Questions about
medications, depression, functional status, and history of previous
falls were asked.
Results: 14 patients thus far have completed the Fall
Stop…MOVE STRONG program. Average age of population is 79
years old. Functional Reach Test improved 2 cm. 77% of the participants
at high or moderate risk for falls (

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binge drinking daily. One week prior to admission he slipped on wet
concrete floor suffering a small forehead laceration but refused medical
attention.Admission vital signs were within normal limits.The patient
was alert and well oriented,but agitated,rude,cursing and laughing.He
made self-deprecating comments, dirty jokes and mocked
physicians of “being stupid”.The pupils were anisocoric but reactive
to light and the extraocular movements were intact. He had a regular
cardiac rhythm, and clear lungs. Strength was 5/5 in the upper extremities
and 4/5 in the lower extremities.Cranial nerves II-XII were
grossly intact and the DTR’s +2 throughout. He had a Glasgow coma
scale of 15/15,a MMSE of 28/30 and a normal Geriatric Depression
Scale.Laboratory work up revealed slight hyponatremia
(132mmol/L),a compensated metabolic alkalosis and mild hypoxemia.A
brain CT scan demonstrated a right chronic subdural
hematoma with evidence of re-bleeding. Haldol 2 mg every 12 hours
was administered that controlled his aggressiveness and hallucinations,but
his inappropriate behavior and bouts of laughter continued.
Eight hours after the hematoma was evacuated all inappropriate behavior
resolved.Involuntary emotional expression disorder is a distressing
disorder that is frequently overlooked and misdiagnosed.The
clinical impact can be severe,with unremitting and persistent symptoms
that can be disabling to patients.
D85 Encore Presentation
Psychoeducational Interventions for Caregivers of Seniors: A
Systematic Review.
K. Aung, K. Stevens. UT Health Science Center at San Antonio, San
Antonio, TX.
Supported By: This research was supported by the MESA Center
for Health Disparities, which was funded by a grant from the
National Institute for Nursing Research.
Background: Psychoeducational interventions are structured
programs designed to train caregivers to effectively deal with problems
associated with caregiving. By teaching specific skills to manage
stress on an ongoing basis, such interventions could improve caregiver
depression, caregiver burden, the level of perceived stress, anxiety,
and coping skills. Objective: To assess the effects of psychoeducational
interventions compared to the standard levels of knowledge
provision in enhancing the support and guidance offered to caregivers
of seniors. Methods: Electronic searches of Medline, EM-
BASE, the Cochrane Central Register of Controlled Trials, the
CINAHL, and PsycINFO were undertaken, supplemented by crossreference
searching. All relevant randomized controlled trials were
selected. Quasi-randomized trials, non-randomized trials and observational
studies were excluded. Data were extracted from included
papers. Risk of bias in the included studies was assessed using the
methodology of the Cochrane Collaboration. Data from all trials
were synthesized and summarized. Results: All included trials involved
caregiving to seniors with dementia. Inadequate reporting of
incomplete outcome data increases the risk of attrition bias. Failure to
report allocation concealment led to difficulty in judging the risk of
selection bias. The nature of intervention, duration of intervention
and tools used for measurement of outcomes were different across
the trials. Marked heterogeneity of interventions and outcome measures
across the trials precluded pooling of data and conducting metaanalysis.
Psycho-educational intervention probably has a positive effect
on caregiver depression and possibility has positive effects on
caregiver burden, coping, perceived stress, and anxiety but the effects
were not consistent across the studies. Most of the intervention programs
resulted in improvement of some domains of caregiver outcomes
rather than globally. Conclusions: Psychoeducational interventions
could be potentially useful but interventions should be
customized in accordance with the particular needs of the individual
caregivers. Lack of consistency of beneficial effects on some outcomes
across different studies and the potential risks for selection
and attrition bias prohibited us from drawing firm conclusions. More
well-designed, conducted and reported randomized studies investigating
the effectiveness of psychoeducational interventions are
needed.
D86 Encore Presentation
Medication Reconciliation in Transition of Care: Broken Telephone
or Patient Safety Goal?
L. Sinvani, 1 J. Beizer, 4 M. Akerman, 2 L. Lutsky, 3 C. Cal, 3 Y. Dlugacz, 3
K. Masick, 3 R. Shah, 1 G. Wolf-Klein. 1 1. NSLIJ Health System, New
Hyde Park, NY; 2. Feinstein Institute for Medical Research,
Manhasset, NY; 3. Krasnoff Quality Mgt. Institute, Great Neck, NY; 4.
College of Pharmacy, St. John’s University, Queens, NY.
BACKGROUND: There has been a dearth of studies on the
transition of older patients from hospital admission to subacute rehabilitation
and discharge home. We studied medication discrepancies
across a large Health Care system.
METHODS: Chart review utilizing randomized electronic medical
records (EMR) and paper chart medication reconciliation lists
across three transitions: hospital admission to discharge (time I), hospital
discharge to sub-acute rehab (time II) and sub-acute rehab admission
to discharge home or long term care (time III). Medication
discrepancies were grouped as intentional or unintentional.
RESULTS: In the 44 charts analyzed, average age was 71.4
(range: 41-91), with 68% female, 77.3% surgery versus 22.7% medicine.
Median stay in the hospital was 5.5 days and 14.5 days in skilled
facilities. Total number of medications documented at time I, II, and
III were 284, 472, and 545 respectively. Total medication discrepancies
were 358 (time I), 318 (time II), and 330 (time III); 100% of patients’
records had drug discrepancies and 58% were unintentional.
When analyzing average number of medications per patient at each
transition, time I increased from 6.5 to 10.7 (p

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was determined in a cohort of older adults seeking care in an outpatient
incontinence clinic.
Methods: Medication consumption was analyzed from 142 older
patients aged 60+ participating in a longitudinal cohort study of urge
and mixed incontinence recruited from outpatient incontinence clinics.
The International Consultation on Incontinence Questionnaire-
ICIQ-UI-SF was used to detect the severity of incontinence. Descriptive
statistics were used to analyze prevalence of drug use. Regression
analyses sought to determine an association between any putative
medication use and the severity of incontinence.
Results: Participants had a mean age of 71 ± 7years and 83%
were female. The mean number of comorbid conditions was 5±3, and
patients consumed on average 7± 4 different medications. The prevalence
of medications precipitating lower urinary tract symptoms was
54%. Overall, 21% of patients used benzodiazepines, 13% ACE inhibitors,
12% calcium channel blockers, 11% estrogens, 10% other
antidepressants, 5% NSAIDS, 4% other GABAergic medication, 3%
loop diuretics, and 1% alpha-blockers,. There was no association between
the severity of incontinence and any medication use.
Conclusion: The prevalence of use of medications potentially
causing or exacerbating lower urinary tract symptoms in the elderly is
high. Discontinuation or substitution of these medications should be
attempted as part of the first-line treatment approach for older adults
seeking care for bladder symptoms.
KEY WORDS: Older adult, lower urinary tract symptoms,
medication
D88
Association of executive function impairment, history of falls and
physical performance: a population-based study in Eastern France.
S. W. Muir, 1 O. Beauchet, 3 C. Annweiler, 1,3 M. Speechley, 2
M. Montero Odasso. 1,2 1. Geriatric Medicine, University of Western
Ontario, London, ON, Canada; 2. Epidemiology & Biostatistics,
University of Western Ontario, London, ON, Canada; 3. Neuroscience,
University of Angers, Angers, France.
Background: An emerging area of interest in falls research is impaired
cognition that disturbs higher levels of control of balance and
gait on fall risk. Postural stability is a complex skill involving the coordination
of motor and sensory systems in perceiving environmental
stimuli and responding to perturbations to control body movement.
Executive function (EF) is required for divided attention and responding
to changes within the environment. The objectives of this
study were to estimate: 1) the prevalence of impaired EF, 2) the association
between impaired EF and falls, and 3) the association of impaired
EF and physical function used in the evaluation of fall risk.
Methods: Cross-sectional study of 5097 older adults without dementia
received a comprehensive geriatric assessment (July 2008 to December
2010). The assessment included cognitive testing (Clock
Drawing Test, CDT), physical performance testing (Timed Up & Go
Test (TUGT) and grip strength), and self-report of falls in the previous
12 months. A modified Poisson regression evaluated the association
between impaired EF and falls. Linear regression evaluated the
association between impaired EF and the TUGT and grip strength.
Results: Using the CDT, 25% had impaired EF. The prevalence of any
fall in the last year was 27% and 35% among those with and without
abnormal EF respectively. In the adjusted modified Poisson analysis,
impaired EF was associated with any fall [RR=1.13, 95%CI (1.03,
1.25)], serious fall-related events [RR=1.30, 95%CI (1.02, 1.66)], but
recurrent falls was not significant [RR=1.13, 95%CI (0.93, 1.37)]. In
the adjusted linear regression, impaired EF was associated with a
longer time to complete the TUG, indicating a worse performance,
and diminished grip strength compared to people with normal EF.
Conclusions: Impaired EF in the absence of dementia was prevalent,
one quarter of studied sample of community-dwelling older adults,
and has a strong association to falls, fall-related injuries and decreased
ability on physical performance testing. The use of the clock
drawing test is a reliable and easy to administer EF test that can be
used routinely in comprehensive fall risk evaluations.
D89
A comparison of cognitive and manual dual-task challenges on gait
in people with Mild Cognitive Impairment: a cross-sectional study.
S. W. Muir, 1,3 K. Gopaul, 3 M. Montero Odasso. 1,2 1. Geriatric
Medicine, University of Western Ontario, London, ON, Canada; 2.
Epidemiology & Biostatistics, University of Western Ontarion,
London, ON, Canada; 3. Gait & Brain Lab, Lawson Health Research
Institute, London, ON, Canada.
Background: Gait impairment is a prevalent feature among
older adults with cognitive impairment. Assessing gait using the dualtask
paradigm, a secondary cognitive or manual task, evaluates the interaction
between cognition and mobility. Dual-task testing also provides
a valid means to identify fall risk by exposing mobility deficits.
Comparative studies on differential effects by the type of dual-tasks
have been restricted to cognitive tests on gait. The objective was to
evaluate the effect of manual and cognitive dual-task challenges on
gait in people with Mild Cognitive Impairment (MCI). Methods:
Cross-sectional study of 57 adults with MCI (mean age=75.4 (6.4))
and 25 cognitively normal controls (mean age=71.5 (4.1)). Gait was
assessed using an electronic walkway under single, dual-task (counting
backward from 100 by ones, counting backwards from 100 by sevens,
and carrying a glass of water) and multi-task test conditions. Gait
velocity and dual-task cost were the main outcome measures. An adjusted
repeated measure ANOVA was performed to assess the effect
of cognitive group and walking condition. Results: Gait velocity was
significantly slower in the MCI group in all tests. The manual dualtask
confers a challenge not different from the cognitive dual-task of
counting backwards by ones while walking for people with MCI and
normal cognition. Performance of the more complex cognitive task of
serial seven subtractions produced a significant reduction in gait velocity
in both groups, but there was a greater dual-task cost in the
MCI group at 31.8%. Dual-task costs are additive under simple manual
and cognitive challenges. The addition of the simple manual task
to serial seven subtraction while walking did not add to dual-task gait
costs but did negatively affect the cognitive performance in people
with MCI.
Conclusions: This study has demonstrated that not all dual-task
challenges are equivalent in their ability to challenge an individual
and identify deficits. This lack of interchangeability of tasks, between
manual and cognitive secondary tasks and among cognitive tasks, is
important for translating research into clinical practice by providing a
graded progression of task difficulty.
D90
CHARACTERISTICS OF FRAIL PATIENTS IN A GERIATRIC-
HIV PROGRAM: THE EXPERIENCE OF AN URBAN
ACADEMIC CENTER AT ONE YEAR FOLLOW-UP.
M. A. Ruiz , E. Aguilar, P. Sirisha, M. Frontini, C. Cefalu . Medicine,
Louisiana State University Health Sciences Center, New Orleans, LA.
Purpose of Study:
To determine the prevalence and severity of frailty and its associated
factors in patients >60 infected with HIV in an urban academic
center.
Methods Used:
A total of 80 patients > 60 years infected with HIV were
screened and 26 patients were transferred to our newly created Geriatrics-HIV
Frailty program. We divided this group of already frail patients
in three different subgroups; the mildly, moderately and the
very frail groups based on the number of domains failed during the
initial geriatrics screening.
Summary of Results:
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The percentages of mildly, moderately, and severely frail elderly
patients in our cohort were 20% 50% and 30% respectively. Cognitive
impairment (30%), multiple co-morbidities (60%), and history of
AIDS-related opportunistic infections (40%) were correlated with
frailty status. Smoking was highly prevalent in all groups. The average
number of medications used per patient was 8.1 with 65% of patients
being compliant with their regimens.
Conclusions:
We found that cognitive impairment, presence of co-morbidities,
high number of medications used, and past history of any opportunistic
infection are factors prevalent in severely frail patients infected
with HIV in our cohort. The significance of these factors in
development and progression of frailty syndrome in HIV-positive patients
needs to be elucidated.
D91
Outcomes for elderly breast cancer patients in Louisiana.
M. A. Ruiz , D. Williams, C. Cefalu. Medicine, Louisiana State
University Health Sciences Center New Orleans, New Orleans, LA.
Introduction: Breast cancer is common in the United States and
Europe. Worldwide, the incidence of breast cancer has increased at
annual rate of 3.1% and mortality from breast cancer has increased at
an annual rate of 1.8%. Elderly breast cancer patients are diagnosed
with a higher stage of disease, undergo less surgery and receive hormonal
treatment as monotherapy more frequently This population
also has a decreased relative survival. This study was designed to review
differences if any in diagnosis, treatment modalities and survival
between elderly >65 and young

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Results: 22 (33.9%) of the subjects were non-frail, 31 (47.7%)
were pre-frail, and 12 (18.5%) were frail. 39 (60%) were female and
the mean age was 80.6 ±6.4. Transferrin (ng/mL) increased significantly
by frailty status (non-frail: 43.4 ±11.4, pre-frail: 54.3 ±11.9, frail:
58.3 ±10.2, p

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other forms of technology. Interviews were recorded and transcribed.
Responses were analyzed qualitatively using grounded theory.
Results: 10 participants comprised the analytic sample. Mean
age of participants was 71 years. 80 percent were female. All identified
as Asian, Black, or Latino. Three main themes emerging from the
interviews included: (1) enhanced social engagement, (2) intellectual
stimulation, and (3) empowerment derived from social and cultural
integration. A majority of participants expressed interest in using the
Internet for communication purposes. Many of the respondents felt
there was educational value to be gained from using the Internet to
find information; respondents expressed a desire to continue learning
through use of the computer at home or taking additional courses.
Most reported self-perceived improvement in confidence and competency
in using a new tool. Participants reported feeling they belonged
to a community from which they were once excluded after completing
the course. Perceived sense of enhancement to their cognitive and
functional abilities also emerged as a major theme.
Conclusion: The use of computers and the Internet can produce
functional, psychological, and social effects unique to elders entering
a world of new languages, structures, and social interactions. Further
exploration into quality of life impacts for isolated elders using the
computer and Internet is needed.
D97 Encore Presentation
What are Hospice Providers Doing to Reach African Americans . . .
and what works?
K. S. Johnson, 1,2 M. N. Kuchibhatla, 2 J. A. Tulsky. 2 1.
Medicine/Geriatrics, Duke University, Durham, NC; 2. Center for
Aging, Duke University, Durham, NC.
Supported By: Beeson Career Development Award in Aging
Research (5K08AG028975)
National leaders recommend that hospices develop practices
and policies which increase access to care for minorities.The extent to
which hospices employ strategies to reach African Americans, a group
historically underrepresented in hospice, has not been well-described.
Objective: To describe hospice providers’ strategies to increase
service to African Americans.
Methods: Survey of North and South Carolina hospices. We
used Spearman correlations to examine the association between
provider practices and: (1) commitment to increasing service to
African Americans; (2) % of African Americans served by the hospice
based on 2008 Medicare Data.
Results: Of 80 hospices (65% response rate) surveyed, 78% reported
strategies to increase service to African Americans, but only
20% reported that strategies were reviewed to determine effectiveness.
Most participated in education/outreach: 73% with nursing
homes; 68% with churches; 56% with physicians; 55% with hospitals;
20% with civic groups. Hospices endorsing greater commitment to increasing
service to African Americans more often participated in outreach
to churches and civic groups (r=0.28 – 0.36, p

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of all strokes in the elderly. Warfarin anticoagulant therapy reduces
annual ischemic stroke risk by about two thirds in AF patients. With
institution of coverage for medications by Medicare Part D program
introduced in 2006, we wanted to know whether rates of warfarin use
were higher than previously reported after institution of the program.We
also used the Medicare Part D prescription drug data to examine
national warfarin use by patient characteristics and geographic
location.
Methods: We conducted a retrospective cohort study of 41,447
Medicare beneficiaries aged 66 and older with at least 2 atrial fibrillation
diagnoses in 2008 and at least 1 in 2008. All subjects were enrolled
in Medicare Part D by 2008. Chi-square test was used to examine
differences in warfarin use (defined as 2 warfarin prescriptions in
2008) by patient characteristics (age, ethnicity, sex, Medicaid eligibility,
entering Part D coverage gap, comorbidities, having contraindications
to warfarin, and seeing a cardiologist or a PCP) and by Hospital
Referral Regions. Hierarchical generalized linear models were used
to examine how patient characteristics impact the likelihood of warfarin
use only among patients with no warfarin contraindications, a
sample size of 34,947.
Results: The overall use rate was 66.8%. In bivariate analysis,
patients who received warfarin therapy were more likely [P

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D102
Clinician’s perception of infections and laboratory utilization at a
long term care facility.
J. Kopacz, 1,5 P. D. Sychangco, 2 D. Russo, 2,5 Z. Huang, 2,5 N. Mariano, 1,3
C. Urban, 1,3 S. Segal-Maurer. 1,4 1. Infectious Diseases Section, NYHQ,
Flushing, NY; 2. Geriatrics Division, NYHQ, Flushing, NY; 3.
Microbiology, NYHQ, Flushing, NY; 4. Medicine, Weill Cornell
Medical College, New York, NY; 5. SCNR, Briarwood, NY.
Introduction
Infectious Diseases (ID) consults are not readily available in
long term care facilities (LTCFs). This study assesses clinician perception
of incidence and prevalence of infections, laboratory utilization
and use of antibiotics at a LTCF.
Materials and Methods
A two-step study was conducted at a 320-bed, hospital-affiliated
LTCF: 1. Six month retrospective analysis of all microbiologic specimens
; 2. 14 question IRB approved survey assessing number of patients
treated, use of diagnostic tests, perceived frequency of infections,
and choice of antibiotics. Answer choices included “never,
rarely, sometimes, often, always.” Clinicians did not have access to retrospective
laboratory data collection.
Results
All 11 LTCF healthcare (HCWs) providers (9 MDs, 2 RNP)
completed the survey. Blood tests were ordered with a change in
physical exam by 8 HCWs “often” and 3 “always” (chest radiographs
infrequently). All HCWs stated urine infections were most common
and they “always” ordered urinalysis (UA) to accompany urine cultures
(UCx). Of 435 UCx specimens, 264 (61%) were positive. Of
these, 236 (89.4%) had an accompanying UA (85% positive). Six
HCWs ordered blood cultures (BCx) “often” and all stated “sometimes”
or “rarely” found the results helpful. Of 167 patients who had
BCxs, 13 (7.7%) were positive with 3 (1.8%) considered true bacteremia
(6 of 13 patients received unnecessary treatment). Perceived
C difficile infection (CDI) prevalence was over 25% and all HCWs
“often” ordered CDI assays. Of 889 CDI assays sent, 94 (11%) were
positive (by ELISA). In spite of CDI concern, fluoroquinolones were
the most frequently prescribed antibiotics. All HCWs stated they
would use an antibiogram if available.
Conclusions
Positive UAs correlated well with positive UCx, obviating use of
routine UAs for all patients. BCx were rarely positive and not clinically
useful, consistent with clinicians’ impression (cost savings
$1,895). CDI rates may be underestimated with ELISA assay and education
is required to limit use of CDI associated antibiotics. HCW
education via an antibiotic stewardship program would improve laboratory
utilization and antibiotic use, help reduce nosocomial infections,
and lead to cost savings.
D103
Nursing home improvement collaborative to reduce potentially
avoidable hospital transfers.
R. Tena-Nelson, 4 K. Santos, 4 L. Herndon, 5 E. Weingast, 2 S. Amrhein, 4
K. S. Boockvar, 2,1 J. Ouslander. 3 1. JJP VA Medical Center, Bronx,
NY; 2. Jewish Home Lifecare, New York, NY; 3. Florida Atlantic
University, Boca Raton, FL; 4. Continuing Care Leadership
Coalition, New York, NY; 5. Massachusetts Senior Care Foundation,
Boston, MA.
Supported By: New York State Departments of Health and Labor
Background: Nursing home (NH) residents experience frequent
hospital transfers, some avoidable. Interventions to Reduce Acute
Care Transfers (INTERACT) provides tools and strategies to assist
NH staff in early identification, communication, and documentation
of changes in resident status.
Objective: To implement INTERACT among members of Continuing
Care Leadership Coalition (CCLC), a NY metropolitan area
NH provider association, and evaluate educational and hospitalization
impacts.
Methods: Funding was obtained from a NY State health workforce
training grant. Members of CCLC were invited to participate
regardless of their baseline transfer rate. 13 education sessions (7 inperson)
were conducted over 1 year. Sessions engaged NH executives,
department heads, front-line nursing staff and their labor union,
and staff from NHs’ partner hospitals. Topics included the INTER-
ACT implementation process; use of simple standardized communication
tools, advance care planning tools, care paths, and change in
condition support tools; quality review of hospital transfers; exercises
for refining clinical skills; teamwork; and lessons learned. One session
used a high-fidelity patient case simulator.
Results: There were 150 participants from 32 facilities. 94% of
NHs were non-profit with 331 beds on average. After training 84%
of participants responded that they were more confident in educating
others about interventions to reduce preventable hospitalizations.
Eighty percent indicated that their organization had a plan in
place to coordinate INTERACT efforts in the next 3 months with a
referring hospital. NHs reported high acceptance of, and compliance
with, use of INTERACT tools. To date, two NHs reported 37% and
18% reductions in hospital transfers as compared to the year prior to
implementation.
Conclusions: Use of a collaborative model among a group of
urban nursing homes resulted in good acceptance and uptake of the
INTERACT intervention. The program has the potential to impact
NH resident care through standardized approaches to communication,
early identification of clinical issues, decision-support, and support
for stronger partnerships between acute and post-acute care
providers.
D104
The PEACE Pilot Study: Convergence of Geriatrics and
Palliative Care.
K. R. Allen, 1,2 S. M. Radwany, 2,3 D. J. Kropp, 3,2 D. Ertle, 4
S. Fosnight, 2,3 P. Moore, 2 S. E. Hazelett. 2 1. Geriatrics & LifeLong
Health, Riverside Health System, Newport News, VA; 2. Summa
Health System, Akron, OH; 3. DFCM, NEOMED, Rootstown, OH; 4.
Area Agency on Aging 10B, Uniontown, OH.
Supported By: National Palliative Care Research Center
(NPCRC)and
The Summa Foundation
Background: Although geriatrics and palliative care are distinct
disciplines, the populations they serve often overlap, especially for
home-bound patients with chronic life-threatening illness.
Purpose: To describe the feasibility of a randomized pilot study
testing the effectiveness of a geriatrics/palliative care (PC) hybrid intervention
to deliver early in-home interdisciplinary care management
to improve the quality of PC in Ohio’s community-based longterm
care Medicaid waiver program, PASSPORT.
Methods: New PASSPORT enrollees were randomized to the
intervention (n=40) or usual care (n=40). The intervention involves
an in-home geriatrics/PC needs assessment by a trained PASSPORT
case manager (CM). The CM presents the findings to an interdisciplinary
team who devise an individualized care plan based on the consumer’s
goals and best practice guidelines. The CM implements the
plan with the consumer, family and primary care physician (PCP).
The primary outcomes upon which we expected our intervention to
have a positive effect include: 1) Symptom management, 2) Quality of
life, 3) Mood, 4) Decision making/care planning, and 5) Spirituality.
Results: No significant differences were found between groups
regarding baseline demographics. At 6 months no differences were
found in performance of ADLs or IADLs. Mean differences and 95%
confidence intervals were calculated for each of the primary outcomes.
All confidence intervals included zero indicating no significant
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difference between groups. We have demonstrated the feasibility of
the PEACE intervention with respect to enrollment rate, appropriateness
of the inclusion/exclusion criteria, ability of CMs to implement
the intervention and willingness of PCPs to participate. Elements
requiring revision in larger RCT include selection of different
outcome measures, the use of dedicated palliative care CMs and incorporation
of in-home evaluations by pharmacists, pastoral care and
palliative care RN team members.
Discussion: The outcome measures used in this pilot appeared
to be more appropriate for a population at the end of life. More appropriate
outcomes for our population would include medication appropriateness,
goal attainment, completion/honoring of ADs, quality
of life and symptom assessment tools with less focus on end of life.
D105
Prevalence of Very Low Bed Use to Prevent Bed-Related Fall-
Injury in Hospitals: Preliminary Findings.
L. C. Mion, 1 R. I. Shorr, 2 A. F. Minnick, 1 M. Dietrich, 1 G. Hunt, 1
B. Donaghey. 1 1. Vanderbilt University, Nashville, TN; 2. University of
Florida, Gainesville, FL.
Background: Annually 1 million hospital patients fall with a
10% injury rate. Hospital fall prevention has been only modestly effective
despite >20 years effort. Very Low Beds (VLB) have been
used in long term care settings and expert panels suggest VLBs to
prevent fall injury for hospitals. Only one study exists of VLBs in hospitals
and found no impact on fall-injury rates. Further, a growing
number of reports indicate adverse events for patients, staff and families.
Objective: To determine prevalence of VLB use in NICHE hospitals
(Nurses Improving Care of Hospitalized Elders), impact on
fall-injury rates, and adverse events to patients, families and staff.
Methods: A web-based survey was distributed to 288 NICHE Coordinators
in November 2011. Survey items determined VLB prevalence,
criteria for use, types of units deployed, effect on fall-injury rates, and
adverse events as a direct result of VLB. Descriptive analyses were
performed using SPSS.
Results: To date, there have been 131 responses (45%). Of these,
29 sites (22%) used VLBs; 17 (59%) with padded floor mats. 41%
own and 59% rent VLBs. Most (74%) do not track patient use or
number of bed-days of use (88%). Only 19% track effectiveness of
VLB. General medical and surgical units were the most frequent
users (56%); 31% used in ICUs. Most (60%) have used VLBs for 3+
years. Most (63%) have no policy or procedure for use. 52% of sites
reported at least one patient VLB-event with falls (21%). Staff events
included: injury (10%), falling/tripping (20%), and difficulty maneuvering
equipment (24%). 35% of the sites noted family VLB-events.
52% believe VLB benefits outweigh VLB risks for adults 65. Fall rates ranged from 1 to 4.5 and fall-injury
rates ranged from 0.5 to 1.5/1000 patient-days. Added comments expressed
concerns over costs and staff consistent use of the beds because
of ‘hassles’ for nurses in procurement and transfers.
Conclusions: Less than 1/4 of NICHE respondents use VLBs.
No consistent criteria or procedure was evident. Few track use or effectiveness.
However, most believe the benefits outweigh the risks for
older patients. Adverse events occurred in up to 52% of the sites. Similar
to studies on hip pads, staff adherence was a concern. Carefully
designed studies are necessary prior to policy changes to incorporate
VLBs in acute care settings.
D106
Geriatric Home Care Reduces Hospitalizations in Very Frail Elderly
in Toledo, Spain.
C. Castillo, C. Rodriguez, C. García, A. Bartolomé, M. Diaz de Cerio,
C. Gómez, M. Cuadrado, M. Gomez, B. Aguirre, A. Carbonell.
Geriatrics, Hospital Virgen del Valle, Toledo, Toledo, Spain.
Authors: C.Castillo, C.Rodriguez, C.García,A.Bartolomé, M.Diaz
de Cerio, C.Gómez, M.Cuadrado, M.Gomez, B.Aguirre,A. Carbonell
Institution: Hospital Virgen del Valle, Spain
Introduction: The goal in Geriatric Home Care (GHC) is to improve
quality of life for patients and their families when they face a
non-curable life threatening disease. It is not easy to keep patients
with multiple chronic diseases at home because of their complex
treatments and the difficulty determining terminality; therefore, patients
are frequently hospitalized and very often die in the hospital.
We studied the functional status and the number of hospitalizations
of non-oncologic patients admitted in our GHC Unit.
Methods: We reviewed the charts of 519 patients. We excluded
oncologic patients. In the analysis we included main diagnosis, reason
for admission in our GHC Unit, the New York Heart Association
scale (NYHA), use of home oxygen, the Global Deterioration Scale
(GDS), the Barthel index, the number of hospitalizations 12 months
before and 12 months after admission in GHC, the presence of
anorexia and/or disfagia, and the Charlson Index.
Results: 238 patients were non-oncologic. 32% were admitted as
non-oncologic palliative patients. Mean age was 85.53 (SD 5.6) mean
time of stay in GHC was 5.2 months (SD 5.5). 20% of the 238 patients
had a NYHA of III-IV. 24% of the patients were on home oxygen. Severe
dementia was present in 18% of the patients. Severe dependency
was found in 52%. Anorexia and/or disfagia were present in 25% of
the patients. Charlson index above three was found in 31% of individuals.
Before admission in GHC mean number of hospitalizations
was 1.94 (SD 1.84; 95% CI 1.61-2.07) and after GHC it was 0.8 (SD
1.4; 95% CI 0.7-1.075), therefore we achieved a 55% reduction in the
number of hospital admissions. 52% of patients died during their stay
in GHC, of which 32% died at home.
Conclusions: In our GHC Unit Geriatricians manage very old
patients with severe advanced chronic diseases who are hospitalized
very often. After being evaluated by GHC the number of hospitalizations
is reduced and an important percentage of patients die at home,
reducing inadequate use of health system resources. In the future, we
should potentiate care giver support at home in order to improve our
goal of reducing hospital use by this population.
D107
Palliative Oncologic Patients Die at Home and Palliative Nononcologic
Patients Die in the Hospital.
C. Castillo, C. Rodriguez, C. García, A. Bartolomé, M. Diaz de Cerio,
C. Gómez, M. Cuadrado, M. Gómez, B. Aguirre, A. Carbonell.
Geriatrics, Hospital Virgen del Valle, Toledo, Toledo, Spain.
Background: It is relatively easy to determine terminality in an
oncologic disease, but it is difficult with non-oncologic diseases, therefore
patients are frequently hospitalized and very often die in the
hospital. In our Geriatric Home Care Unit (GHC) our goal is to improve
the quality of life of our patients, and prevent inadequate use of
health care resources. We studied the number of hospitalizations of
oncologic and non-oncologic patients admitted in our GHC.
Methods: We reviewed the charts of oncologic and non-oncologic
patients followed in our GHC between 2008 and 2010 and collected
demographic data such as age and sex, time followed by GHC,
the number of hospitalizations 12 months before and 12 months after
admission in GHC, the number of deaths and where the patients died.
Results: We studied 519 patients of which 281 were oncologic
and 238 were non-oncologic. Of the oncologic patients, mean age was
83 (SD 5.2), 64% were men and their mean time in GHC was 4
months (SD 4.2). Mean number of hospitalizations 12 months before
admission in GHC was 1.34 (SD 1.32; 95% CI 1.16-1.46) and 12
months after admission was 0.5 (SD 0.9; 95% CI 0.44-0.65); this result
represented a 60% reduction in the number of hospitalizations. 90%
of patients died, and 76% of deaths were at home. Of the non-oncologic
patients, mean age was 85.5 (SD 5.6), 56% were women and
mean time in GHC was 5.25 months (SD 5.5). Mean number of hospitalizations
12 months before GHC was 1.94 (SD 1.84; 95% CI 1.61-
2.07) and 12 months after GHC it was 0.8 (SD 1.4; 95% CI 0.7-1.075);
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this result represented a 55% reduction in the number of hospitalizations.
52% of the patients died and 32% died at home.
Conclusions: Even though oncologic patients and frail patients
with multiple chronic advanced diseases share similar symptoms at
the end of life, it is easier to keep oncologic patients at home till they
die. Most likely, this is because in non-oncologic patients it is more
difficult to determine whether a relapse is irreversible or not. We believe
that with better support and education to main care givers we
can improve achieving goals of management.
D108
Improving care Through Collaboration: The Development of a Post-
Acute Care Coordination Network.
J. Chohan, W. Zafirau, S. Hazelet. Post Acute and Senior Services,
Summa Health System, Akron, OH.
Background: Healthcare reform is going to require integration
of services across the continuum of care to improve both efficiency
and quality.
Purpose: This paper describes a unique collaboration between
an acute care hospital and 26 neighboring skilled nursing facilities
(SNF) whose purpose was to improve communication between these
providers in an effort to improve quality of care, reduce hospital
length of stay, optimize transitions and reduce readmission rates for
at risk patients.
Methods: Formation of the Care Coordination Network (CCN)
which implemented electronic communications between facilities, a
standardized transfer form from the hospital to SNF, and a standardized
change in condition form for transfer from the SNF to the
hospital.
Results: The hospital’s average length of stay was reduced from
7.52 days in 2002 to 7.2 days in 2010. Furthermore, the 31 day readmission
rate for post acute patients who were discharged to a skilled
facility dropped from 26% to 20% in 2010. The mortality rate for
cases readmitted to the hospital began at 9% in 2003 and has fluctuated
over the years studied between 12.5% to as low as 7%. At the
end of the study, the readmission rate was at 9% in 2010.
Conclusions: Participation in a Care Coordination Network is
mutually beneficial for hospitals, SNFs, and at risk patients. Hospitals
benefitted from a shorter length of stay, improved bed capacity, and
fewer readmission rates. SNFs benefitted by having increased referrals
from the hospital, more streamlined census management, as well as
improved ability to classify patients into Resource Utilization Groups
due to improved information exchange. Finally, patients were clearly
provided with improved quality of care with these implementations.
D109
A Transformational Model of Caring for independent older adults -
The COLLAGE and Vitality 360 Program.
J. Fonseka, 1 R. Schreiber, 1,3 A. Russotto, 2 R. Jones, 2 A. Rosenberg, 2
M. Bryan, 2 J. Morris. 2 1. Department of Medicine, Hebrew Senior
Life, Boston, MA; 2. Institute For Aging Research, Hebrew Senior
Life, Boston, MA; 3. Medicine, Harvard Medical School, Boston, MA.
Supported By: Hebrew SeniorLife
Background: Vitality 360 is an innovative program of self engagement
that was developed at Hebrew SeniorLife and piloted at
Orchard Cove (OC), a continuing care community (CCRC) in Canton,
MA. OC is part of a consortium of housing and CCRC sites
called COLLAGE .COLLAGE utilizes the Community Health Assessment
(CHA) measurement tool, to identify opportunities of
health and wellness programs to meet the ever changing needs of
older adults living independently. The CHA is administered yearly
and was developed by InterRAI (An International organization of
clinicians and researchers). It is a comprehensive assessment of an individuals’
physical, mental, spiritual, vocational and social status.
After the CHA is done, the patient is offered access to the Vitality
360 program. A Vitality Coach (VC) works with the individual to understand
what their life goals are, and identifies barriers to reaching
these goals. A Vitality plan is developed and monitored collaboratively
over the year.
Methods: 189 residents at OC Independent living were enrolled
in COLLAGE. Out of the 189 residents, 90 patients were identified
but only 69 could be matched on the basis of baseline characteristics
to residents from comparison COLLAGE sites, where Vitality 360
was not available.The broad categories of goals identified by the Vitality
Coach were physical and mental health, volunteering, lifelong
learning, spiritual and life enrichment
Results: Outcomes monitored included changes in residents
self-reported mood problems, health status, satisfaction with life and
fitness participation. There were significant improvements in some of
these parameters and overall quality of life.
Conclusions: Based on these findings, the COLLAGE and Vitality
360 program can positively impact residents’ quality of life by empowering
them to focus on goals that are most important to them.
This resulted in improved satisfaction with life. This model of engagement
warrants further study as an intervention in community
dwelling older adults to enhance quality of life.
D110
Patient- And Family-Centered Rounds On A Geriatric Inpatient
Service: Resident And Staff Perspectives Of Bedside Rounds.
J. D. Schlaudecker, 1 A. Stecher, 2 K. Meganathan. 1 1. Geriatrics,
University of Cincinnati, Cincinnati, OH; 2. University of Cincinnati
College of Medicine, Cincinnati, OH.
Supported By: GACA
Reynolds Foundation
Background: Patient- and family-centered rounds (PFCR) is a
model for empowering patients and families and improving communication
and care in an academic, inpatient setting. While well studied
in the pediatric setting, little is known about the application of PFCR
to the geriatric population.
Methods: In summer 2011, 86 unique encounters of 13 residents
and 10 staff were surveyed immediately following a beside PFCR experience.
For comparison, 71 unique encounters of 11 residents and
14 staff on another service that does not use PFCR completed the
survey.
Results: 94% of residents experiencing PFCR found the process
beneficial to patients, compared to 80% of residents practicing traditional
rounds. 92% of residents experiencing PFCR found the process
beneficial to other residents, compared to 80% practicing traditional
rounds. 90% of residents participating in PFCR said the process improved
relationships with patients and families. 63% of residents in
PFCR agreed that PFCR improved resident education, compared to
traditional rounds. 84% of residents in PFCR gained a “better understanding
about patients compared to traditional rounds”. 96% of this
group agreed they were working as a part of a team, compared to
70% of residents in traditional rounds. 100% of residents in the
PFCR group agreed with the idea that PFCR “enhances my ability to
communicate with patients”.
100% of staff in the PFCR group agreed “my questions were answered
about the patient”, “I am working as a part of a team”, “I understand
the patients care plan for the rest of the day better than had
I not participated in PFCR”, “PFCR enhances my ability to address
fears and worries of patients”, and “PFCR improves communication
between the members of the care team.”
Conclusions: The positive responses of those participating in
PFCR indicate that PFCR can lead to positive care experiences for
resident and staff of geriatric patients. Compared to traditional
rounds, PFCR is at least as beneficial for both residents and staff in
enhancing communication, education, and teamwork. More research
is needed with a larger sample to investigate how PFCR outcomes
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and satisfaction compare to traditional care, but the potential for care
improvement, enhanced education, and improved resident and staff
satisfaction in inpatient geriatric care is great.
D111
Implementation of a Community-Hospital Partnership to Improve
Transitions from Hospital to Home.
J. L. Thorud, 1 A. K. Hochhalter, 1,2 A. B. Stevens, 1,2 H. R. McGhee. 3 1.
Scott & White Healthcare, Temple, TX; 2. Texas A&M Health Sciences
Center, Temple, TX; 3. Central Texas Aging and Disability Resource
Center, Belton, TX.
Supported By: Project is supported by grants from the U.S.
Administration on Aging and the Center for Technology and Aging.
Background: The objective of the Texas ADRC Evidence-Based
Care Transition Program is to reduce hospital readmissions by educating
and empowering patients to manage their healthcare needs. The
program employs the evidence-based Care Transitions Intervention®.
Methods: Eligible patients, age 60 or older and hospitalized at
the participating hospital, are identified through referrals from hospital
personnel and auto-generated reports of electronic medical record
data. Intervention services are offered to eligible patients in the hospital
or by phone after discharge. The free, 30-day program consists of
a home visit and two follow-up phone calls which focus on goal setting
and four “pillars”: creating an accurate medication list, preparing
for and attending a follow-up medical appointment, identifying signs
of exacerbation (“red flags”), and using a personal health record. The
program evaluation follows the RE-AIM framework to assess the potential
value of the program for improving the health of communities;
aspects of program reach into the target population and program
adoption are described in this presentation.
Results: After six months of operation, 39% (467/1183) of patients
referred to the program were eligible and 35% (N=165) enrolled.
The average age of enrollees was 73; 85% were white; 14%
were Hispanic or Latino; 59% were female; and 93% lived in a small
metro area with fewer than one million residents. The Patient Activation
Assessment, a coach-rated assessment of the degree to which patients
participated in the program, showed that over 50% of participants
were actively engaged in the program. Of the 89% of patients
who set a goal, 67% either met or made “a lot of progress” in meeting
it. Readmissions to the same hospital within 30 days were 13.6% for
patients who completed all intervention contacts compared to 23.4%
for those who were eligible but did not enroll.
Conclusions: To date, the program has successfully reached a
large number of patients. The evaluation reveals a need to either increase
program uptake among eligible patients or offer different
types of care transitions interventions for those who choose to decline
services. The next phase will expand the program into additional
hospitals and embed additional coaches within the ADRC offices in
communities.
D112
The Inpatient Hospital Experience of Caregivers of Older Adults: A
Qualitative Study.
J. A. Steimle, 1 J. Colburn, 2 C. Christmas. 2 1. Ohio University Heritage
College of Osteopathic Medicine, Athens, OH; 2. Division of Geriatric
Medicine and Gerontology, Johns Hopkins University School of
Medicine, Baltimore, MD.
Supported By: American Federation for Aging Research and
National Institute on Aging
Purpose: The purpose of this study is to interview caregivers of
older adults to learn more about their experiences of having their loved
ones in the hospital, and to suggest ways to improve that experience.
Methods: Caregivers were referred by the patient’s geriatricians
or solicited via flier posted in the clinic and were administered semistructured,
recorded, and transcribed interviews to better understand
their perceptions of the hospital experience.
Results: 25 interviews were analyzed. The average age of patients
was 83 and that of caregivers was 59. 16 caregivers were daughters
or daughters-in-law, 5 were spouses, 2 were sons, 1 was a niece,
and 1 was a state provided caregiver.
On a burden scale with a maximum 16 points, 15 caregivers(60%)
reported low levels of burden (0-8) while 10 (40%) reported
high levels of burden (9-16). Caregivers performed an average
of 6.5 activities of daily living (ADLs) in the home setting but 3.2
in the hospital setting. The majority of caregivers rated the transition
to home very highly according to the 3 question Care Transition
Measure.
6 themes emerged from the analysis of the semi-structured interviews
with caregivers: communication, hospital setting, quality of
care, outpatient care and transition, caregiver involvement, and sensitivity
to the patient’s unique medical conditions.A range of comments
within each theme suggested heterogeneity of experience for the
caregivers. The most common suggestions to improve the hospital experience
when directly asked was to improve communication as well
as to have patience and understanding with patients and caregivers.
Conclusions: In this study of caregivers of older adults after a recent
hospitalization, we found that there remain many challenges
around communication between caregivers and the medical team
both during the hospital stay and at discharge. This analysis suggests
that interventions designed to enhance the education of hospital
providers about communicating with caregivers and about the special
needs of older adults could improve the hospital experience for older
adults and their caregivers.
D113
Identifying Waste in a Geriatrics Home Care Practice’s Laboratory
Ordering Process Using Lean Techniques.
J. A. Eng, 1,2 R. M. Zitnay, 1 K. James, 1 M. Sissoko, 1 M. Young, 1
G. Gupte, 2 W. Suen. 1 1. Medicine-Geriatrics, Boston University School
of Medicine, Boston, MA; 2. Boston University School of Public
Health, Boston, MA.
Supported By: John A. Hartford Foundation, Health Resources and
Services Administration
Background: “Lean” is a quality improvement philosophy that
focuses on maximizing customer value while minimizing waste
throughout a system. Eliminating waste, or non-value-added steps,
decreases cost, time, and resources needed to perform services. The
main aim of this study is to identify ways to improve the routine laboratory
ordering process in a geriatrics home care practice using the
lean techniques of process mapping and identifying wastes. Methods:
The authors identified and contacted various stakeholders to map the
routine laboratory ordering process from when the clinician placed
an order until receipt of results. The authors collected time stamped
data for 8 key steps in orders placed by two clinicians over 30 days.
The authors analyzed the time data, identified non-value added steps,
and further refined athe process map. Results: The authors collected
data on 23 laboratory orders. Examples of non-value added steps
identified from the process map included creation of a printed order
sheet, walking the printed order sheet from the printer to the secretary’s
bin, waiting for the secretary to pick up the order sheet, having
variation in secretarial verification of account status, faxing of the
order to thean outside laboratory, and waiting for the fax confirmation.
Of the 8 steps tracked, authors identified order wait time in the
secretary’s bin (average 29.89 hours, range from 0.08 to 74.90 hours,
n=16) as the non-value added step that would be most readily modified.
Conclusion: Lean techniques, such as using process mapping and
identifying non-value added steps, are useful for recognizing the inefficiencies
in home care laboratory ordering practices. Future plans include
restructuring the process and better utilizing electronic medical
records systems to reduce waste in the routine home care laboratory
ordering process.
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D114
Fall Reduction in an ACE Unit-A Model for Quality Improvement
1,2 J.R Ortiz, 1,2T. Efeovbokham, 1 C.Stephens-Kelly, I,Rohner
1,2Theodore Suh 1 UT Health Science Center in San Antonio &
2CSRHCC.
J. R. Ortiz, 1,2 T. Efeovbokham, 1,2 C. Stephens-Kelly, 1 I. Rohner, 2
T. Suh . 1,2 1. Geriatrics, UTHSCSA, San Antonio Texas, TX; 2.
Geriatrics, Cristus Santa Rosa, San Antonio, TX.
PURPOSE: Identifying specific risk factors for those who fall in
a hospital Acute Care of the Elderly (ACE) Unit can lead to a targeted
intervention to prevent falls among hospitalized older adults.
BACKGROUND: Falls are a common problem in hospitalized
older adults, with about a third of hospital falls resulting in injuries
such as fractures, head and soft tissue trauma, which contribute to increased
length of stay (LOS), impaired rehabilitation, greater comorbidity,
more transitions to long-term care and greater hospital costs.
The main risk factors for falls in the hospital include gait instability,
confusion, urinary incontinence, previous falls and certain drugs.
METHODS: At the start of this study, our 10-bed ACE Unit at
Christus Santa Rosa Hospital-City Centre had the highest fall rate in
the hospital at just over 10 /1000 bed days. Our goal was to lower the
fall rate to 3.4 /1000 bed days. The ACE team developed a multicomponent
intervention, consisting of differentiating very high from high
fall risk patients, hourly rounding and mandatory use of bed alarms
for very high fall risk patients, and an incentive for ACE Unit nurses
consisting of a free lunch at the end of a month without any falls.
RESULTS: This intervention began on March 1/2011. For over 4
consecutive months (March-June), there were no falls in our ACE
Unit. We had one fall each in the months of July-Sept. and no falls in
Oct. For the last quarter (July-Oct.), the fall rate for our ACE Unit
was 3.5 /1000 bed days. The estimated cost to implement this change
was $850, plus $100 monthly to maintain it. If a fall adds an average of
4 days to the LOS, each prevented fall saves ~$12,800. If one conservatively
estimates that 2 falls were prevented monthly with this intervention,
then the annual projected cost savings is over $307,000.
CONCLUSION: Specific strategies to reduce falls in hospitalized
older adults have been successful. Differentiating those at highest
risk for falls is essential. Increased nurse rounding and diligent
bed alarm use for those at highest fall risk can reduce falls. A nominal
reward to nursing staff for their efforts to reduce falls was also effective.
There are potentially large cost savings to hospital from the prevention
of falls and resulting injuries.
D115
CARE: A Volunteer Approach to Reducing Delirium in the
Emergency Department.
J. Arnold, M. Sanon, A. Chun. Department of Geriatrics and Palliative
Medicine, Mount Sinai School of Medicine, New York, NY.
Supported By: The Medical Student Training in Aging Research
program of the the American Federation for Aging Research
The emergency department is a critical point of care for the elderly
and delirium is of particular concern in the chaotic ED environment.
Patients who develop delirium in the ED have been shown to
be at increased risk of adverse outcomes, have a more complicated
clinical course, and a higher likelihood of being sedated to control agitation.
The Care and Respect for Elders with Emergencies (CARE)
program is an ongoing effort jointly developed by the Department of
Geriatric and Palliative Medicine and Department of Emergency
Medicine at The Mount Sinai Medical Center specifically designed to
reduce the incidence of delirium in the ED. CARE adapts the successful
approaches from inpatient volunteer programs to the ED environment.
The goals of this retrospective cohort study were to understand
which elderly ED patients were being visited by CARE
volunteers and to characterize their clinical outcomes compared the
the general elderly ED population for evidence that the volunteer
program was having an impact on delirium. We looked at EMR data
from 8009 visits to the ED by elderly patients over an 11 month period
which included 104 volunteer visited patient visits. We found significant
differences in the ethnic composition of the volunteer visited
and non-visited populations with volunteers less likely to visit Hispanic
patients. Volunteer visited patients had lower ESI scores at
triage (were more urgently ill), had significantly longer ED lengths of
stay, were significantly more likely to be admitted to the hospital and
more likely to return to the ED within 30 days. Despite a seemingly
more complicated clinical course, volunteer visited patients were less
likely to be sedated during their ED visit. The results of this study
agree with the expectation that volunteers are visiting more acutely
ill patients but also raise questions about the selection bias that warrants
further investigation. While the intentional and potentially unintentional
volunteer assignment bias limits the value of comparing
clinical course, the difference in sedation rate suggests that the
CARE volunteer program may be reducing the incidence of delirium
in the ED.
D116
Palliative Care Interventions in Advanced Chronic Diseases: A
Systematic Review.
J. E. Roberts, M. C. Reid, R. D. Adelman. Weill Cornell Medical
College, New York, NY.
PURPOSE: Palliative care’s (PC) potential to improve quality
of life and provide symptom relief has received increased attention,
but it remains unclear how commonly such interventions target diverse
chronic illnesses. This study determines the occurrence and efficacy
of PC interventions for chronic non-cancer and cancer disorders.
METHODS: PubMed, MEDLine, CINAHL and Abstracts in
Social Gerontology were searched (1/80-10/11) where terms included
palliative care, chronic obstructive pulmonary disease (COPD), end
stage renal disease (ESRD), advanced heart disease (AHD) and cancer.
Studies were limited to English-language papers reporting on
multi-component PC interventions for adults with cancer, COPD,
ESRD or AHD. Study quality was assessed.
RESULTS: 1613 citations were identified. 41 met eligibility criteria
and described 35 unique interventions. 21 targeted patients with
cancer, and fewer targeted patients with AHD (n=4), ESRD (n=6), or
multiple diseases (n=4). No study enrolled COPD patients exclusively,
but multiple disease interventions included COPD patients.
Five were RCTs and 30 were observational studies. Four of 30 observational
studies and 4 of 5 RCTs were of high methodologic quality.
Interventions were delivered in inpatient units (43%), outpatient
clinics (51%), and home visits (46%), and by nurses (34%), physicians
and nurses (17%), physicians (6%), or multidisciplinary teams
(43%). The mean number of intervention components was 3.8 (range
2-7), common components included symptom management (77%),
advance care planning (49%), psychological support (49%), and care
coordination (43%). Symptom burden was the most common outcome
(46%), followed by medical care utilization (34%) and care satisfaction
(31%). Fifteen studies reported improvements on all or
most outcomes, 12 reported some improvements, and 1 showed no
improvements. The most common symptom improvements were in
pain (n=9) and nausea (n=7). Advance care planning increased as a
result of interventions in 6 studies spanning all disease categories.
CONCLUSIONS: Most PC interventions continue to target patients
with cancer. While 77% report positive effects, methodologic
quality was judged to be poor and only 14% employed an RCT design.
Over half lacked data on the schedule and intensity of the intervention
sufficient for replication. Research on multi-component PC
interventions targeting chronic non-cancer illnesses and employing
rigorous research methods is urgently needed.
D117
Home Based Transitional Care.
J. Leland, J. Cariaga, D. Davis. James A Haley VA, Tampa, FL.
June Leland MD, Jose Cariaga MD, Darlene Davis MHA
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James A. Haley VA Tampa FL
Background:
Nationally, 20% of veterans discharged from a VA inpatient
care unit are readmitted within 60 days of discharge. As a quality improvement
program, the Tampa VA initiated a Home Based Transitional
Care Program to support discharged veterans during the first
28 days following a hospital discharge.
Program Description:
The program is consult based and provides for an in home visit
by an RN and Kinesiotherapist. The RN visit which occurs within 4
days of discharge includes medication reconciliation, review and reinforcement
of discharge orders, identification of clinical status changes,
offering and coordination of enrollment for chronic care programs
such as CCHT, HBPC, MFH and/ or purchased home care services.
The RN provides follow-up care and case management for up to 28
days. The kinesiotherapist performs a home safety evaluation (environmental
and functional assessments); fall risk assessment, and recommends
or orders necessary equipment for home safety. The team
members provide follow-up care and education for up to 28 days.
Outcomes:
Veterans serve as their own baseline for rate of readmission for
a maximum of 6 months prior to the index discharge during which the
HBTC consult was placed. A readmission rate is established for each
veteran during a time frame equal to the amount of time that has
passed since the veteran was seen by the HBTC team for up to a maximum
of 6 months.
Analysis was completed on 120 patients seen Oct 2010 thru Sept
2011. Readmission rates were reduced by 28% at 14 days, 33% from
15-30 days, and 68% over 30 days. There was a 50% reduction in bed
days of care.
For those evaluated, 53% had medication errors identified, 56%
were recommended additional home services, 39% were issued nursing
supplies, 73% were issued DME, and 100% were educated regarding
medication and home safety.
From program participant surveys:
85% felt comfortable after hospital discharge.
100% felt HBTC staff was professional.
30% claimed HBTC staff taught them something new.
100% endorsed that medications were explained thoroughly.
95% stated that HBTC increased their satisfaction with the VA.
55% claimed that their HBTC visits prevented them from going
back into the hospital.
100% of veterans who were provided with supplies stated that
the usage of equipment or supplies was properly demonstrated.
D118
Multi-faceted effort to improve Hospitalized senior care at a large
Tertiary teaching medical center.
S. Soryal, 1 K. Padua. 2 1. American Geriatrics Society, Milwaukee, WI;
2. geriatrics, Aurora health care, milwukee, WI.
Supported By: non
Our model of care was created to improve senior care in a large
tertiary care hospital focusing on three different efforts.
The first effort is implementing the ACE Concept on almost all
hospital floors. The Acute Care for The Elders concept focuses on
prepared environment with standard equipment for seniors, patientcentered
interdisciplinary care, medical review by a geriatrician as
part of the interdisciplinary team, and early discharge planning. Our
ACE Concept was implemented on sixteen different medical floors
(fourteen of them were medical surgical floors, one medical intensive
care unit, and one inpatient rehab unit).
Geriatricians lead the team utilizing an innovative electronic
medical record tool called ACE tracker, which in real-time identifies
high risks patients for complications in the hospital.
The second effort was the collaboration with the hospitalist
group by attending the morning rounds once a week in a geriatric
hospitalist rounds discussing patients who are in the hospital who are
80 years and older. The geriatrician will also use ACE tracker to identify
high risks patients for complications and use the opportunity as
an educational time for group of nine hospitalist.
The third effort was to start ACE consult service and accept referrals
from admitting physicians to help manage complex patients in
the hospital. Most of the reasons for referrals were to manage delirium,
agitation, dementia, functional decline, frailty, polypharmacy,
identify goals and plans of care, and discharge planning. Physicians
who requested referrals were hospitalist, family practices physicians,
internal medicine physicians, cardiologists, physiatrists, critical care
specialists, neuro-surgeons, and orthopedic surgeons.
After one Year the ACE program showed improvement in
processes of care by decreasing Foley catheter use, reducing restraint
use for non-ICU floors and increase in PT/OT and social
service referrals.
The Geriatrics hospitalist round have helped the hospitalists as
they care for seniors and they expressed their satisfaction thru a survey
conducted.
The ACE program has seen 478 consults in its first Year and
Geriatricians were able to show cost savings for patients seen on consult
service( 252 $ per patient ) and reducing length of stay by one day.
D119
Using Cognitive Screens to Predict Pillbox Organizational Skills.
K. J. Anderson, 1,2 A. Huie-Li, 3 C. Willmore. 4 1. Clinical Pharmacy,
Cross Road Medical Center, Glennallen, AK; 2. Pharmacists Int’l
Consulting Specialists, University Place, WA; 3. Clinical Pharmacy, VA
Connecticut Healthcare System, New Haven, CT; 4. Pharmacology,
Union University, Jackson, TN.
Supported By: This study was funded by Blue and You Foundation
for a Healthier Arkansas.
Background:Proactive assessment of medication management
skills can mitigate adverse medication-related events thereby reducing
incidence of emergent care or exacerbation of chronic
disease.Brief cognitive/pillbox skill screens were correlated with pillbox
loading accuracy for predictive value using the patient’s medications.Methods:We
conducted a prospective, cross-sectional, pilot
study in a rural primary care clinic.Inclusion criteria:diagnosis of diabetes
and ability to load a pillbox with >1 medication. Cognitive/literacy/pillbox
skills screens were administered during 3 visits over a ~6
mo period.Pillbox assessment (personal medications loaded in a 28-
compartment pillbox) was initiated when the patient presented with
medications. Average completion time was ~30 min scored by Pillbox
Fill (PBF) method.Screens administered: Mini-Cog=Three Item Recall
and Clock Draw Test (short and long-term memory); Medication
Transfer Screen=MTS (decipher 4 prescriptions, sequence and locate
pills in a pillbox, count); Medi-Cog=Mini-Cog+MTS, Medication
Safety Screen=MEDScreen (Three Item Recall and MTS SF - abbreviated
2-question MTS); 4 o’clock screen=FIR+CDT+AFS (Four Item
Recall, Clock Draw Test, and Animal Fluency Screen); and MTS-
Bean Fill=MTS BF (decipher 4 prescriptions, sequence and locate
beans in a pillbox, count).Results: Forty-nine patients completed the
study: ave age 60, (range 36-84 yrs); 55% AA and 45% White; 71% F;
47% with

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D120
Geropsychiatric NP Practice in LTC: Not Just a Med Check.
K. A. Bickerstaff, G. Rogers, C. Chaperon. Community Based
Health, University of Nebraska Medical Center College of Nursing,
Omaha, NE.
Supported By: HRSA Grant 1 D62 HP 15054-01-00
Purpose: This pilot study examined the effectiveness of a
Geropsychiatric Nurse Practitioner in a Long Term Care facility.
Background: Older residents of long term care facilities have
numerous challenging unmet physical and mental health needs. Medications
are frequently used as a rapid resolution to manage mood
and behavioral symptoms. Studies have shown that many of the medications
available are not appropriate for a population over the age of
65. Among the adverse effects can be delirium, life-threatening side
effects, and serious drug-drug interactions as well as a decrease in active
socialization.
Methods: Core interventions that all participants received were
a gold standard comprehensive psychiatric exam and review of all
psychotropic medications. Validated tools used included MDS3
BIMS, MDS3 Behavior, MDS3 Mood, and MDS3 ADLs during time
period of one year.
Design: Retrospective Chart Review of 10% of randomly selected
residents seen by a Geropsychiatric NP in a long term care facility
over a one year period.
Setting: A corporately owned, 150 bed, inner city skilled nursing
home in a large mid-western city.
Population: N=14 long term care facility residents over age 65
seen after referral by staff for evaluation and treatment of cognition,
mood, or behavioral symptoms.
Outcomes:
1. Numbers and types of psychotropic medications used.
2. Mental health modalities ordered by Geropsychiatric NP:
non-pharmacological interventions, cognitive therapy, and increased
socialization.
3. MDS3 Domains of Cognition, Behavior, and ADL function
over a one year period.
Preliminary Results: Analysis of MDS3 records for 3 residents
show positive trends of improved mood and behavior while maintaining
cognition and function. Overall unnecessary psychotropic medications
were eliminated or doses reduced on average of one med discontinued
and 1.3 dose reductions per resident. Each resident had
one added psychotropic medication during the year appropriate for
current symptoms at the time. Each resident received individualized
cognitive, behavioral, and socialization therapy on a monthly basis by
a Geropsychiatric NP.
Conclusion: Geropsychiatric NP intervention may decrease unnecessary
medication use among elderly residents of long term care
facilities and improve both mood and social behaviors.
Key Words: geropsychiatric, nursing, practice
D121
The importance of medication reconciliation in post-hospitalization
patients in an ambulatory geriatric clinic in Singapore.
K. Tan, T. Tan. Department of Geriatric Medicine, Tan Tock Seng
Hospital, Singapore, Singapore.
Even though medication reconciliation is an essential part of
clinical practice, it is often neglected in a busy ambulatory practice.
Older adults who had a recent hospitalization for acute illnesses often
had their medications changed or doses adjusted during the hospital
stay. With these changes, older adults may face medication-related
problems which may lead to poor outcomes if not addressed.
Objective:
To investigate the incidence of medication discrepancies and
medication related problems in older adults post hospitalization.
Methods:
All patients with scheduled appointment at the outpatient geriatric
medicine clinic at Tan Tock Seng Hospital were screened for a
recent admission (within the prior 3 months).
Patients identified were interviewed by a clinical pharmacist on
the day of the appointment prior to their doctor’s consultation. Any
medication discrepancies as compared to the discharge medication
list and medication-related problems noted during the interview will
be highlighted to the patient’s physician. These issues will be examined
in this pilot study.
Results:
295 patients (65.4% female, mean [S.D.] age, 82.3 [7.8] years)
were reviewed between the months of November 2010 to June 2011.
146 patients (49.5%) have 1 or more medication discrepancies detected
during the interview by the pharmacist.
Medication discrepancies due to medication changes by patients
or their caregivers accounted for 58.9% of the discrepancies identified.
These discrepancies include omission of medications that should
be continued (54.3%), failure to discontinue medications that were
stopped during the admission (22.8%), and administering medications
at the wrong doses or frequency (22.8%).
The remaining 41.1% of the medication discrepancies were secondary
to prescribing or dispensing errors made during hospitalization
(40.0%) or changes made by physicians from another specialty
(21.7%) or institution (38.3%) after the discharge from the hospital.
Conclusion:
Medication discrepancies are highly prevalent in older adults in
the post-hospitalization period. Medication reconciliation is an essential
tool at identifying these discrepancies so that it can be addressed
to improve patient safety and quality of patient care.
D122
Clostridium difficile-Associated Disease Recurrence in US Long
Term Care Facilities.
H. Friedman, 1 P. Navaratnam, 1 G. Reardon, 2 K. P. High, 3 M. Strauss. 4
1. DataMed Solutions LLC, Hillard, OH; 2. Informagenics, LLC,
Columbus, OH; 3. Wake Forest School of Medicine, Winston Salem,
NC; 4. Optimer Pharmaceuticals, Inc, San Diego, CA.
Supported By: Optimer Pharmaceuticals provided funding for
this study.
Howard Friedman, Prakash Navaratnam, and Gregory Reardon are
paid consultants engaged by Optimer. Marcie Strauss is an employee
of Optimer. Kevin P. High served on the Optimer Advisory
Council and is a consultant for Optimer.
BACKGROUND: Predictors of recurrent Clostridium difficileassociated
disease (rCDAD) and its association with patient characteristics,
resource utilization, and outcomes in the long term care
(LTC) setting were assessed. METHODS: Demographics, Minimum
Data Set (MDS) 2.0 assessments, and pharmacy records of residents
were analyzed (AnalytiCare LTC database). Residents with an MDS
CDAD code (1/01/07–9/30/10; earliest=index date), ≥1 MDS assessment
≤120 days both pre-and post-index, and metronidazole (MET)
or vancomycin (VAN) received ±7 days of index date were included.
Patients were censored at the earliest of: discharge with no re-admission
≤30 days, latest MDS+90 days, end of study, or death. rCDAD
was defined as MET or VAN being dispensed after >28 day washout
after last fill/refill for the initial episode. Descriptive statistics were
used to compare patient characteristics and resource utilization between
rCDAD and non-rCDAD cohorts. Cox proportional hazard
analysis of index drug cohorts were constructed to identify predictors
of time to recurrence. RESULTS: Of 1145 selected CDAD patients,
225 (19.7%) had ≥1 rCDAD before censoring. Mean age (77–78 y)
and Charlson Comorbidity Index scores (mean=3.0) were similar for
both rCDAD and non-rCDAD cohorts. Prevalence of 26 different comorbidities
was also similar for rCDAD and non-rCDAD cohorts;
most common were recent urinary tract infection (54% and 51%, re-
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spectively), diabetes mellitus (40% and 45%), and congestive heart
failure (31% and 37%). The rCDAD cohort had an 86% longer preindex
length of stay (LOS) in the LTC facility (P

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In addition to 7 specific factors that patients identify as probable
cause, a miscellaneous category exists for qualitative explanation.
Furthermore, objective factors such as number of prescribed medications,
primary care visit between hospitalizations, and mental health
or cognitive diagnoses are also tracked for these individuals.
Results: While no specific factors have been isolated as a primary
cause for readmission, patient feedback such as pre-mature discharge,
quality of post-discharge care, and medication issues are
being reviewed. Preliminary results show patients believe their condition
will require readmission (28.33%) while some patients believe
they were discharged prematurely (26.67%). When paired with the
objective data collected as noted above, we surmise that embracing
the patient and family perspective in discharge planning may reduce
the likelihood of their readmission.
Conclusions: Bringing the patient and family’s perspective into
care promotes a holistic approach to healthcare that enhances successful
discharge planning. The role of social work in completing
these assessments from a psychosocial perspective has been a successful
model in our institution in obtaining this information as they
are then also able to implement clinical interventions and connect
persons with appropriate resources that will reduce the likelihood of
a readmission.
D126
Identification of medication discrepancies in discharge paperwork
among patients in the CO-OPERATE Geriatrics/Surgery comanagement
program.
L. M. Walke, 1,2 R. A. Rosenthal, 1,2 M. F. Perkal, 1,2 S. Jeffery, 1,3
M. Maiaroto, 1 R. Marottoli. 1,2 1. VA Connecticut, West Haven, CT; 2.
Yale School of Medicine, New Haven, CT; 3. Univ of CT, Storrs, CT.
Background: Accurate communication regarding medication
regiments is critical to efforts to decrease preventable rehospitalizations
as older adults transition across treatment environments. Electronic
medical records (EMR) can improve communication between
providers and patients but discrepancies in medication list documentation
may thwart these efforts.
Aim: To describe the prevalence of medication discrepancies in
the documentation provided to surgical patients and nursing agencies
or facilities at discharge.
Methods: Surgery patients aged ≥70 years with an expected
peri-operative course ≥ 48 hours are eligible for CO-OPERATE, a
co-management program between geriatrics and surgery. The geriatrics
team consists of a geriatrician, geriatric NP and clinical pharmacist.
We examined the EMR of CO-OPERATE patients discharged
home with nursing services or to nursing facility for
discrepancies in the medication lists included in the patient discharge
instructions and the W10. A medication discrepancy was defined as
the omission of a medication on either list or differing dosing instructions.
Various surgical subspecialties participate in CO-OPERATE
including General Surgery, Cardiothoracic, Orthopaedics, Plastics,
Urology, and Vascular.
Results: The average age of our patients was 83.5 years. All were
discharged on ≥5 medications; 65% received ≥10 medications. In the
first year of the program, ≥1 medication discrepancy between the
W10 and patient discharge instructions was noted for 30% of patients
regardless of the number of medications prescribed. Discrepancies in
documentation occurred most frequently for pain medications, antidepressants,
and vitamins to supplement deficiencies.
Conclusion: Almost two thirds of the surgical patients in our comanagement
program were discharged with ≥10 medications; discrepancies
in documentation varied by medication class. Determining
if other factors contribute to discrepancies, and grading the severity
of discrepancies, may help target our quality improvement efforts.
Redesigning the EMR to alert clinicians of discrepancies in discharge
documentation could improve communication between providers
while aiding efforts to decrease adverse drug effects and preventable
hospitalizations among older adults transitioning through the continuum
of care.
D127
Breaking Down the Silos in Geriatric Inpatient Care.
L. Tank, M. Parulekar, J. Previdi, N. Benoit, A. Sarkar, L. Mansour.
Geriatrics, Hackensack University Medical Center, Hackensack, NJ.
Background: Incidence of delirium is high in elderly patients
and it is associated with increased mortality and morbidity and increases
length of stay.
Objective: To integrate Hospital Elder Life program (HELP) in
Geriatric Service Line (GSL) to improve perceptions of care, treatment
and services for geriatric patients (age 70yrs and over) by preventing
delirium, functional decline and length of stay (LOS) in hospital
setting.
Method: The GSL with HELP presented a proposal for disease
specific certification (DSC) for Joint Commission on the Accreditation
of Healthcare Organization (JCAHO).Random sample of 40 patients
per month on 6 HELP units were enrolled using the inclusion
criteria (70 year or older with at least one risk factor such as cognitive
impairment, mobility impairment, vision impairment, hearing
impairment, dehydration, and should be able to communicate verbally
or in writing) through nursing assessment, in multidisciplinary
rounds, and/or by chart review. Metrics included were number of indwelling
urinary catheter days, fall and pressure ulcer rate and use of
psychotropic medication (Haldol, Ativan, Ambien, and Benadryl)
and LOS.
Results: Data was collected from January–August 2011.The
mean indwelling Foley days was 3.4, mean fall rate was 0.6%, pressure
ulcer rate was 0.3%, mean rate of psychotropic meds used was
13.75% and LOS was 3.7 on HELP units as compared to 6.2 on other
units (40% reduction).
Conclusion: The GSL in addition to the multidisciplinary team
has HELP volunteers which has made this a unique model and has
received the distinct honor by JCAHO for disease specific certification
in geriatrics, 1st in the nation.
D128
MEDICAL SERVICE USE IN DEPRESIVE PATIENTS
RECRUITED AT A COLLABORATIVE CARE
MANAGEMENT PROGRAM IN AMBULATORY ELDERLY.
M. Schapira, M. Smietniansky, M. F. Albornoz, P. Hernan,
D. Matusevich, C. Guerra, J. Esteban, M. E. Ramos, L. Camera.
Hospital Italiano de Buenos Aires, Buenos Aires, Argentina.
Supported By: Hospital Italiano de Buenos Aires
CONTEXT: Depression is a common disorder among older
adults sustaining high morbidity, mortality and health care utilization.
Nonetheless, depression remains underdiagnosed and undertreated
leading to adverse outcomes.
In a previous interventional study, we demonstrated that using a
managed care approach depression a reduction of the depressive
symptoms in our population. However, we did not evaluated outcomes
related to medical service use.
OBJETIVES: To determine the rates of medical services utilization
including consults and in depressive patients recruited from our
“Collaborative Care Management Program”.
METHODS: A before/after study was designed to assess the impact
of multifactorial interventions in older adults with depression.
PARTICIPANTS: 91 patients aged 65 and older referred to the
program by primary care physician, with a diagnosis of clinical depression
at baseline assessment. Age mean 77 years. Female 72%.
Intervention: Patients were recruited for an initial comprehensive
geriatric evaluation. Intervention patients had bimonthly followup
visits, social evaluation, access to psychiatric consultation, support
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of antidepressant management and/or psychotherapy, weekly phone
interviews to assess the course of the symptoms and/or detect any
other problem, and weekly round case discussion with multidisciplinary
team.
Main outcomes measures: Medical records were reviewed from
one year prior to and one year after the recruitment in order to
measure overall consultations, consultations wih primary care physicians
and specialists, consultations to emergency room (ER) and
hospitalizations.
RESULTS: Overall the following outcomes were significantly
reduced in the intervention group: consultations (p=0.001); consultations
with primary care (P=0.001);consultations with specialists
(P=0.002) and admission at ER (P=0.004) . There was not significantly
reduced in hospitalizations.
CONCLUSIONS: Our findings suggest that the intervention
could be effective in reducing health care utilization. These findings
are beyond the improving achieved in depressive symptoms as was
previously proved in our setting.
D129
Does a Palliative Care Consult decrease the cost of caring for
hospitalized patients with Dementia?
M. Araw, 1 C. Araw, 1 T. Mir, 1 T. Liberman, 1 M. Saad, 2 L. Corrado, 1
C. Sison, 3 G. Wolf-Klein. 1 1. NSLIJ Health System, New Hyde Park,
NY; 2. St. John’s University, Queens, NY; 3. Feinstein Institute for
Medical Research, Manhasset, NY.
Introduction: Caring for the 5.4 million Americans with
Alzheimer’s dementia (AD) is estimated at 183 billion dollars/year.
The study aims to compare the impact of a Palliative Care Consult
(PCC) on the pharmacy cost in hospitalized AD patients.
Methods: Retrospective study of hospitalized elderly patients
with end stage dementia who received a PCC between January 1,
2010 and October 1, 2011. Statistical methods used were Signed-rank
test and McNemar’s test.
Results: Of the 60 patients studied, average age was 86 (range:
70-100) with 27% male and 73% female, 54% white and 20% black.
Eighty seven percent were discharged; 37% of the discharged patients
were transferred to skilled nursing facilities and 22% went
home with home care services or with home hospice (18%). Most patients
(70%) had DNR with 38% signing after PCC. Median time between
date of admission and PCC was 3 days (range: 1-25). When
comparing pharmacy cost before and after PCC, the average cost per
patient per day prior to PCC was $31.16 ± $24.71 and $20.83 ± $19.56
post PCC (p=.003). When looking specifically at pharmacy cost per
category before and after PCC, antibiotic class cost was $9.32 ± $14.94
vs. $6.42 ± $10.65; cardiac medication class cost was $1.15 ± $2.75 vs.
$0.71 ± $1.36; analgesic class cost was $1.36 ± $5.07 vs. $2.35 ± $5.35
(p

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D132 Encore Presentation
A multicomponent delirium management program improves
functional outcomes in hospitalized older persons.
M. Chong, 1 M. Chan, 1 L. Tay, 1 J. Kang, 2 H. Han, 2 Y. Ding, 1 T. Tan. 1 1.
Department of Geriatric Medicine, Tan Tock Seng Hospital,
Singapore, Singapore; 2. Nursing Service, Tan Tock Seng Hospital,
Singapore, Singapore.
Supported By: This study was funded by Ministry of Health
(Singapore) Health Quality Improvement Fund (HQIF)
Introduction:
Delirium is associated with poor survival, functional outcomes
following acute hospitalisation episode. The Geriatric Monitoring
Unit (GMU) models after the Delirium Room with adoption of core
interventions from Hospital Elder Life Program and use of evening
bright light therapy to consolidate circadian rhythm and improve
sleep. This study set out to examine if this multicomponent GMU
program improved outcomes in delirious elderly patients compared
to usual care.
Methods:
We studied delirious patients (pre-GMU) admitted to geriatric
department one-month before GMU implementation (n=47) and recruited
GMU patients over an 11-month period (n=84). Baseline demographics,
Charlson comorbidity and severity of illness index (SII),
duration of delirium, functional status (modified Barthel Index
(MBI) on admission/ discharge), falls, physical injuries, pressure ulcer
and nosocomial infection rate were collected.
Results:
Significant male preponderance were noted with slightly higher
Charlson comorbidity (3.6 vs 2.1), SII score (2.2 vs 2.1) and pre-existing
dementia (72.3% vs 66.7%) in GMU patients. GMU patients had
significantly shorter delirium period compared to pre-GMU patients
(7.6 vs 15.1 days). GMU patients showed greater functional improvement
on MBI (19.3+1.9) compared to pre-GMU patients (7.5+11.2).
No patients in GMU were physically restrained compared to 44.7% in
the pre-GMU group. Falls rates were similar in both groups with no
injuries sustained. GMU patients had a significantly lower pressure
ulcer (61.7% vs 1.2%) and nosocomial infection rate (23.4% vs 1.2%).
Conclusion:
This study shows initial evidence for benefits of multicomponent
delirium management program. It adheres to geriatric principles
of restraint-free environment while addressing patient safety concerns.
Clinical benefits included shorter delirium duration, increased
functional gains with decreased complications of immobility.
D133
Innovative Home-Visit Based Medicine Resident Curriculum
Decreases CHF Patients’ 30-Day Readmissions & Improves Patient
Education.
O. B. Lahoud, 1 A. Siddique, 1 S. Goldberg, 1 M. Hecht. 1,2 1. Internal
Medicine, Maimonides Medical Center, Brooklyn, NY; 2. Division of
Geriatrics, Maimonides Medical Center, Brooklyn, NY.
Background: Improving transitional care from hospital to home
has been a focus of CMS to reduce costs and readmissions. Naylor
and Coleman showed improvements in transitional care in chronic
care patients; a review by Buchanan outlines teaching interventions
involving residents. Record reported decreased readmissions in CHF
patients via a resident education curriculum involving phone call follow-ups
to patients post-discharge. We propose a resident curriculum
model focused on patient education and home visits.
Methods: Maimonides Medical Center developed an 8-week
curriculum for medicine residents with 3 primary goals: 1)Improve
patient education via IHI Teach Back Method using a 4-item questionnaire,
2)Educate residents on optimal CHF management based
on ACC/AHA guidelines, 3)Involve residents in PI, 4)Visit patients at
home to ensure safe transition and provide further patient education.
Results: We demonstrated 1)Improved patient education, 2)Decreased
CHF patients 30-day readmissions, 3)Improved Resident
transitional care knowledge (data not shown).
Conclusion: A curriculum focused on transitional care can be
implemented in a residency program to improve CHF patient education
and readmission rate via emphasis on teach back and home visits.
We are currently investigating this model in other chronic diseases.
References: Jencks et al. NEJM 2009;360(14):1418-1428.
Naylor et al. J Am Geriatr Soc. 2004;52(5):675-684.
Coleman. J Am Geriatr Soc. 2003;51(4):549-555.
Buchanan et al. Acad Med. 2011;86:628-639.
Record et al. Arch Int Med. 2011;117(9):858-859.
D134
Geriatric Palliative Care- A two year review of a new service.
M. Lerch. Geriatric Dept., Protestant Hospital Bethanien Iserlohn,
Iserlohn, Germany.
Background:The demographic change does not only alter the
approach to rehabilitation and geriatric care but also indicates the
need for a different view concerning end-of life policies for the elderly
and the oldest old. In conventional palliative care settings elderly
patients and there needs are not rarely insufficiently represented.
Therefore two years ago our clinic implemented a new geriatric
palliative care service on a redesigned 6 bed ward to cater for this
clientele bringing together the geriatric team effort and the palliative
knowledge and training for the senior patient
Methods: Review of the geriatric palliative patients considering
age, sex, main diagnosis, main symptoms that led to the admission,
number of admissions and discharges in to home care, scores
for self-sufficiency (Barthel), disease progress (ECOG), pain (VAS),
depression(GDS), cognition (MMST, Clock completion) and nutrition
(MNA)
Results: From September 2009 until September 2011, 91 palliative
care patients (52 male, 39 female) with a mean age of 72,4, were
admitted into the new service, with a return rate of 1,6. 58 were able to
return to a self-determined life.The mean stay was 12,4 days.Approx.
91 % of the admissions were due to a cancer (lung 20,9%, abdominal
17,3%, prostate 12,7%, 41 % various cancer varieties), 5,4 % were
due to cardiovascular diseases and 2,7 % due to end-stage dementia.
The main symptoms that led to the admission were pain, nausea
and cachexia. The mean Barthel score at admission was 50,2 and 52,1
at discharge, the mean GDS was 6,79, the mean MMST 21,1 and the
clock completion test 3,6, where as the nutrition was low with a MNA
of 6,31
Conclusions:Geriatric patients with an end-of life situation, especially
those without a cancer, are in need of a multiprofessional
geriatric team to address immobility and lack of self-sufficiency and
the cognitive decline as well as the pain relief, symptom control and
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nutrition. In this combination a temporal or permanent return to the
home care setting and a self-determined life is feasible even in the
oldest patients and the growing number of patients with cardiovascular
diseases and dementia
D135
A Retrospective Case Control Study Comparing Actual Total Costs
of Acute Care for Elders (ACE) Interdisciplinary Consult Team
Patients with Matched Controls at the University of Wisconsin
Hosptial and Clinic (UWHC).
M. J. Siebers, 1,2 M. Brenny-Fitzpatrick, 3 A. Bhattacharya. 3 1. Division
of Geriatrics and Gerontology, University of Wisconsin School of
Medicine and Public Health, Madison, WI; 2. GRECC, Middleton VA
Hosptial, Madison, WI; 3. University of Wisconsin Hosptial and
Clinics, Madison, WI.
The ACE interdisciplinary team has consulted on patients at the
UWHC since 2006. The UWHC is a teriary care teaching hospital.
The ACE consult team sees hospitalized patients over the age of 64
years at the request of the attending physician on each ward service.
The ACE team consists of a full-time advanced practice RN and a
part-time team pharmactist, social worker, geriatrician and physical
therapist. The geriatrician’s time is supported by billings from the
ACE consult; other team members are supported by the UWHC. The
ACE team consults on patients 5 days a week and meets weekdays to
review each ACE consult patient both for the initial evaluation and
follow-ups. The ACE program has seen 1807 ACE consult patients
through June 2011. From the 1192 intial ACE team consults on
unique patients, 382 ACE consult patients were matched with hospitalized
control patients for age within 5 years, gender, severity of illness
(3M APRDGR), primary DGR and year of hosptial stay. The
cases and contols were compared by activity based accounting for actual
total costs and length of stay (LOS). The average actual total cost
for the hospital stay was $3,039 less for the patients seen by the ACE
interdisciplinary consult team than it was for the matched controls (pvalue=0.006).
The LOS was 0.13 days less for the ACE interdisciplinary
consult patients compared to controls (NS). For the 1194 unique
ACE consult patients seen, the ACE team consultation saved
$3,622,488 in total actual costs since 2006 or $695,295.20 in cost reductions
per year. The savings for the hospital was over $500,000 per
year when the cost of the ACE interdisciplinary program (primarily
the salaries of the professionals on the ACE team) was taken into account.
The total actual cost savings for the ACE team consult is
clearly not all related to reduction in the LOS. Medication changes
for the ACE consults are the most common recommendation. They
may account for some of the ACE interdisciplinary consult team’s reduction
in total actual cost for each elderly patient seen in the hospital.
We believe that geriartic care is improved at UWHC, not just
money saved, by the ACE consult.
D136
Delirium Prevention Protocol Implementation in the Acute Care for
the Elderly (ACE) Unit: Using a Culturally Competent Approach
and Quality Improvement Tools.
M. Dang, 1 S. Oakes, 1,2 I. Rohner. 2 1. School of Medicine, UTHSCSA,
San Antonio, TX; 2. Acute Care of the Elderly (ACE) Unit, Christus
Santa Rosa- City Centre, San Antonio, TX.
Supported By: MSTAR, AFAR.
Aim: To increase the utilization of the cognition and mobility
components of the delirium prevention protocol to 90% in the next 3
months at the ACE unit at Christus Santa Rosa City Centre by using
a culturally competent approach.
Background: Delirium is a major problem in hospitals. Prevention
is a key component and using quality improvement tools and culturally
competent approaches to prevent delirium enhances patient
care. Interdisciplinary teams are vital in order to make sustainable
changes towards patient safety. Due to the lack of attention in preventing
delirium, especially in culturally Hispanic settings, this project
focuses on engaging both English and Spanish speaking patients and
their families.
Methods: An inter-professional task force was formed at the
ACE unit. Using quality improvement tools, pre and post intervention
methods were as follows: a “fish bone” analysis was done to identify
barriers in delirium prevention and observations on the staff’s
cognition and mobility strategies were measured. After team analysis,
a focus on education and family involvement were chosen for interventions
consisting of nurse training sessions on utilization of the
mini-cog exam. Furthermore, medical students were trained to do the
CAM (confusion assessment method) on all admissions and bilingual
white boards with the 6 areas of the prevention protocol to use as
part of the hourly rounds were designed to educate patients and caregivers
as well as bilingual brochures on delirium.
Results: Compliance increased for the mobility protocol from
0% to 80%. Engaging the patient/family in stimulating activities increased
from 0% to 67%. Using the CAM to screen for delirium increased
the least from 0% to 23%. Compliance in orienting the patient
to date and/or location increased from 0% to 58% with the
second highest increase and compliance in orienting the patient to
person increased from 28% to 68%.
Conclusions: The prevention protocol relies heavily on individuals
rather than being inherent to the system, as seen in compliance to
the CAM. Results also showed that families are more involved if the
language barriers are addressed. Tools that are bilingual can facilitate
care of the patient and standardization of educational tools for the
student learners rotating in the ACE unit is vital.
D137
Prevalence and Correlates of Alcohol Use Among Older Taiwanese
Adults: Analyses of the 2005 Taiwan National Health Interview
Survey (NHIS).
J. C. Lin, 1 A. A. Moore. 2,3 1. Internal Medicine, Cheng Ching Hospital,
Taichung, Taiwan; 2. David Geffen School of Medicine, UCLA, Los
Angeles, CA; 3. Integrated Substance Abuse Programs, UCLA, Los
Angeles, CA.
Background: Correlates of alcohol use have been examined extensively
among younger adults and older adults; however, most studies
have not included large samples of older Asian adults. This study
evaluated the prevalence, socio-demographic, and health-related correlates
of alcohol use among older Taiwanese adults using data from
a national survey.
Methods: Study sample included 2,727 individuals 65 years and
older who participated in the 2005 NHIS, a cross-sectional survey of
nationally representative household samples in Taiwan. Alcohol use
was categorized into abstainers, infrequent drinkers (1-2 times per
month), weekly drinkers (1-3 times per week), and daily drinkers.
Due to small sample sizes, a category of frequent drinkers was created
that combined weekly and daily drinkers for regression analyses.
Multinominal logistic regression was performed to determine the
socio-demographic and health-related correlates of the different categories
of alcohol use.
Results: Almost 80% of older Taiwanese adults were abstainers,
10.2% were infrequent drinkers, 3.5% were weekly drinkers, and
6.5% were daily drinkers. Individuals who were younger, male, those
with good or better self-perceived health, and current smokers had
increased odds of being drinkers. Individuals with more years of education
had increased odds of being infrequent drinkers compared to
those with lower education; however, this association was not observed
among the frequent drinkers. Individuals who were former
smokers or current betel nut users had increased odds of being frequent
drinkers compared to abstainers.
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Conclusions: There were similarities between the socio-demographic
and health-related correlates of alcohol use among older Taiwanese
adults and older adults from other ethnicities. Former or current
use of other substances was also associated with more frequent
alcohol use. Future studies should evaluate whether the effect of alcohol
use on health-related outcomes among older Asian adults
would differ from older adults of other ethnicities.
D138
Quality of Hospice Care for Patients with Dementia.
J. Albrecht, 1 J. C. McGregor, 2,3 E. K. Fromme, 3 D. S. Lee, 2,3
J. P. Furuno. 2,3 1. University of Maryland, Baltimore, MD; 2. Oregon
State Univeristy, Portland, OR; 3. Oregon Health & ScienceUniveristy,
Portland, OR.
Background: Patients with dementia comprise an increasing
percentage of hospice recipients; yet research on the quality of hospice
care for patients with dementia is lacking. We used data from the
2007 National Hospice and Home Care Survey (NHHCS) to compare
quality of care in dementia patients to all other hospice patients.
Methods: The 2007 NHHCS is a nationally-representative sample
of 4,733 U.S. hospice discharges. Data were collected through inperson
interviews with agency directors and staff and patient medical
records. A current primary diagnosis of dementia was defined as
ICD-9 codes: 290.0, 290.42, 294.8, 294.9, 331.0, 331.11, 331.4, 331.82,
and 331.9. Quality indicators were compared between patients with
and without dementia. These include: transfer to hospice in the last 3
days of life, tube feeding, depression, absence of an advanced directive
or do not resuscitate (DNR) order, stage II or greater pressure
ulcers, use of emergent care, antibiotic receipt, continuity of residence
and pain reported at last assessment. All estimates were weighted to
account for the survey’s complex sampling design. Chi-square and
Student’s t-tests were used for comparisons, and statistical significance
was defined as p

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physicians. Implementation of strategies to improve recognition of
cognitive impairment may improve care of these patients, particularly
at the time of hospital discharge.
D141
Arizona Alzheimer’s Registry: Strategy and Outcomes.
K. T. Saunders, 1 C. Holt, 2 J. B. Langbaum, 2 W. Chen, 2 N. High, 2
C. Langlois, 2 M. Sabbagh, 3 P. N. Tariot. 2 1. College of Medicine,
University of Arizona, Phoenix, AZ; 2. Banner Alzheimer’s Institute,
Phoenix, AZ; 3. Banner Sun Health Research Institute, Sun City, AZ.
Supported By: NIA ADCC P30 AG19610, State of Arizona
Medical Student Training in Aging Research (MSTAR) Program
Background: The Arizona Alzheimer’s Consortium (AAC) is a
statewide Alzheimer’s disease (AD) research consortium funded by
NIA and the state of Arizona. In 2007 the AAC created a screening
and referral process for people interested in participating in AD related
research, as well as a relational database called the Arizona
Alzheimer’s Registry (AAR). The goals of the AAR were to increase
awareness of AD research and accelerate enrollment into AAC clinical
research projects. The AAR matched Registrants to AAC research
according to interest, location, and eligibility.
Methods: Enrollment was by open invitation to volunteers age
50 and older. Registrants were recruited by community outreach,
mass mailings, earned and paid media, and the Internet. Those interested
received a welcome packet, consent, and questionnaire, which
were reviewed by trained staff via telephone prior to brief cognitive
screening. Evaluation of medical history, cognitive status, and interests
resulted in the Registrant being referred to existing AAC studies
or being held for future referral.
Results: 2263 people contacted the AAR; all but 231 were given
a welcome packet. 1257 consented and 1182 underwent an initial cognitive
screening. Earned media was the most effective recruitment
strategy. Participants had a mean age of 68.1 (SD 10.6), 97% were
Caucasian, had 15.2 (SD 2.7) mean years of education, and 60% were
female. 30% reported a family history of dementia, 20% reported a
diagnosis of cognitive impairment or dementia, and 70% subjectively
reported normal cognition. The initial telephone assessment revealed
681 with no impairment, 269 with possible cognitive impairment, and
234 with possible dementia. 301 were referred to AAC sites.
Conclusion: The AAR exceeded its goals of increasing awareness,
Registry recruitment and research referral. This model was well
received by the community and served as a mechanism for volunteers
to explore their own cognitive status while making a contribution to
the scientific community. The established infrastructure and experiences
gained from the AAR will serve as the prototype for the webbased
Alzheimer’s Prevention Registry, a national registry focusing
on AD prevention research.
D142
Prevalence of Disruptive Behaviors Among PACE Participants.
K. Kwak, 1 M.Trahan, 2 M. McNabney. 2 1. Stony Brook University
School of Medicine, Stony Brook, NY; 2. Division of Geriatric
Medicine and Gerontology, Johns Hopkins University, Baltimore, MD.
Supported By: Johns Hopkins University; MSTAR Program
Background: Disruptive behaviors occur in approximately 63%
of adult day center participants. The Program for the All-inclusive
Care of the Elderly (PACE) is a capitated and comprehensive service
delivery system for older adults. PACE participants attend an adult
day center where all care is coordinated and provided in order for
participants to continue living in the community. The rate of disruptive
behaviors among a PACE population is unknown.
Objective: To study the frequency and type of disruptive behaviors
typically displayed among PACE participants.
Methods: This study took place at one PACE location in Maryland.
To measure disruptive behaviors in PACE participants, we used
the Cohen-Mansfield Agitation Inventory-Community (CMAI-C),
consisting of 36 agitation items.
Results: One hundred forty-two PACE participants (79% female)
were included in the study. Dementia was present in 67
(47%) participants. Among all the participants attending the PACE
day center, 35.9% (45% with dementia and 28% without dementia)
displayed at least one disruptive behavior once a week. The
most frequently rated disruptive behavior was verbally non-aggressive
behaviors (e.g., constant, unwarranted requests for attention,
restless).
Conclusions: PACE dementia participants display less disruptive
behavior than seniors attending traditional day centers and residents
living in nursing homes. From a psychosocial perspective, these
results suggest that PACE might be better equipped to meet the physical,
emotion, or social needs of participants when compared to traditional
models of care.
D143
Guideline quandary in VTE prophylaxis management in elective
joint replacement.
J. Prager. Geriatrics, Mount Sinai Hospital, New York, NY.
Introduction:
Managing VTE prophylaxis from an evidence based approach,
guidelines have been created from within both the American College
of Chest Physicians (ACCP) and the American Academy of Orthopedic
Surgeons (AAOS). Elective joint replacement epitomizes multidisciplinary
care between orthopedics and internists to manage VTE prophylaxis
concurrently while following conflicting recommendations.
Case:
An 85 year old female with a history of osteoarthritis presented
to a tertiary care center for a scheduled left total hip arthroplasty for
worsening symptoms of osteoarthritis. Patient was admitted to the orthopedic
service. Post-operative day 0, patient was started on aspirin
325mg BID for 35 days for VTE prophylaxis. On post-operative day
9, patient’s hemoglobin had steadily decreased to 8.3 g/dl from a
baseline of 12.7 g/dl. Patient was transfused 1 unit of packed red
blood cells. Patient was discharged home with instructions to follow
up with primary physician. Prior to patient’s appointment, patient
called the primary physician’s office on a Saturday reaching the on
call provider describing asymmetric leg swelling of post-operative
leg. The on-call physician recommended for the patient to go to emergency
room for evaluation for VTE, which was negative on ultrasound.
Discussion:
The ACCP recently updated VTE prophylaxis in 2008 categorizing
elective joint replacement as a high risk procedure necessitating
low molecular weight heparin i.e. enoxaparin, fondaparinux, or warfarin
with an INR goal of 2.5. ACCP recommends against aspirin as
VTE prophylaxis for elective joint replacement. Orthopedic concerns
rest heavily on the underestimation of bleeding complications with
evidence showing a 9% bleeding risk with 10 day course of ACCP
recommended VTE prophylaxis coupled with 4.7% readmission rate
in a study of 290 patients. AAOS recommendations are founded on
evaluating patient’s risk of VTE combined with risk of bleeding. Aspirin
remains as a treatment despite randomized controlled trials
demonstrating superiority of low molecular weight heparin in secondary
outcomes. Who should manage VTE prophylaxis? The longstanding
internist or the current orthopedic surgeon? With the advent
of newer agents i.e. rivaroxaban, the interest of patient safety is paramount
to arrive at a unifying management protocol to decrease VTE
post elective joint replacement while minimizing peri-operative
bleeding.
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D144
The Use of 308nm Excimer Laser as an Effective and Safe
Treatment for Psoriasis in the Geriatric Population.
J. W. Wong, 1,2 J. Koo. 2 1. University of Utah School of Medicine, San
Francisco, CA; 2. Dermatology, University of California San
Francisco, San Francisco, CA.
Supported By: Photomedex supports this research.
Introduction: In dermatology, one of the most common and miserable
skin conditions is psoriasis. Geriatric patients suffer from psoriasis
with a greater proportion than any younger age group because
psoriasis is a chronic disease. Psoriasis is one condition which tends to
become more generalized and severe with age. The worst and most
miserable type of psoriasis is generalized plaque psoriasis, which is almost
uniformly treated with immunosuppressants such as methotrexate,
cyclosporine, and biologic agents. However, geriatric patients are
most at risk for lifelong systemic immunosuppression. Due to the risk
of cancer, infection, heart disease, and other comorbidities, there is a
great need to find a way to treat geriatric patients with generalized
psoriasis that is not immunosuppressive and with less systemic risks.
Excimer laser is an ideal treatment. It is more powerful than traditional
UVB or PUVA phototherapy because it is a targeted treatment
that only exposes thick psoriasis plaques to therapy and is not
limited to side effects such as causing noninvolved skin to burn. Thus,
more aggressive amount of energy can be delivered to the plaques.
Our study has shown that the use of the 308nm excimer laser in combination
with topical therapy achieves better therapeutic efficacy
than any available biologic agents in half of the time with no possibility
of systemic side effects. Methods: Moderate-to-severe psoriasis patients
have been recruited for the study. 308 nm excimer laser is used
twice weekly until reaching 75% or better improvement according to
the psoriasis area and severity index (PASI 75) for a maximum of 12
weeks. Patients are instructed to apply clobetasol spray twice daily
for the first 4 weeks (Weeks 1-4), then calcitriol ointment for the next
4 weeks (Weeks 5-8), and finally, both clobetasol spray and calcitriol
ointment for the last 4 weeks (Weeks 9-12). Results: Of the 14 patients
enrolled, 85% have achieved great improvement (PASI 75) in
only 6 weeks as compared to etanercept, adalimumab, and ustekinumab
where no more than 68% achieve PASI 75 in double the time
(12 weeks). Conclusion: Our study shows promising results that geriatric
patients with generalized psoriasis can be treated most conveniently
with an external therapeutic modality with essentially no systemic
side effects and no immunosuppression.
D145
Cardiac structure and function and renal insufficiency in the oldest old.
J. Stessman, 1 Y. Maaravi, 1 J. M. Jacobs, 1 D. Leibowitz. 2 1. Institute for
Aging Research, Department of Geriatrics and Rehabilitation,
Hadassah-Hebrew University Medical Center, Jerusalem, Israel; 2.
Heart Institute, Hadassah-Hebrew University Medical Center,
Jerusalem, Israel.
Background:
People over the age of 85 are the world’s most rapidly growing
age group and have a high incidence of both cardiovascular disease
and chronic kidney disease (CKD). The relationship of abnormalities
in cardiac structure and function and renal insufficiency in this age
group is unclear. The objective of this study was to examine the association
between renal function and cardiac structure and function in
an age-homogenous, community-dwelling population of subjects
born in 1920-1921.
Methods:
Subjects were recruited from the Jerusalem Longitudinal Cohort
Study. Echocardiography was performed with a portable
echocardiograph at the subjects place of residence. Standard
echocardiographic assessment of cardiac structure and function was
performed. Glomerular filtration rate (GFR) was assessed by the
Cockroft-Gault formula with abnormal GFR defined as ≤ 60
ml/min/1.73 m2.
Results:
310 subjects (146 males, 164 females) were enrolled in the study.
There were no significant differences between subjects with normal
and abnormal GFR in indices of cardiac structure. Ejection fraction
(57.0 ± 10.4% vs. 54.4 ± 10.3%; p < 0.08) and indices of diastolic function
(E:e’ 12.4 ± 5.0 vs. 12.3 ± 4.6; p = 0.89) were not significantly different
between the two groups.
Conclusions:
Our study did not demonstrate an association between reduced
GFR and echocardiographic indices of systolic and diastolic function
in a community-dwelling population of the oldest old.
D146
Mass Houdini:The Case of the Disappearing Duodenal Mass.
L. M. Thomas, A. Prakash, K. Ramasamy, J. Smith, H. Choudhry.
Bayonne Medical Center, Bayonne, NJ.
Case Presentation:This is a case of 72 year old female presenting
to the ER with right upper quadrant abdominal pain radiating to the
back and vomiting for the past 3 weeks.She had difficulty in tolerating
food due to the vomiting.No history of diarrhea,fever,chills or urinary
complaints.Her past history was significant for uterine cancer diagnosed
15 years ago,treated with hysterectomy and brachytherapy,CAD
s/p CABG and osteoarthritis for which she is on NSAIDS for the past
10 years.Her physical examination was unremarkable.CBC,amylase,lipase
and liver function tests were within normal limits.Her K(5.8)and
creatinine(2.4)levels were elevated.CT abdomen showed diffuse,infiltrative
mass encircling the duodenum,invading the pancreatic head and
gallbladder.With a working diagnosis of adenocarcinoma arising from
the duodenum,infiltrating the pancreas and gall bladder,a biopsy was
done.Biopsy samples showed extensive chronic duodenitis with gastric
heterotopias and gastric mucus cell metaplasia.With a benign result on
biopsy,a diagnosis of penetrating duodenal ulcer was made.The patient
was kept NPO and was started on TPN and IV PPIs.She responded
well and was symptomatically better. After one week,she was started
on a diet and was able to tolerate the intake.Repeat CT scan done two
months later, showed complete resolution of the previously seen duodenal
mass and she remains asymptomatic till now.Discussion:Peptic
ulcer disease in the elderly can present as an intra abdominal mass simulating
malignancy due to penetration of surrounding tissues leading to
inflammation and adhesions.Studies show that even though the prevalence
of active duodenitis is low in chronic NSAIDS users,local ulceration
can take place and is dose dependent. Conclusion:This case illustrates
that awareness of this uncommon complication of peptic gastro
duodenal ulcer disease is helpful in the diagnosis of this benign lesion.
An unnecessary invasive procedure and incorrect treatment strategy
can be avoided by making a firm diagnosis with the help of biopsy.
D147
The effect of cholinesterase inhibitors on cardiovascular health.
M. George, 1 G. Azhar, 1 A. Balamurugan, 2 J. Wei. 1 1. Geriatrics,
University of Arkansas for Medical Sciences, Little Rock, AR; 2.
Family and Preventive Medicine, University of Arkansas for Medical
Sciences, Little Rock, AR.
Background: Cholinesterase inhibitors (donepezil, rivastigmine,
galantamine) are often prescribed to slow the progression of demen-
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tia in geriatric patients, but they may be associated with cardiovascular
side effects that increase morbidity. Currently, there are few specific
criteria to assess the risks and benefits of cholinesterase inhibitors
and there is insufficient data regarding monitoring for
potential cardiovascular side effects.
Methods: We sought to evaluate cardiovascular side effects such
as bradycardia, syncope, near-syncope, dizziness or falls that might be
associated with taking cholinesterase inhibitors. The electronic medical
records (EMR) of all patients from the Reynolds Institute on
Aging (RIOA) who completed a clinic visit during the period of August
1, 2009 to October 31st 2009 and who were taking cholinesterase
inhibitors were reviewed. The medical history of these patients before
and after initiation of cholinesterase inhibitors was examined.
Results: The EMR of 82 patients who were taking
cholinesterase inhibitor were retrospectively reviewed. The mean age
of patients was 81 years. The patients were predominantly female
(73%) and were white (79%). Memory loss/disorder (59%) was the
most common reason for initiation of cholinesterase inhibitor, followed
by Alzheimer’s disease (21%) and some form of dementia
(17%). Four patients were deceased since the index clinic visit (5%).
The common new cardiovascular symptoms reported after the initiation
of cholinesterase inhibitor were: bradycardia – 9% (N=7); atrial
fibrillation or arrhythmia – 5% (N=4); syncope or near syncope– 4%
(N=3); sick sinus syndrome – 2.4% (N=2). Dizziness was reported in
13 % of the patients (N=11). Falls were reported by 11% of the patients
(N=9). Sinus bradycardia (15%) (N=12) was the most common
new EKG finding, followed by bundle branch block (7%) (N=6) and
atrial fibrillation (4%) (N=3).
Conclusions: Cardiovascular side effects of cholinesterase inhibitors
are common, morbid and under-appreciated. More studies
are needed to better understand this problem. Monitoring for potential
cardiovascular side effects of cholinesterase inhibitors will enhance
compliance and maximize benefits in vulnerable older patients
with cognitive impairment while preventing potentially devastating
cardiovascular complications.
D148
Screening, Diagnosis, and Treatment of Osteoporosis in Patients
with Dementia.
L. J. Gleason, K. R. McCormick, J. Frankel, S. M. Friedman.
Department of Medicine, University of Rochester, Highland Hospital,
Rochester, NY.
Background: Older adults with dementia are at higher risk for
fractures than cognitively intact individuals and some studies have
shown that these patients are less frequently screened and receive
fewer treatments for osteoporosis.
Objective: To examine rates of screening, diagnosis, and treatment
of osteoporosis in older adults with and without dementia at an
academic outpatient geriatric clinic.
Methods: We performed a retrospective chart review of 440 patients
ages ≥ 65 who entered into the Geriatric and Medicine Associate
Practice (GAMA) between January 2000 and December 2007.
Baseline characteristics were recorded including age, gender, body
mass index (BMI), self-reported health status, and activities of daily
living (ADLs). Patients with dementia were compared to those without
cognitive impairment, with respect to the screening, diagnosis,
and treatment of osteoporosis.
Results: Of the 440 patients included in the study, the average
age was 78.9 years old, 304 (69%) were women, 89% of patients were
able to complete 5/5 ADLs, and 53 (12%) were diagnosed with dementia.
We found that only 53 patients (12%) had a recorded DEXA
scan within six months of enrollment in the clinic, and those with dementia
were less likely to have had a DEXA scan (11.3% vs. 25.3%,
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Methods: Cross-sectional analysis of a subset of the Canadian
Study of Health and Aging (1996 wave) that completed a diagnostic
cognitive assessment. Non-cancer pain was measured
using the 5-point verbal descriptor scale, dichotomized into
“no/very mild” versus “moderate” or greater pain. Cognitive status
was clinically assessed and categorized as NCI, cognitive impairment
no dementia (CIND), Alzheimer’s Disease (AD), and
vascular dementia (VaD). Multivariable logistic regression was
utilized to analyze the relationship between pain report and cognitive
diagnosis controlling for covariates (demographics, comorbidity,
IADL’s, and depression).
Results: 1,658 (96.7%) of participants that completed a diagnostic
cognitive assessment had their cognitive status designated and a
pain measure completed. Overall, the frequency of pain report varied
with cognitive status among the four groups, (Chi-square 9.16,
p=0.02). 34.7% (263/757) of persons with NCI reported moderate or
greater pain, compared to 39.1% (223/570) CIND (p=0.11), 28.5%
(73/256) AD (p=0.08), and 40% (26/65) VaD (p=0.42). In the fullyadjusted
multivariate model, compared with persons with NCI, the
odds of reporting moderate or higher pain was not significantly different
among persons with CIND OR=0.86 (0.65,1.13; p=0.28), AD
OR=0.68 (0.44,1.04; p=0.08), or VaD OR=0.80 (0.36,1.80; p=0.59).
Conclusion: A noteworthy proportion of older adults with and
without dementia report moderate or greater pain and did not vary
with cognitive status. Given that dementia represents a consistent risk
factor the under identification and undertreatment of pain, efforts to
improve pain management in this vulnerable population remain a
high priority for future research.
D151
Help seeking for incontinence by adults with heart failure.
K. Lindeman, 1 Y. Li, 2 M. H. Palmer. 2 1. University of North Carolina
School of Medicine, Chapel Hill, NC; 2. School of Nursing, University
of North Carolina, Chapel Hill, NC.
Supported By: Detrol Clinical Research Program, 2005-2007;
MSTAR, 2011 American Federation for Aging Research
Background: Urinary incontinence (UI) and heart failure (HF)
are both prevalent conditions that have significant impact on quality
of life, but little information is available about HF patients seeking
help for urinary incontinence. The objective of this study is to identify
patient factors associated with help-seeking for UI in HF patients.
Methods: This study is a secondary analysis of cross-sectional
data collected between 2005 and 2007 in a 22 bed hospital unit and 2
out-patient clinics for HF. Two hundred ninety six men and women
that were 20 years or older with HF diagnosis participated in the original
81-item survey. UI help-seeking was defined as an affirmative response
to a single item on reporting UI to a doctor or nurse. Incontinence
Impact Questionnaire-7 (IIQ-7) and the Urogenital Distress
Inventory-6 (UDI-6) were used to assess level of impact of UI on
quality of life.
Results: 134 (45%) participants (median age 62 years; 45.5%
male) had UI, 60 (44.8%) had at least two other urinary symptoms,
and 45 (34%) sought help for UI. Bivariate analyses revealed that
IIQ-7, UDI-6, presence of other urinary symptoms, and interaction
between sex and age were significantly associated with help-seeking
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Results: For the first aim, time of day and mobility were significant
predictors of positive affect displays;gender,age,and education were significant
predictors of negative affect displays. The results of the second
aim showed three distinctive trajectory groups for positive affect and
two groups for negative affect. Positive affect comprised three groups: 1)
a low stable group; 2) a fluctuating group displaying afternoon peaking;
and 3) a fluctuating group displaying morning peaking. Negative affect
included two groups: 1) a low stable group; and 2) a fluctuating group.
Conclusions: The present study showed that people with dementia
showed not only a considerable range of affect displays but also significant
within-person variation in positive and negative affects.Therefore,
a tailored intervention considering variations of affect display may
be required to improve emotional well-being of people with dementia.
D154
Stress in Adult Children Caring for Older Parents with Dementia: A
Pilot Study.
L. M. Solberg, 1 L. B. Solberg, 2 E. N. Peterson. 1 1. Internal Medicine,
Vanderbilt University, Nashville, TN; 2. Office of Research, Meharry
Medical College, Nashville, TN.
Supported By: Robert E. Wise M.D. Research & Education
Institute, Lahey Clinic, Burlington, MA
Background: Adults caring for parents and their own children
are the “sandwich generation”. Their stress is noted in the behavioral
sciences, but largely absent in medical literature. Clinical experiences
showed adult children accompanying parents with dementia on clinic
visits verbalized distress. The objective of this IRB-approved descriptive
survey was to determine among a convenience sample of adult
children caring for their parent with dementia the prevalence and
severity of emotional and social changes and financial burden since
assuming caregiver role.
Methods: The study took place at a geriatric private practice.
Adult children caregivers completed a 51-item survey (Cronbach’s
alpha .80) on impact of the caregiving role on emotion, stress, and finances
and coping mechanisms. Of those surveyed 85/95(89%) were
returned. 45/85(47%) respondents were primary caregivers of demented
elderly parents and 18/45(47%) were of the “sandwich generation.”
Descriptive statistics were conducted using SPSS.
Results: On average caregivers were 54 years old, 36/45(80%)
women, 28/45(62%) were married, 38/45(84%) had children,
18/45(47%) were “sandwich generation.” There was no significant difference
in mean caregiver burden between the sandwich generation and
non-sandwich generation adult children. Caregivers reported little impact
on their professional lives. Over a third reported stress in caring for
the older adults’ daily needs, felt more irritable, and more feelings of
anxiety. 53% reported taking their parent to doctors’ appointments was
emotionally difficult. Participating in activities of interest/hobbies decreased,
but not time spent with friends. Helpful services were seminars
on care of demented parents (58%),meetings with social workers for resource
availability (63%), and seminars on coping mechanisms (53%).
Conclusions: Adult children caring for demented parents experienced
stress, anxiety, and sadness. Caregivers’ emotions were negatively
impacted but not their finances or careers. Emotional stress decreased
activities of interests, but not social interactions. Clinicians
need to direct attention to the caregivers’ emotional well being as
part of routine care of the elderly. Helpful coping mechanisms were
identified by the respondents. Further program development to support
adult children caregivers may be beneficial.
D155
Driving Habits of Seniors Over 80 and the Perceptions of Their
Relatives: When and How Should They Stop?
M. Majid, 1 N. Arif, 1 M. Akerman, 2 C. Nouryan, 1 G. Wolf-Klein. 1 1.
North Shore-LIJ Health System, New Hyde Park, NY; 2. Feinstein
Institute for Medical Research, Manhasset, NY.
INTRODUCTION: The safety of older drivers has become an
increasing issue of concern in today’s environment. We surveyed drivers
over 80 years old and family members to explore driving habits
and comfort levels of both.
METHODS: Surveys were distributed in a geriatric outpatient
practice and subacute rehab facility to patients over the age of 80 who
were still driving and who were accompanied by a family member.
RESULTS: Of the 74 surveys completed, drivers were, on average,
85.5 yo, male (57%), and college or graduate school educated
(69%); 81% rated driving as important or essential. Half (49%) reported
driving with passengers. Most (65%) drove at least 5 days a
week, and on highways (81%), in rain (78%), at night (59%) or in
snow (41%). A quarter (24%) admitted getting lost and 27% reported
having a fall. When asked who they would rely on if they could
no longer drive, 43% indicated children, 26% friends, 16% car service,
and 14% spouse.
When comparing surveys between octogenarian drivers and relatives,
81% rated themselves as “good” or “excellent” drivers while
relatives rated them significantly less (58%, p=0.0342). When asked if
the subject should still be driving, 11% of drivers and 42% of relatives
answered “no” or “not sure” (p=0.0027).
When asked which medical conditions would force driving cessation,
drivers had lower percentages than their relatives for all answers
except visual loss as follows: worsening medical conditions
(32% v 62% respectively, p=0.0104); hearing loss (14% v 32%,
p=0.0531); mobility issues (35% v 54%, p=0.1016); and visual loss
(59% v 59%, p=1.00). When asked whether “anyone ever recommended
that you/they stop driving”, 13.5% of drivers and 23% of relatives
answered “yes” to the question (p=0.3594). Drivers reported
that recommendations to stop driving only came from children
(100%), but their relatives reported that spouses (11%), children
(67%) and friends (22%) had all advised in on the subject.
CONCLUSION: In general, octogenarian drivers were rarely
told to stop driving. They rated themselves as significantly better drivers
than their relatives did, and seldom admitted that they should not
be driving, despite their relatives’ opinion.
D156
Evidence for “accelerated aging” in older adults with disability?
I. R. Molton, M. C. Goetz, M. Jensen, A. M. Verrall. Rehabilitation
Medicine, University of Washington, Seattle, WA.
Supported By: This project is supported by a grant from the
Department of Education, NIDRR grant number H133B080024.
BACKGROUND: Improvements in medical care have led to
longer life-spans for people with disabilities acquired early in life.
However, there is some evidence that these improvements in
longevity are offset by increased rates of medical conditions, due to a
more rapid decline of organ system functioning in persons with disability.
This phenomenon has been called “accelerated aging.” However,
the existence of this phenomenon has not been adequately established
in large samples with adequate age-matched controls.
METHODS: The present study assessed self-reported rates of
certain medical conditions in a large national sample of people with
either spinal cord injury (n=540), post-polio syndrome (446), muscular
dystrophy (382) or multiple sclerosis (640), and compared them to
normative data taken from the National Health Interview Survey
(NHIS) of more than 21,000 adults. Health conditions assessed included
hypertension, coronary artery disease, cancer, diabetes, pain
conditions, and vision trouble. Comparisons were conducted in four
age bands: 18-44, 45-65, 65-75, 75+. Chi-square and independent samples
t-tests were used for all analyses.
RESULTS:Participants in the experimental sample were primarily
Caucasian (92%) and female (63.3%), with an average age of 54.5 years.
Results suggested that, across age bands, individuals with disabilities reported
greater rates of hypertension, arthritis, joint pain and difficulties
with vision (all p values < 0.05). However, in more advanced age bands
(65-75 and 75+), adults with disabilities also reported greater frequency
of organ system diseases (diabetes, coronary artery disease, and cancer)
than were present in age matched national norms (all p values < 0.01).
AGS 2012 ANNUAL MEETING
S239

P OSTER
A BSTRACTS
CONCLUSIONS: These results lend support to the idea of “accelerated
aging” of organ systems in persons growing older with longstanding
physical disabilities. Health care providers should be aware
of the special medical needs associated with organ system decline in
these individuals.
D157
Brain Grey Matter Volume of the Putamen and Clinical Correlates
of Motor Skill in Walking.
J. M. VanSwearingen, 1 S. Perera, 2 C. Rosano, 3 H. J. Azenstein, 4
J. S. Brach, 1 S. A. Studenski. 2 1. Physical Therapy, University of
Pittsburgh, Pittsburgh, PA; 2. Geriatric Medicine, University of
Pittsburgh, Pittsburgh, PA; 3. Epidemiology, University of Pittsburgh,
Pittsburgh, PA; 4. Psychiatry, University of Pittsburgh, Pittsburgh, PA.
Supported By: Pittsburgh Older American’s Independence Center, 1
P30 AG024827; K23 AG026766
Background: Grey matter volume (GMV) of the whole brain
and regions has been associated with age-related changes in gait and
motor sequence learning. It is unclear if whole brain or regional
GMV relates to motor skill of walking. We examined the relation of
GMV in the putamen, involved in selection, timing and automaticity
of well-learned motor sequences, with clinical correlates of motor
skill in walking in older adults with mobility limitations.
Methods: We used baseline data from a RCT of exercise interventions
in older adults with slow gait who also completed structural
brain imaging (n=41, mean age 76.7±5.6).Automatic labeling pathway
method was used to determine total brain volume, whole brain GMV
and GMV of the putamen and additional brain regions associated
with age-related changes in gait from the structural MRI. The GMV
in the additional regions was included to determine if a relation to the
putamen was unique or generalized. Motor skill in walking (energy
cost of walking, stance time variability [STV] and the Figure of 8 Walk
[F8W] cadence) and gait speed were recorded in a different session.
Partial correlations, controlling for age, gait speed and total brain volume
(GMV+WMV+CSF) were used to determine the adjusted correlations
(r) between brain GMV and motor skill in walking.
Results: Controlling for age, gait speed and total brain volume,
putamen GMV was related to all measures of motor skill in walking:
energy cost of walking (r=-.33, p=.040), STV (r=.37, p=.020), and
F8Wcadence (r=-.44, p=.005). Whole brain GMV was related only to
F8W cadence (r=-.38, p=.016). The only other regions associated with
motor skill in walking were the precentral region related to STV
(r=.33, p=.029), and the hippocampus related to F8W cadence (r=-.33,
p=.046).
Conclusion: GMV in the putamen was associated with most clinical
measures of motor skill in walking. Age-related changes in brain
circuits for motor sequence task performance may be a central contributor
to the timing and coordination difficulties in gait of older
adults. The putamen may be an important brain region of interest in
future studies to determine whether interventions that improve
motor skill in walking also change the brain.
D158
Aging with Longstanding Physical Disability: A Focus Group Study.
K. Yorkston, A. Verrall, K. L. Johnson. Rehabilitation Medicine,
University of Washington, Seattle, WA.
Supported By: This project was funded by a grant from the
Department of Education, NIDRR grant number H133B080024.
Background: People aging with longstanding physical disability
must deal with competing trajectories. Physical function is declining
while confidence in the ability to cope is improving. Social support is
likely to decline with retirement & aging significant others while
medical management is improving thus increasing life expectancy.
Methods: Four focus groups were conducted soliciting advice for
health care teams seeing patients aging with a longstanding disability.
Participants included people with spinal cord injury (N = 7), postpolio
syndrome (N = 7), multiple sclerosis (N = 5), and muscular dystrophy
(N = 4). All were at least 45 years of age and living with their
disability for at least 8 years. Focus groups transcripts were reviewed
and coded using Atlas.ti and a framework of themes was developed.
Results: Four major themes emerged which are described in
Table 1.
Conclusions: Health care providers should acknowledge the
skills that people with longstanding disability bring to the task of prioritizing
their goals and managing their condition. Healthcare
providers can assist them in developing individualized self-management
interventions that help to maintain function and independence
as they age.
Table 1. Focus Group Themes
D159
Motor Learning Ability in Walking Relates to Physical Function in
Older Adults.
M. Zaldana, 2 J. M. VanSwearingen, 1 S. A. Studenski, 2 J. S. Brach. 1 1.
Physical Therapy, University of Pittsburgh, Pittsburgh, PA; 2.
Geriatric Medicine, University of Pittsburgh, Pittsburgh, PA.
Supported By: Research/Grant Support: Pittsburgh Older
American’s Independence Center, 1 P30 AG024827; Pitt Clinical
Research Training- Geriatrics/Gerontology T32 AG021885; K23
AG026766
Background: Motor learning is important in the recovery or
adaptation of performance in daily life after age-related changes in
neuromotor function. Backward walking is a motor task with a similar
motor sequence and complexity as forward walking but less practiced
(ie less skilled). We examined the relation of changes in gait
variability, an indicator of motor skill learning, over repeated trials of
backward walking to physical function in older adults.
Methods: Community-dwelling older adults (77.1 years±6.1,
n=67) independent in ambulation performed 4 repeated trials of
straight path backward walking and usual walking over a computerized
walkway. Mean backward and usual walking gait speed and
mean gait variability (stance time standard deviation, STV) for the
first two and last two trials of backward walking were calculated.
Mean percent change in STV between the first and last two trials of
backward walking represented motor learning ability. Physical function
in daily life, the Late-Life Function and Disability Instrument
overall functioning (LLFDI total) was recorded in the same session.
A linear regression model was used to examine the contribution of
motor learning in walking ability to physical function in daily life,
controlling for age, usual gait speed and backward walking gait speed.
Results: Motor learning ability in walking independently contributed
to physical function, while controlling for age, usual and
backward gait speed. The mean percent change in STV contributed
(β=-.22, p=.03) to the variance in LLFDI total beyond age and usual
gait speed (β=.53, p

P OSTER
A BSTRACTS
D160
Outcome of Older Patients Undergoing Total Hip or Total Knee
Arthroplasty.
R. V. Samala, 1 J. O. Ciocon, 2 P. Patel, 3 D. Galindo, 2 J. Loquias. 2 1. The
Harry R. Horvitz Center for Palliative Medicine, Cleveland Clinic,
Cleveland, OH; 2. Geriatrics, Cleveland Clinic Florida, Weston, FL; 3.
Orthopedics, Cleveland Clinic Florida, Weston, FL.
Background: In spite of the proven benefits of total joint arthroplasty,
doubts about pain relief, progression of ambulation, and maintenance
or improvement of functional capacity pervade. The present
study aimed to determine the outcome of older patients undergoing
primary elective total hip (THA) or total knee arthroplasty (TKA)
for osteoarthritis
Methods: A cross-sectional study was done at Cleveland Clinic
Florida which included adults 65 years and older who underwent
THA or TKA between July 1, 2010 and February 28, 2011. Patients
with other inflammatory joint diseases, acute fracture, or revision surgery
were excluded. Medical records were reviewed and telephone
interviews were conducted at 6 and 12 weeks post-surgery. Outcome
measures were pain level, living condition, ambulation status, and
functional status.
Results: Fifty three participants completed the study; mean age
was 73 years, 49% were female, and 43% had THA. There were significantly
more patients who were pain-free, neither bound to wheelchair
nor bed, and independently functional at home by 12 weeks.
There were significantly more THA patients who ambulated independently
than those who required an aid (p

P OSTER
A BSTRACTS
Aggressive treatment of many cancers includes surgical interventions,
with accompanying risks of morbidity and mortality. There is
substantial heterogeneity in older adults’ functional reserve and ability
to tolerate and recover from major physiological stressors. Geriatric
assessment has developed in the gerontology literature as an important
prognostic tool to risk-stratify community-dwelling older
adults. These principles have been explored with the goal of identifying
patient-level risk factors for adverse surgical outcomes. In this review,
we examined the utility of components of a Comprehensive
Geriatric Assessment (CGA) as predictors of adverse outcomes
among older patients undergoing major surgery.
Methods: Medline, EMBASE, and the Cochrane Library were
searched for prospective studies examining components of CGA
among geriatric patients undergoing elective surgery. Outcome parameters
included 30 day postoperative complications and mortality,
and discharge to a non-home care institution. Within and across the
studies, we evaluated which CGA components were associated with
the outcome(s) of interest.
Results: The initial search identified 125 potentially relevant articles,
of which ten articles based on seven studies met criteria for
evaluation. Across the studies, chronological age was consistently
found not to be an independent predictor of poor outcomes. Dependencies
in ADLs and cognitive impairment were associated with increased
incidence of complications and mortality. Impairment in
IADLs was also associated with discharge to non-home care institutions
in two studies.
Conclusions: Across a diversity of surgical settings and patient
populations, the results of these studies support an association between
poor functional status and adverse geriatric surgical outcomes.
These consistent results argue for inclusion of focused geriatric assessment
as part of routine presurgical care in older adults. In addition,
the development of targeted interventions for vulnerable individuals
so identified may provide innovative means of mitigating the
risk of major surgical interventions for this increasing proportion of
the population.
D164 Encore Presentation
A Pooled Analysis of Surgical Complications: Results from the
RECORD Program.
M. R. Lassen, 1 M. Gent, 2 A. K. Kakkar, 3,4 B. I. Eriksson, 5
S. D. Berkowitz, 6 A. Turpie. 2 1. Glostrup Hospital, Glostrup,
Denmark; 2. McMaster University, Hamilton, ON, Canada; 3.
Thrombosis Research Institute, London, United Kingdom; 4.
University College London, London, United Kingdom; 5. Sahlgrenska
University Hospital, Mölndal, Sweden; 6. Bayer HealthCare
Pharmaceuticals, Montville, NJ.
Supported By: This research was funded by Bayer HealthCare
Pharmaceuticals Inc. and Janssen Research and Development, LLC.
Background: Surgical complications after total hip or total knee
arthroplasty (THA or TKA) are a primary concern for surgeons and
can increase the cost and length of hospitalization, re-admission rates,
and incur additional surgeries. Such complications include a wide
range of conditions including bleeding, infection, and hemarthrosis.
The phase III RECORD program investigated the oral, direct Factor
Xa inhibitor rivaroxaban for the prevention of venous thromboembolism
after THA (RECORD1, 2) or TKA (RECORD3, 4). The
focus of this analysis from the pooled data from the four RECORD
studies was to investigate whether rivaroxaban regimens are similar
to enoxaparin regimens in the incidence of surgical complications
after THA and TKA.
Methods: Patients (N=12,729) were randomized to receive rivaroxaban
10 mg once daily for 35±4 days or enoxaparin 40 mg once
daily for 35±4 days (RECORD1) or 12±2 days followed by placebo
(RECORD2). In RECORD3 and 4 patients received prophylaxis for
12±2 days with rivaroxaban 10 mg once daily or enoxaparin 40 mg
once daily (RECORD3) or enoxaparin 30 mg twice daily
(RECORD4). Surgical safety outcomes were analyzed in the safety
population over the total treatment duration pool.
Results: The incidence of serious adverse events related to surgery,
such as post-procedural infection, operative hemorrhage, wound
dehiscence, postoperative wound infection, incision site hemorrhage,
and hemarthrosis, was similar in the rivaroxaban (30/6,183: 0.49%)
and enoxaparin (35/6,200: 0.56%) groups.
Conclusions: These data suggest that surgical safety outcomes
are unlikely to differ between rivaroxaban and enoxaparin
regimens.
S242
AGS 2012 ANNUAL MEETING

A UTHOR
Abadir, P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B55, B61
Abarca-Gomez, I . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C39
Abbott, R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B122
Abbott, R D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B124, C53
Abdo, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C148
Abi Rafeh, N . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C148
Abraham, I . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A125
Abrams, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P39
Abreu Lanfranco, O E . . . . . . . . . . . . . . . . . . . . . . . . . . . .A48*
Abreu-Lanfrranco, O . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B35
Acquista, D A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C63
Adachi, R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A51
Adelman, R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P36
Adelman, R D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D41, D116
Adeniye, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C147*
Adepoju, L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C49
Ador-Dionisio, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C147
Africa, B L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A3*, A4*
Agarwal, S J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A163*
Agbor-Bawa, W . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A100
Agnew, R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B25*
Aguilar, E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D90
Aguirre, B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D106, D107
Ahalt, C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C105
Ahl, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C36
Ahmad, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A63*
Ahmed, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C82*
Ahmed, I . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A117
Ahmed, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B77
Ahsan, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B68
Aizenstein, H . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B163
Ajmal, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C112
Akerman, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D86, D155
Akintan, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A28
Akintan, A I . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C5*
Al-Mallah, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A161
Alagiakrishnan, K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D10*
Alamo, J G . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D17
Albaba, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B23*, B24*
Albiol Tomàs, N . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C164, D40
Albornoz, M F . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D128
Albrecht, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D138*
Alessi, C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B89, B158
Alexandra, P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A51
Algase, D L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D153
Ali, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C148*
Alirhayim, Z . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A161
Allegre, A A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A62
Allen, C M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C142*
Allen, K R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D104*
Allman, R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B127
Allman, R M . . . . . . . . . . . . . . . . . . . . . . . . . . .A50*, B92, P13
Almeida, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B148*
Almeida, L M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C50
Alston, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A37, C41
Alweis, R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A17
Alwine, L K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A34
Amdur, R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A95
Aminbakhsh, R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A104*
Amjad, H . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B52*
I NDEX
Ammann, P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B58*
Amrhein, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D103
Amtmann, D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C158*
Amuan, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A45
Anand, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B12, C3
Anderson, B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C45
Anderson, K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D54, D63
Anderson, K J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D119*
Anderson, R A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C74
Anderson-Malico, R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C58
Andrade, L C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D17*
Andresen, E M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P32
Andrew, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B149, D150
Ang, Y . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A15, A32*
Angeles, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A3, A8, B16
Anger, J T . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B80
Ankuda, C K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B50*
Annweiler, C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C141*, D88
Anthony, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D63
Antony, R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C76
Appa, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C33
Arabelo, H . . . . . . . . . . . . . . . . . . . . . . . . . . . .A3, A4, A8, C16
Arabelo, H A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B16
Arai, H . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C42
Arakawa, R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A94*
Araujo, K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A49
Araw, C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D129
Araw, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D129*
Archbald-Pannone, L . . . . . . . . . . . . . . . . . . . . . . . . . . . .B137*
Ard, K L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A96
Arenson, C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A84, C76*
Argento, V . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A101
Arif, N . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C130, D155
Arling, G . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B110
Arnold, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D115*
Aronson, L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P39
Arora, R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A6
Arora, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A19*, C13
Arshad, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B16*
Arya, L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P25
Ashraf, M S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A146*
Ashton-Miller, J A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D80
Asik, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A141
Aslam, I . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B21*
Asnis, D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D18
Assal, M F . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A25
Asthana, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C117
Atkinson, H . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A72
Atkinson, H H . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D61
Atreya, A R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C13*
Atwood, P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A138
Aubry-Rozier, B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D149
Audi Ferrer, R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C164
Auerbach, H . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P37
Aung, K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B38*, D85*
Aung, Z . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A104
Austin, P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A80
Avelino-Silva, T J . . . . . . . . . . . . . . . . . . . . .A54*, A55*, A81*
Awasthi, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C3
Azenstein, H J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D157
*Indicates presenting author
AGS 2012 ANNUAL MEETING
S243

A UTHOR
I NDEX
Azhar, G . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D147
Aziz, F . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C12, C25*, D24
Bachuwa, G . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A148
Bae, S Y . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A143*
Bai, X . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B123
Baiduc, B Y . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C16*
Baillargeon, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D99
Bakchine, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D27
Baker, L D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P18
Baker, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C65
Balamurugan, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D147
Ball, T . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A125
Balzi, D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B41
Bangalore, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A52*
Bangs, M E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C36
Banks, W A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A131
Bansal, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C120
Bansal, N . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B13*, C125
Barash, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C62
Barchielli, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B41
Barco, R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B92*
Barczi, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C117
Barlow, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B30*
Barnes, C A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C121
Barnes, D E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A149
Baron, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A75, A76, A79
Barr, E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B168
Barre, L K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B37
Barrett, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A64
Barrick, A L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A38
Barrientos-Calvo, I . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C39
Bartels, S J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B37
Bartha, R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C141
Bartolomé, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D106, D107
Basic, D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A116
Basu, D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C21*
Bateman, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A38
Batsis, J A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B37*
Bauer, D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B48
Bauer, D C . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B49, B81, B109
Baum, E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D76
Bautista, M K . . . . . . . . . . . . . . . . . . . . . . . . . . . .C12, C25, D24
Bavendam, T . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C34
Bayer-Carter, J L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P18
Bea, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P31
Beaman, P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P14
Beattie, L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C162
Beauchet, O . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C141, D88
Beben, T . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A25*
Becker, K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B131
Becker, Y T . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D162
Bednarczyk, M . . . . . . . . . . . . . . . . . . . . . . .A5, A6, C18, D19*
Beeber, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C119
Beeber, A S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B113, B114
Beizer, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D86
Belal, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C3, D2
Bell, C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B122, B124, C53
Bell, C L . . . . . . . . . . . . . . . . . . . . . . . . . . . .B68, B120*, B157*
Belladonna, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C146
*Indicates presenting author
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AGS 2012 ANNUAL MEETING
Bellantoni, M R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D98*
Bellantonio, S . . . . . . . . . . . . . . . . . . . .A1, A2, A15, B17, D16
Bellelli, G . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D27
Belleville, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C137
Belza, B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C111
Benedict, L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D76
Benigno, D G . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B8*
Benizry, B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A47
Bennett, K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B170
Benoit, N . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D127
Bentov, I . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P19
Berg, K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D11*
Berger, A E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B139
Berges, I . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C92
Bergman, H . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C162
Bergman, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A109
Berkowitz, S D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D164
Berlowitz, D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B167
Berman, N . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D41
Bernick, J J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D34*
Berry, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P33
Berryman, S N . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D67
Berthoud, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D149
Bertrand, R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B113, B114
Betz, M E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B145*, P6*
Beyea, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B63*
Beyth, R J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C12, C25, D24
Bhagavan, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A1*, A2*
Bhandari, R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C120
Bharel, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A90, A96
Bhat, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C16
Bhattacharya, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D135
Bhattacharya, R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A78
Bhattacharya, S B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A78*
Bickerstaff, K A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D120*
Bickmore, T . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P9
Biedron, C . . . . . . . . . . . . . . . . . .A43*, A44*, A48, B35, C101
Bierrenbach, A L . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A54, A55
Bilbruck, T J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D67
Black, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C162
Black, S E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D27
Blackstone, K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A121, C58
Blake, R Y . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C165
Blanchard, G P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A68, C81*
Blaum, C . . . . . . . . . . . . . . . . . . . . . . . . . . . .B47, B78, B112, P8
Blazey-Martin, D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A96
Bliwise, D L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B76
Bloch, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A149
Block, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D64
Bocirnea, C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C87*
Boersma, D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P15
Boeve, B F . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D92
Bogaisky, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D43
Boling, P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A120, D95
Bonavitacola, P J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A68*
Bonner, L M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P18
Bonsall, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B67
Boockvar, K S . . . . . . . . . . . . . . . . . . . . . . . . . . . .A126, D103*
Bookhart, B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C54, C93
Boonen, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D32

A UTHOR
I NDEX
Bopp, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B159, B164
Borker, P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A69*
Borrie, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C162
Borson, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A135, C158
Boscardin, W . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B31
Boscardin, W J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P1
Bottone Jr, F G . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C161*
Boudreau, R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B36
Boudreau, R M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B109, P30
Bouldin, E L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P32*
Boustani, M A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A47, A88
Bowers, B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C103
Bowling, C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B127*
Boxer, R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P22*
Boyd, C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C104
Brach, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B161, B163, B166
Brach, J S . . .A158, B79, B156, B165, D157, D159, P24*, P30
Bradley, C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P25
Bradley, E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P12
Bradley, S M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D78
Brangman, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B13, C125
Braun, K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B157
Braun, U . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A27, D83
Bravo, N . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D75
Braza, D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D60
Breeding, L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D93
Brennan, M . . . . . . . . . . . .A32, B14, B19, C21, C23, C28, D23
Brennan, M J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A19, C13
Brenny-Fitzpatrick, M . . . . . . . . . . . . . . . . . . . . . . . . . . . .D135
Bresee, C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B80
Brett, B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P37
Bridges, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C117
Briesacher, B A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C106
Brignole, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A86
Brimacombe, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C124
Broce, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B138
Brooks, D B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A82
Brown, A F . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A98
Brown, C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B92
Brown, C J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P13*
Brown, D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D56, D60
Brown, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P25
Brown, L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B121
Brown, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B99*
Brown, R T . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A90*, A96*
Brummel-Smith, K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C65
Brunker, C P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C109
Brunson, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C45
Brunton, K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B146
Bryan, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D109
Buchbinder, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B27
Bueno, H . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B152
Bukata, S v . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A20
Bula, C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B84, C128, D48
Burgio, K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B132
Burke, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C10*
Burkett, J G . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D95*
Burleson, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A138
Burnett, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B75, B93, D26*
Burnham, C . . . . . . . . . . . . . . . . . . . . . . . .A68, C81, D73, D74
Burns, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C89
Burrows, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P37
Bursztyn, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B134
Burton, C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D92
Busby-Whitehead, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D66
Bushan, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C63*
Buslovich, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A123*
Butler, C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B151
Byerly, L K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D63*
Bylow, K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P4
Bynum, D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B6
Byszewski, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C162
Cabral, H . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B167
Cagle, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B98*
Cal, C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A117, D86
Caldi, F . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C146
Callaghan, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P18
Callahan, C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A99, B110
Callahan, K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A72, D61*
Callister, C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C139*
Camargo, K R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C50
Camera, L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D128
Campanova, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D18
Campbell, K H . . . . . . . . . . . . . . . . . . . .B111*, D152*, D162*
Campbell, N . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A47*, A88*
Campbell, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A83
Campusano, C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C40
Canaday, D H . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B57
Cao, L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C1
Cao, Q . . . . . . . . . . . . . . . . . . . . . . . . . .A80, B71*, B154*, C14
Caprio, A . . . . . . . . . . . . . . . . . . . . . . . . . . .B20, B63, C41, D66
Caprio, T . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B62, D12
Caprio, T v . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A20
Caprio, T V . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A12
Caputo, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D27
Carbonell, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D106, D107
Cardona, F . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B9*, C152*
Carey, E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D64
Cariaga, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D117
Carlini, A R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A162
Carlson, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A63
Carlson, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P12
Carlucci, C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D78
Carnahan, R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P31
Carr, D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B98
Carrabba, N . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B41
Carson, J L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B168
Carthen, D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A4
Caruso, L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P37
Carvalho, A C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C44
Caserotti, P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P30
Cassidy, C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C101
Castillo, C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D106*, D107*
Castillo, R C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A162
Catuogno, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C34
Cauley, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B48
Cauley, J A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P31
Cavallini, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C146
Cefalu, C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D90, D91
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I NDEX
Ceimo, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D75*
Celeste, R K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C46
Cha, S S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B23, B24, D92
Chakka, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B4*, C8
Chakka, A K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B64
Chami, H . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A43, A44
Chan, K C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C159
Chan, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D132
Chang, C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B104
Chang, F . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C27*
Chang, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D19
Chang, M T . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D92*
Chang, S S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B45*
Chao, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B15, P37
Chao, S H . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D47
Chaperon, C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D120
Charness, A L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D139
Charvat, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A160
Chataut, H . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A5*, A6*
Chatterjee, P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A89*
Chatterjee, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B161
Chau, D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A104
Chaudhari, S . . . . . . . . . . . . . . . . . . . . . .A9, B12, C24, D1, D2
Chaudhry, A H . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A92
Chaudhry, S I . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D140
Chaudhuri, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C94
Chauhan, B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B104*
Chaves, P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B1, B2
Chawla, H . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C56*
Cheadle, C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B139
Checchi, J M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D38*
Chelagiri, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D18*
Chen, B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C150*
Chen, D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C22*
Chen, E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B57
Chen, L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B132
Chen, P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B119
Chen, R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B122, C53
Chen, W . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D141
Chen, X . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A38
Chen, Y . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A127*
Cheng, D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P9
Cheng, H . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D50*, D51*
Cheng, H S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A93
Cheng, V . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B61*
Cheng, Y . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C161
Chenna, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A72*
Cherr, G S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B146
Cheung, H . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D100
Cheung, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A98*
Chew, P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B167
Chez, R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A154
Chi, H . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C108
Chiao, Y A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B142
Chikwe, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A164
Chimienti, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D73
Chippendale, T . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B26*
Chittenden, E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D64
Cho, E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A107
Chodos, A H . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C11*
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Chodosh, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B105
Chohan, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D76*, D108*
Chong, K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C40
Chong, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D132*
Chongkrairatanakul, N . . . . . . . . . . . . . . . . . . . . . . . . . .A156*
Chopra, T . . . . . . . . . . . . . . . . . . . . . . . . .A43, A44, A48, C101
Choudhry, H . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D146
Christianer, K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D41*
Christmas, C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D112
Chun, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D115
Chung, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A107
Cigolle, C . . . . . . . . . . . . . . . . . . . . . . . . . .B47, B78*, B112, P8
Ciocon, J O . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A14, D160*
Civin, C I . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B139
Clark, C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B51
Clark, E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B101, C58*, C89*
Clark, E M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A70
Clarrett, D M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B169*
Cleinman, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P29*
Clevenger, C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A40*
Clough-Gorr, K M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P3
Cluff, K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C132
Cobbs, E L . . . . . . . . . . . . . . . . . . . . . . . .A112, A121, C58, C68
Cobian, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D100
Cocanour, C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C45
Cochran, K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A146
Cochrane, B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A150, B44
Coeli, C M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C50
Cohen, C I . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A39
Cohen, L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A38
Coimbra, R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D65
Colburn, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D112
Coll, P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A26
Collins, L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C73, C76
Colloborative, G . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D60
Colloborrative, G . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D56
Colon Cartagena, W . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B19*
Colon-Emeric, C . . . . . . . . . . . . . . . . . . . . . . . .B28, C74*, P45
Colon-Nieves, P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C72
Combest, T . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C98
Comrie, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C162
Conell-Price, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P1
Conley, Y . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B36
Connor, K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B105
Constantine, S M . . . . . . . . . . . . . . . . . . . . . . . . . . . .A97*, C63
Coon, D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D75
Cooper, B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A73
Cooper, D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C132
Corazzini, K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C74
Corbie-Smith, G . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A94
Corcoran, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C64
Cordts, G . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B117
Cornejo, K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A68
Cornell, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B62*
Cornely, O . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C37
Corrado, L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A117, D129
Corrigan, M V . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C87
Cotrell, V . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C79
Counsell, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P14
Counsell, S R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A84, P44

A UTHOR
I NDEX
Covinksy, K E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A105
Covinsky, K . . . . . . . . . . . . . . . . . . . . . . . . . .B31, B98, D6, D44
Cox-Vance, L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D22
Craft, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P18
Crist, K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B155
Croft, L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A164
Crook, D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C37
Crosby, G . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C144
Crowe, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A50
Cruz, D M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C142
Cruz, E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A41
Cruz, N M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B139*
Cruz-Knight, W . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C67
Cuadrado, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D106, D107
Culley, D J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C144
Cummings, D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B154
Cummings, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D27*
Curb, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B120, B157
Curb, J D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C53
Curcio, T . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C38
D’Agostino, R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B128
D’Amico, F . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C85
D’Silva, K A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B136*
D’Souza, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B118*
Dahiya, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A30, A141*
Dahm, P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B136
Dalal, P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A140*
Dalbey, D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D34
Dale, W . . . .A103, A110*, B3, B91, B111, B149, B150, B171,
D150, D152, D162, P4
Daly, J W . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A25
Damaraju, C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C54, C93
Damodarasamy, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P19
Dang, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D136*
Dang, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D100*
Daniels, M J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P32
Danve, A S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C3*
Darvin, K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D93
Date, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D18
Dave, D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D18
Davis, B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P23
Davis, B R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D36
Davis, D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D117
Davis, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B157
Davis, K L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A102, B153
Dayanand, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D100
De Beritto, T V . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A136*
De Marchi, R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C46
de Rekeneire, N . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B43*
Deal, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A37, C41
Deban, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A109
Debonnaire, D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C80
DeCaria, J E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B82*
DeCherrie, L V . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D101
Decker-Maruska, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D70
Defillo Draiby, J . . . . . . . . . . . . . . . . . . . . . . . . . . .D57*, D82*
DeGolia, P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A69
DeJesus, R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A114*
delCarmen, T . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A77
Demiris, G . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C94
Demons, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A72
Demons, J L . . . . . . . . . . . . . . . . . . . . . . . . . . . .D30, D36*, P23
Demontiero, O . . . . . . . . . . . . . . . . . . . . . . . .B140*, C129, P15
Dennis, R a . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B164
Dennis, R A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B159
Denson, K . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D56, D60*, P35
Denson, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D56
Dentino, A N . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C69*
Desai, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D162
Desai, R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A105
Deschodt, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D32*
Dethmers, D L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A103
Detroyer, E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C80*
Devarajan, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D63
Dey, A B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A89, A157
Di Bari, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B41*, C146
Diamond, P M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D26
Diaz de Cerio, M . . . . . . . . . . . . . . . . . . . . . . . . . . .D106, D107
Dietrich, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D105
DiGuiseppi, C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P6
Dillon, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A39
Dimaano, L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B85*
Dinescu, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A112, C68*
Ding, Q . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C1*
Ding, Y . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D132
Diniz, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B1, B2
Diniz, A R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C44*
Diniz, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B1, B2
Dlugacz, Y . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A117, D86
Dobbels, F . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C80
Doberman, D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B117
Dobracki, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B73*
Dodson, J A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D140*, P2*
Dohrenwend, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C160
Dolansky, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A160
Donaghey, B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D105
Donahue, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D20
Dong, H . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A73
Dong, I . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B66
Dong, X . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A111*
Donohue, J M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B49, B109
Donovan, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B22, C106
Dorr, D A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C109*
dos Santos, C M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C46*
Dosa, D M . . . . . . . . . . . . . . . . . . . . . . . . .B34*, B121*, C110*
Dowal, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B119
Downs, P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D27
Drickamer, M . . . . . . . . . . . . . . . . . . . . . . .B65, D20, D57, D82
Drost, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B69
Dubbert, P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B164
DuBeau, C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A64, A65, B5
DuBeau, C E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C34*
Dubin, L J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D125*
Dubina, E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B80*
Duff, K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C139
Duggal, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A105
DuMond, M E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D49*
Dunbar, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C119*
Duncan, C L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C140*
*Indicates presenting author
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A UTHOR
I NDEX
Dunn, C M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A126
Dunton, N E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P32
Duque, G . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B140, C129, P15*
Durst, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D48
Duthie, E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P35, P35
Duthie, E H . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D56, D60
Dworkin, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D63
Dyer, C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A46, B75
Dyer, C B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B93, D26
Eaton, W W . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C48
Ebbert, D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A78
Echt, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P33*
Eckmann, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A166
Eckstrom, E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C79*
Edes, T . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A108*, B115, P10
Edwards, D S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D5
Efeovbokham, T . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D114
Efeovbokhan, T . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A23
Efeovbokhan, U T . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A31
Efoevobokhan, U T . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C122
Efron, D T . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A162
Egras, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C73
Eisenhower, C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C85*
Eiss, B M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D41
El Zammar, Z . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C125
Elarabi, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D23*
Ely, W . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A47
Emmett, T . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A99
Eng, C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P40
Eng, J A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A85, D113*, P3*
Eng, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A78
Engel, P A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A113*
Engelberg, R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B51
Erickson, M A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A131
Eriksson, B I . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D164
Erlichman, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C44
Ernst, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B32*
Ersek, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B149, D150
Erslon, M G . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A163
Ertle, D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D104
Escamilla, A G . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A43, A44
Escarce, J J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A98
Eskildsen, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B67*
Espinal, C M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C17*, C122*
Espino, D V . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C47
Espinoza, S . . . . . . . . . . . . . . . .A87, A119*, C96, D93*, D94*
Esteban, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D128
Evans, L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D75
Evans, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A122*
Fabiny, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D73
Fabrizio, C A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C138*
Faigman, D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C105
Fain, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A125
Fairfield, K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C165
Fan, C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B72
Fan, L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B3, B91
Farber, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A18, D124
Farber, M O . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A47
*Indicates presenting author
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AGS 2012 ANNUAL MEETING
Farias, L L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A81
Farrell, T W . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A82*, A83*
Faselis, C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A95
Faulk, C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A146
Faurot, MPH, PA, K R . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A36
Fedarko, N . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B59
Federman, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P43
Feiereisel, K B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D61
Feldman, E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C38
Feldman, R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B108
Felice, F M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C61*
Felix, M.D., A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A36
Feng, H . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C143
Feng, M A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D163*
Feng, Z . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B121
Fernandes, N . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A147*
Fernandez, E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B123
Fernandez, H . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C66
Fernández Aviles, F . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B152
Ferrucci, L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B99, P29, P30
Finkelstein, E . . . . . . . . . . . . . . . . . . . . . . . . . . . .C113*, C126*
Fischman, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A18
Fiutem, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P22
Flacker, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A124
Flamaing, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D32
Fleegle, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C73
Fletcher, R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A95
Fogel, J F . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C77
Foley, K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D62
Foley, K T . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P13
Fong, K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B124
Fonseka, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D109*
Ford, C R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D62
Ford, P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D53
Forman, C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A144, C151*
Fortinsky, R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B151
Fosnight, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D104
Fox, C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B111, B146
Fox, C S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B128
Foy, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C106
Fracchia, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B41
Fraenkel, L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P28
Francini, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C146
Franco, E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C24*
Franco, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P35
Francois, S J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B165*
Frankel, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B95, D148
Fraser, S A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A109
Freedman, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C162
Frentzel, E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C49
Fried, T . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B52, B53, P2
Friedman, H . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D122, D123
Friedman, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C82
Friedman, S M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A20, D148
Friedman MD, MPH, AGSF, S M . . . . . . . . . . . . . . . . . . . .B95
Frisoli, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B1*, B2*, C44
Frölich, L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D27
Fromme, E K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D138
Frontini, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D90
Fuez, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P5

A UTHOR
I NDEX
Fujikami, G . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C91*
Fukushima, F B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C50
Fuller, K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C126
Fumagalli, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C146
Fung, C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B89
Fung, C H . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B158*
Furman, C D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A22
Furuakwa, K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C42
Furuno, J P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D138
Gagnon, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B86
Galecki, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B47
Galicia-Castillo, M C . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B148
Galindo, D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D160
Gallagher, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D73
Gallego, E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C51*, D39
Galli, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B72
Galvez, A M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B67
Galvin, J E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A139
Gammon, W . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D73
Gan, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P41
Ganem, F . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A54, A55
Ganesan, G . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P41
Gangavati, A S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C71*
Ganz, D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C127
Ganz, D A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B106
Gao, B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C15*
Gao, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A88
Garcia, C H . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C96*
Garcia, N I . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A59*
García, C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D106, D107
García - Cárdenas, V . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C51
García Navarro, J . . . . . . . . . . . . . . . . . . . . . . . . . . . .C164, D40
García-Cardenas, V . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D39
Gardner, C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C123*
Garfinkel, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C49
Garner, K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B164
Garner, K K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B159
Garrido, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B4
Garrido, A I . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C8*
Gau, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A144, C151
Gaubert-Dahan, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A33
Ge, N . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C1
Gehl, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D60
Gelfman, L P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C66
Genao, L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B40*
Gensini, G . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B41
Gent, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D164
George, L V . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C32
George, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D147*
George, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C98
Gerding, D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C37*
Gi, B H . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A93
Gil, L A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A54, A55, A81
Gill, T . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B43
Gill, T M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B45, P28
Gilliam, R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B20
Gilligan, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A125
Gilmore, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C103
Giordano, C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C76
Giulietti, C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C146
Givens, J L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B50
Gleason, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B132
Gleason, L J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D148*
Gleich, G J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B135
Goedken, D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B115
Goel, H . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A125
Goetz, M C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D156
Gold, M S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A34
Goldberg, R J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B46
Goldberg, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D133
Goldenberg, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C153*
Goldenheim, A M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B102*
Goldman, H B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C35
Goldstein, D J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B125
Goldstein, N . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P2
Golightly, Y . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B133
Golightly, Y M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B21
Gomez, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D106
Gómez, C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D106, D107
Gómez, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D107
Gomez-Marin, O . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D100
Gommers, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C80
Gomolin, I H . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C100
Gonzales, R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A116*
Goode, P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B132
Goodson, W . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A149*
Goodwin, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D99
Goodwin, J S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B107*, P11*
Gopalraj, R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C6
Gopaul, K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D89
Gorawara-Bhat, R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A103*
Gorbach, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C37
Gorbien, M . . . . . . . . . . . . . . . . . . . . . . . . . . .A5, A6, C18, D19
Gordon, B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A37, C41
Gordon, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D73
Goren, E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D71
Gorospe, E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B56*
Gosian, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A155
Gottesman, E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C89
Gottesman, E M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A126
Gottlieb, R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D36, P23
Gottlieb, S H . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C15
Gottschalk, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D161
Goubran, R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B162
Gould, E M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A35
Grady, D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C33
Graham, S M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D31
Grammas, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D20*
Grandinetti, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B157
Grandinetti, T . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B157
Graves, A D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B64
Gray, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P31
Gray, S L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B81
Green, P S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P18
Greene, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B11
Greene, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B87*
Gregg, K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P29
Gregory, W . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P25
Greysen, R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A105*
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A UTHOR
I NDEX
Griebling, T L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C34
Griffith, J L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D55
Grissom, C K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P20
Griswold, M E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P29
Groce-Martin, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D72
Grooms, L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C20
Grossberg, G T . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C140
Grossman, S N . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A128
Gruber-Baldini, A L . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B168*
Gruenewald, T . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B32
Gryczynski, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B117
Guerra, C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D128
Guerrant, R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B137
Gugliucci, M R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D58
Guh, E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C145*
Gulati, G . . . . . . . . . . . . . . . . . . . . . . . . . . .A16, A17, D3*, D4*
Gulati, S . . . . . . . . . . . . . . . . . . . . . . . . . . .A16*, A17*, D3, D4
Guo, G . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A104
Guo, N . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A87*
Gupta, A . . . . . . . . . . . . . . . . . . .B143*, C12*, C25, C130, D24
Gupta, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A16
Gupte, G . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A85, D113
Gure, T . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B47*, B78
Gurnani, A S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A139
Gurwitz, J . . . . . . . . . . . . . . . .A64, A68, C81, C106, D73, D74
Gurwitz, J H . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B46
Gutierrez, E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B152
Gutkoski, T P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A57*
Guzik, H . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C130*
Gyurmey, T . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A26*
Ha, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B47, B78
Haan, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D44
Habegger, L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A38*
Hackney, M E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C84
Haddon, L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B114
Hade, E M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B120
Haider, A H . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A162
Hajduk, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B46
Hajjar, E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C73
Hak, V . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C148
Halade, D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A87, D93
Hall, M H . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B94
Hall, W J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D15
Hallen, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D7
Halm, E A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A60
Halphen, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B93
Hambridge, H L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A162
Hamdan, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A86, B90
Hameed, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A118*
Hamrick, I . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B71
Han, H . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D132
Han, L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P28
Hanlon, J T . . . . . . . . . . . . . . . . . . . . . . . . . . . .B49, B81, B109*
Hanoi, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B12
Hans, D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B84, D149
Hanson, A J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P18*
Hanson, G . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C115
Hanson, L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B20
Hanson, L C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B116
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Harada, C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D62
Hardy, S E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A52, A159*
Haring, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B100*
Harrigan, R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B157
Harris, E S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P20
Harris, T . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A137*, B48
Harris, T B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P30
Harrold, L R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C106
Hartley, C J . . . . . . . . . . . . . . . . . . . . . . . . . . . .A62, C61, C149
Hartvigson, P E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A131*
Harvath, T . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C79
Harvey, S M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A134*
Hasan, O . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B103
Hashim, T . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A92*
Hastings, S N . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A42*, D35
Hathaway, C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B6*
Haukoos, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P6
Hausman, D B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B48
Hausman, S P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C132
Haut, E R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A162
Hava, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A36*
Hawkins, K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C161
Hawley, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C107
Hayashi, T . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B60*, C1
Hayes, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A80, B71
Hayley, D C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C124*
Hayward, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C121*
Hazelet, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D76, D108
Hazelett, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A67, B69
Hazelett, S E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D104
Hazuda, H . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C96, D94
Hecht, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D133*
Heckler, C E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B3
Hede, S V . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A62*
Heflin, M T . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D68
Heh, V . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A144*, C151
Heilman, K M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C12
Heim, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A132
Heinen, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A74, A106
Hemmerich, J A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B171*
Henault, L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P9
Hendrix, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D31
Herbert, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D81*
Herman, L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A155
Hernan, P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D128
Herndon, L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D103
Herr, K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B149, D150
Hersh, L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C73
Hess, R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P25
Hess, T . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C107
Hesse, K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A156
Hewston, L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C76
Hibbs, R M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A158*
High, K P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D122*, D123*
High, N . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D141
Higuchi, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B122*
Hile, E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B96
Hile, E S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B79*, P30*
Hilgert, J B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C46
Hill, L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D65*

A UTHOR
I NDEX
Hillstrom, T J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C121
Hilton, T N . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D15
Hirani, S A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A162*
Hirano, H . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C95
Hirsch, C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C88
Hirsch, C H . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C45*
Hobgood, C D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B29
Hobgood, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A120*
Hochhalter, A K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D111
Hochschild, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B75
Hochschild, A E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D26
Hodroge, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A91*
Hogan, D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C162
Holcombe, R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P16
Holcroft, C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A109
Holland, N . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A28, C5
Holmes, E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A39
Holt, C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D141
Holtz, L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B144
Hoover, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A145
Hopper, K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B53*
Horney, C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A42, D35
Hornyak, V . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P24
Hornyak, V A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B166*
Horton, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A41*, A45*
Horwitz, L I . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A105
Hosler, M R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A23
Hossain, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P10
Houston, D K . . . . . . . . . . . . . . . . . . . . . . . . . . .B48, D36, P23*
Hovanes, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C103
Howard, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B11*
Howe, J L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D55*
Howell, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B132
Howell, T . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C72
Hshieh, T T . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B119*
Hsieh, C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C73
Hsu, D C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C88*
Hu, H . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B70
Huang, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C33*, P25*
Huang, D L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C111*, C159*
Huang, E S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D152
Huang, Z . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D33, D102
Hubbs, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D161*
Hughes, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B123*
Hughes, T . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C4
Hughes, T B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C104
Hugo, F N . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C46
Hui, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B130
Hui, S L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A47
Huie-Li, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D119
Huisingh-Scheetz, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D59
Hummel, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B47
Hung, W W . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A126*, P43*
Hunold, K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B27
Hunt, G . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D105
Hurwitz, E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D47
Husain, N . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C103
Hutchison, L C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D67*
Hwang, U . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B30
Hyde, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B34, P39
Hyer, K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B121
Hylek, E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B167
Ifon, D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A121
Iloabuchi, T . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B4, C8
Iloabuchi, T C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P44*
Iloputaife, I . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B86
Imam, S M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D9
Imam, S N . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C55
Imran, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C55
Ina, K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B60
Inaba, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B68, B124*
Inghan, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B1
Inouye, S K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B119
Into, F . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A138
Intrator, O . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B34, C110
Ioannidis, G . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A51
Iraqi, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C4*
Ireton, E S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A59
Irvine, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C162
Irving, K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C80
Isaacs, C G . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B27*
Isabelle, V . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A109
Islam, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B74*, C83*
Itticheria, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C6*
Iturrino, D M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D84
Iwata, I . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D52*
Izhar, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C12, C25, D24*
Izumi, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A151*, C155
Jaber, R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B14*
Jaccard-Ruedin, H . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C128
Jackson, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P37
Jacob-Filho, W . . . . . . . . . . . . . . . . . . . . . . . . . . .A54, A55, A81
Jacobs, J M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B134*, D145
Jahn, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A155
Jain, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B59
James, K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A85, D13*, D113
James, T C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A84*
Jamshed, N . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A66*, B70
Janardhanan, T . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A39*
Janes, K F . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D58*
Jaume-Anselmi, F . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C152
Javelot, H . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D37
Jawad, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D130*
Jeffery, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D126
Jenkins, C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B7*
Jennings, J R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A132
Jensen, L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C117
Jensen, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D156
Jerome, R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A39
Jette, A M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B160
Jetter, T . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A86, B90
Jiang, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C153
Jinhui, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A51
Johansen, K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A68
John, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B138
John, P M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D152
Johnson, E F . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B88
Johnson, J C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D72
*Indicates presenting author
AGS 2012 ANNUAL MEETING
S251

A UTHOR
I NDEX
Johnson, K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A124, P25
Johnson, K L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C158, D158
Johnson, K S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A42, D97*
Johnson, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C101
Johnson, R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P6
Johnson, S B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D9
Johnson, T M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C34
Johnson, II, T M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B76
Johnston, C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B108
Johnston, C W . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C75*
Jolly, T . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A37*, C41
Jonas, W . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A154
Jones, B G . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C69, D5
Jones, R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A95, D109
Joosten, E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C80
Jordan, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B133
Jordan, J M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B21
Jordan, Q . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A124
Joseph, D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B17
Josephson, K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B89, B158
Josephson, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D162
Joshi, K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D33
Jouldjian, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B89, B158
Jovancevic- Misic, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D28*
Juncos, J L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B76
June, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A155
Justice, A C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A105
Kabsoun, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C134
Kaiser, R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A112, C68
Kakkar, A K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D164
Kakwan, U . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A27*
Kalayjian, R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B141*
Kalender-Rich, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C124
Kalender-Rich, J L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B66*
Kalva, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P20
Kamal, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B124
Kamholz, B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B118
Kamm, A M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B171
Kanaan, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B22, C106
Kang, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D132
Kaplan, D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C113
Kaplowitz, L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C113
Kapoor, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B167*
Karanam, C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D100
Kardachi, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D78
Kariolis, I . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C63, D33*
Karter, A J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D152
Karumanchi, P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C55
Karunadharma, P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P19
Kashan, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A148*
Kashyap, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D87*
Katon, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A135
Katon, W . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B42
Katz, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B167
Katz, P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C110
Kaul, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C120*
Kaushik, V . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A29*
Kawai, F . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B147*
Kay, G . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C35
*Indicates presenting author
S252
AGS 2012 ANNUAL MEETING
Kayani, N . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D76
Kayani, N A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A67*, B69*
Kaye, K S . . . . . . . . . . . . . . . . . . . . .A43, A44, A48, B35, C101
Kearsley, L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D36, P23
Kelley, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B104
Kelley, A S . . . . . . . . . . . . . . . . . . . .A70, C66*, D101, P7*, P43
Kelley, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A142*
Kelley, S D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A163
Kelz, R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C64
Kennedy, G J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A123
Kennedy, R E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A50
Kenny, A M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P22
Kenny, R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B72
Keough, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D73, D74
Kerins, G . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D140
Kerr, E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B112, P8
Kerr, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B155
Khalid, F . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A161
Khalili, D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A40
Khan, A . . . . . . . . . . . . . . . . . . . . . . . . . .A68, B80, C72*, C99*
Khan, B A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A47
Khan, S A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P21
Kheirbek, R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A95*
Khoo, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A116
Khosla, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A19
Khosravanipour, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B67
Kiel, D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P33
Kiely, D K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A90, A96
Kikuchi, E L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A81
Kilpatrick, B S . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A102, B153
Kim, D H . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B33*
Kim, H . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C95*, D80
Kim, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C95
Kim, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A164*
Kind, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C103
Kind, A J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C117*
Kindler, H . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P4
King, A C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A149
King, B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C103*
King, K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A155
kinosian, b . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B115*, P10*
Kinosian, B . . . . . . . . . . . . . . . . . . . . . . . . . . .A108, C114, P40*
Kinzie, V . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A146
Kirk, G . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A63
Kirschenbaum, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B126
Kistler, C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B113, B114
Kistler, C E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B27, C107*
Kitt, E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C23*
Kitzman, D W . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B48
Klay, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D16
Klepac, L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A108
Kline, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C57
Knebl, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A134
Knell, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A100
Knight, S J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P5
Knoefel, F . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B162
Ko, F . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A18
Kochersberger, G . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C110
Kodama, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C42
Koh, E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P41

A UTHOR
I NDEX
Kohn, N . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B143
Kojima, G . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C53*
Kojima, N . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C95
Komiyama, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C135*
Koo, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D144
Kopacz, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D102*
Kopits, I . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D13
Kopits, I M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B160*
Korc-Grodzicki, B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A165
Kordahl, R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C117
Kosc, E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C132
Kostas, T . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C116
Kostas, T R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B97*
Kothari, R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A11*
Kotwal, A A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A110
Kowgier, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C162
Koya, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D21*
Kozikowski, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C57
Krahn, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C162
Krall, D M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C144*
Kraus, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P25
Kraus, S R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C34
Kraus, V . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B133
Kraus, V B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B21
Kravvariti, E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C112*
Kressig, R W . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D27
Krieg, C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D149
Krieg, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B84, D149*
Krishna, A . . . . . . . . . . . . . . . . . . . . . . . . . . . .A43, A44, C101*
Kristof, L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B151*
Kritchevsky, S B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B48
Kropp, D J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D104
Kuchibhatla, M N . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D97
Kulkarni, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A9
Kulkarni, S P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C3
Kuller, L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B36
Kumar, H . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C98*
Kumar, N . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A157
Kumar, P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A157*
Kumari, D . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A9, B12, D1, D2
Kunik, M E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B54
Kuo, Y . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B107, D99, P11
Kurata, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A61*
Kusz, H . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C160
Kwak, K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D142*
Lachs, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P42*
Lachs, M S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C102
LaCroix, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B44, B120, P31
LaCroix, A Z . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A150
Lagoo-Deenadayalan, S . . . . . . . . . . . . . . . . . . . . . . . . . . .B170
Lahoud, O B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D133
Lai, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C91
Laird, R D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B116
Laiteerapong, N . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D152
LaMantia, M A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B29*
LaMori, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C54, C93
Lampert, R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P2
Lamy, O . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B84, D149
Landay, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B141
Landerman, L R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A42
Lands, R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A91, A142, A143
Lane, K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B130
Langa, K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B47
Langa, K M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A56
Langbaum, J B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D141
Langlois, C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D141
Lansing, B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C59
Lapane, K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D95
Lapid, M I . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D92
Lasater, K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C79
Lassen, M R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D164*
Laszlo, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B84
Lathia, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C147
Lau, D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B149
Launer, L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B122, C53
Laura, H . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B63
Le, M T . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B125*
Le, T . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C94
Leal, I . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A152, A153
Leavitt, J A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D92
Lecea, N . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A148
Lederman, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B141
Lee, D S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D138
Lee, H B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C48
Lee, K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D153*, P39
Lee, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B105, P38
Lee, P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B78
Lee, R H . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P45*
Lee, S . . . . . . . . . . . . . . . . . . . . . . . . . . .A15*, A32, B17*, D130
Lee, S J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P1*
Lee, T . . . . . . . . . . . . . . . . . . . . . .A80*, A107*, B71, C55, D79
Lehana, T . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A51
Leibowitz, D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D145
Leiding, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A5, A6, C18
Leiding, M J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D19
Leiferman, K M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B135
Leiter, A C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B126*
Leland, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D117*
Lemay, C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C106*
Leng, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A63
Leo-Summers, L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B43, P28
Leon, L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C89
Leonard, B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C134, D75
Leone, A F . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C157
Leong, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A104
Lepcha, N . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A112*
Lerch, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D70*, D134*
Leslee, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C33
Lessard, D M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B46
Lesser, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C130
Lester, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D34
Lester, P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C100
Leucker, T . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A24*
Levenson, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B103*
Leverenz, J B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P18
Levey, A I . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B11
Levin, M A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P27
Levin, S N . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B46*
Levine, A C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B126
*Indicates presenting author
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A UTHOR
I NDEX
Levine, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D45*
Levine, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P37*
Levy, C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B115
Lewis, C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C107
Li, H . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A63
Li, I . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C132*
Li, L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B169
Li, T . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A129
Li, Y . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D151
Liang, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B78
Liang, L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A98
Liao, D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A57
Liberman, T . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A117, D129
Lichtenberg, P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A44, C101
Lidsky, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B170
Limaye, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A75*, A76*, A79
Limm, B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C104*
Lin, C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B55
Lin, F R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B169
Lin, H M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P27
Lin, J C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D137*
Lin, N . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A128*
Lin, P S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A93
Lin, R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A39
Lin, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C24
Lin, S M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A81
Lin, Y . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D99
Lindeman, K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D151*
Lindenberger, E . . . . . . . . . . . . . . . . . . . . . . . . .B101, C58, C66
Lindsey, M L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A87, B142
Lingler, J H . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A71
Lipman, H . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C60*
Lipsitz, L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B86, C71
Lipsitz, L A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B33
Lisse, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A145
Litrivis, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D124
Little, M B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A166
Liu, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C67*
Liu, C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B128*
Liu, D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C108*
Liu, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P32
Liu, P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C36
Livote, E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B101, C89, P43
Loehrer, P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B130
Logio, L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A77, P36
Long, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C131
Longenecker, F . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C26*
Longstreth, W T . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A98
Loquias, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D160
Lough, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B86*
Louie, T . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C37
Lowenstein, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B145, P6
Lowery, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D99*
Lowman, J D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P13
Lowry, B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C124
Lowry, K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B161*
Loza-Diaz, G . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C129*, P15
Lu, F . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C52*
Lu, P H . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A136
Lui, F . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C53
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Lum, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C7*
Luna, G . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C29*
Luo, F . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C1
Luong, K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D124*
Luque, A E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D15
Lutsky, L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D86
Luz, C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C90
Lyass, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B128
Lyketsos, C G . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C138
Lyles, M F . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D30*
Lyons, K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C76
Ma, N . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B168
Maaravi, Y . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D145
MacKenzie, T A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B37
Mackin, L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P39
MacKnight, C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C162
MacLean, E W . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B129*
Macnow, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C64*
Madan, R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A115*
Madero, G . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A133
Madrigal-Leer, F . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C39*
Magaziner, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B168
Maheshwari, N . . . . . . . . . . . . . . . . . . . . . . .A9*, B12*, D1, D2
Mahnken, J D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B66
Mahoney, J F . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A71
Maiaroto, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D126
Mailliard, L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D59
Majeski, J D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C44
Majid, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D155*
Major, K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B84*
Makela, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C29
Makris, U E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P28*
Malik, K S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D14*
Mallon, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D100
Malmstrom, T K . . . . . . . . . . . . . . . . . . . . . . . . . . . .C140, C142
Malone, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C72, C99
Manchester, G . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A65
Manini, T . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B120
Manocha, D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B13, C125*
Manor, B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B86, C136*
Manov, N . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A13
Mansour, L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C2, C56, D127
Manu, E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C59*
Manwani, B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A63, B61
Manwani, B R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B55*
Marallag, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P19*
Marcantonio, E R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B168
Marchionni, N . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B41, C146
Marcum, Z A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B49*
Mariano, N . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D102
Marino, R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C165
Marottoli, R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D126
Marottoli, R A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A49*
Marszalek, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A117
Marszalek-Litauska, A . . . . . . . . . . . . . . . . . . . . . . . . . . . .C57*
Martelli, V . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A109*
Martin, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B89, B158
Martinez, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B123
Martinez, L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D52, D68*

A UTHOR
I NDEX
Martínez, E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C164*
Martínez Almazán, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D40
Masaki, K . . . . . . . . . . . . . . . . . . . . . . . .B68, B120, B122, B157
Masaki, K H . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C53
Masick, K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D86
Massaro, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B128
Mather, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A119
Matining, R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B141
Matti-Orozco, B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A8, C16
Mattox, K M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C32
Matusevich, D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D128
Mazor, K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C106
McBride, J M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B116*
McCann, R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B62
McCormick, K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C82
McCormick, K R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D148
McCormick MD, PhD, K R . . . . . . . . . . . . . . . . . . . . . . . . .B95
McCranor, B J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B139
McCreath, H . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B106
McCullough, L B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B54
McCullough, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B18*
McDonough, C M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B160
McGarry, K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P7
McGee, S . . . . . . . . . . . . . . . .A64, A65, A68, C81, D73*, D74*
McGhee, H R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D111
McGlann, G . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A43, A44
McGough, E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C94
McGregor, J C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D138
McIntosh, K P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D12*
McLean, S A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B27
McMahan, R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P5
McMahon, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D79
McNabney, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D142, P40
McNamara, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C59
McNett, H . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D63
Medina Munoz, L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C55
Meeks, W M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P29
Meganathan, K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D110
Mehr, D R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C49*
Mehta, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A77, P36
Mejnartowicz, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D11
Melis, R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A74, A106, D77
Mello, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C146
Melstrom, E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B171
Men, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P20
Mendieta F., M G . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B152*
Merkin, S S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A98
Messina, F C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B29
Meulenbroek, O V . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C133
Meyers, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A102
Meyers, J L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B153
Mi, D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P44
Miao, Y . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B31
Migliori, R J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C161
Milisen, K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C80, D32
Miller, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B67
Miller, B L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A128
Miller, D K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B29
Miller, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C37
Miller, M L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D31
Miller, N . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A27
Miller, R K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D71*, D72*
Mills, W L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A155*, B54*
Min, L . . . . . . . . . . . . . . . . . . . . . . .B39*, B47, B78, B112*, P8*
Minani, T . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D75
Minnick, A F . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D105
Mintzer, M J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D69
Mion, L C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D105*, P32
Mir, T . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A117, D129
Mitchell, C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B113, B114
Mitchell, L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D62
Mitchell, S L . . . . . . . . . . . . . . . . . . . . . . . . . . . .A90, A96, B50
Mitnitski, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A122
Modak, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B138
Mody, L . . . . . . . . . . . . . . . . . . . . . . .A44, B35, B39, C59, C101
Moed, R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B160
Moffett, H H . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D152
Mohammed, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C134*
Mohile, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B3, B91
Mohile, S G . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A110
Mohler, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A125
Moiduddin, H . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C55*
Mold, J W . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B111
Molinuevo, J L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D27
Molton, I R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D156*
Moncada, L V . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B8
Monette, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A109
Monette, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A109
Monod, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B84, C128, D48*
Montero Odasso, M . . . . . . . . . . . . . . . .B74, C83, D88*, D89*
Montero-Odasso, M . . . . . . . . . . . . . . . . . . . . . . . . . .B82, C141
Montine, T J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P18
Montz, K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B144
Moodhe, N E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A126
Moons, P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D32
Moore, A A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A57, D137
Moore, C C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C47*
Moore, P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D104
Moore, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A37, A160, C41
Mor, V . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B121
Morano, B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A126
Moreira, D C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C50
Moreno, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C11
Moret, F . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C128*
Morgan, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A113
Morgan, I . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A73
Morgan, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B132
Morley, J E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C140, C142
Morris, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D109
Morrison, L J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D64*
Morrow, G . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B3
Mossello, E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C146*
Moudouni, D K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C49
Mouton, C P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C156*
Moye, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A155, B54
Moylan, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P39
Muir, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B74, C83
Muir, S W . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D88, D89
Mulgund, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A51
Mulligan, B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A155
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A UTHOR
I NDEX
Mulsant, B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C137
Mungthin, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A130
Muntner, P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B127
Murabito, J M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B128
Murphy, E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A65
Murphy, K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A46
Murphy, K M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D30
Murray, M D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A88
Mushiyev, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B12, D1
Musich, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C161
Muss, H . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A37, C41
Mustian, K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B3
Myers, D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P25
Myers, J S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D71
Mysiw, W . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B120
Nace, D A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A71
Nadkarni, N K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B163*
Naeim, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B91
Naessens, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C115
Naessens, J M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A127
Nagaraja, V . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A125*, A145*
Naglie, G . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C162*
Naik, A D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A155, B54
Najm, W . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A154*
Nakagawa, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A18*, B101*
Nanda, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A83
Naqvi, S S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A22*
Nassef, C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A38
Nathan, S N . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A21*
Nau, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B36
Navaratnam, P . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D122, D123
Nazir, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B64*, C8
Neal, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C79
Neamtu, D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C20*
Neiberg, R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B48
Nelson, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B133
Nelson, A E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B21
Nelson, C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C36*
Neukam, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B155*
Newman, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B36, B49
Newman, A B . . . . . . . . . . . . . . . . . . . . . . . . . . .B81, B109, P30
Newman, D K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C34
Newman, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B108*
Newman, R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A80
Newton, E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B33
Ng, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B140
Ng, W K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C86
Nguyen, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P35*
Nguyen, L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A128
Ni, P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B160
Nicholas MD, MPH, J A . . . . . . . . . . . . . . . . . . . . . . . . . . . .B95
Nichols, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D7
Nicklas, B J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D30
Nicolas, K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B87
Nidadavolu, L S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P21*
Niedernhofer, L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B36
Niedernhofer, L J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P21
Nielsen, M E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D163
Nieri, W . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C134, D75
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Nijgha, C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D83
Nitta, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C42*
Nnodim, J O . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D80*
Nonnenmacher, C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D37
Norman, R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P34*
Norris, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D71
Norris, C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A39
Nouryan, C . . . . . . . . . . . . . . . . . . . . . . . . . . . .C57, C130, D155
Novak, V . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C136
Nurpeisov, V . . . . . . . . . . . . . . . . . . . . . . . . . . .A28*, A58*, C5
Nutescu, E A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C54, C93
Nwaiwu, O . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C49
Nye, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B71
O’Brien, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P1
O’Connor, K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D75
O’Halloran, A M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B72*
O’Leary, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B53
O’Toole, E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A69
Oakes, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A115, D136
Oakes, T M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C36
Oates, D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B102
Obering, C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A78, A100
Odden, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D44*
Ogbevire, C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B150
Oh, E S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C138
Ohl, M E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A105
Ohuabunwa, U . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B67
Ohuabunwa, U K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A124*
Okoronkwo, S M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B142*
Okura, T . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A56*
Olde Rikkert, M . . . . . . . . . . . . . . . . . . . . . . . .A74, A106, D77
Olde Rikkert, M G . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C133
Oleson, E . . . . . . . . . . . . . . . . . . . . . . . . . .A64*, A65*, B5, C81
Olmedo, B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D11
Olsen, G S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C109
Olson, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A5, A6, C18
Olson, J C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D19
Omonte, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C51, D39*
Ong, E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A9, B12
Ong, E C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D1*, D2*
Ooi, W . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A30*, A141
Ootsuki, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C42
Oreja, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C51, D39
Ornstein, K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D101
Orso, F . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B41
Ortiz, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D39
Ortiz, J R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D114*
Ortiz - Alonso, F . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C51
Orwig, D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B168
Osborn, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D53
Ostfeld-Johns, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B95*
Ostir, G . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C92*
Otero, D M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C19*
Otsuka, R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A12*
Ouchida, K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A77, P36*
Ouslander, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D103
Ouslander, J G . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C34
Owens, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A132
Ozminkowski, R J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C161

A UTHOR
I NDEX
Paasche-Orlow, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P9*
Pacchia, C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B90
Pacchia, C F . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A86
Padala, K P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B159, B164
Padala, P R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B159, B164*
Padilha, D P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C46
Padua, K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C99, D118*
Pagel, P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C99
Palacios, J C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D69
Palla, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D9*
Palla, K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D79
Pallan, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A51*
Palli, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D42
Palmer, M H . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D151
Palsson, O S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B129
Pan, C X . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A118, C63
Pan, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A37, C41
Pandey, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A121*, C58
Pandya, N . . . . . . . . . . . . . . . . . . . . . .A102*, B153*, C54, C93
Panzer, V . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A138*
Paolo, A M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B66
Papademetriou, V . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A95
Pappas, T . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B170
Paquin, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B97
Paquin, A M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C116*
Pardasaney, P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B160
Park, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B42*, B89*
Parker, K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B57*
Parker, M M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D152
Parker, R W . . . . . . . . . . . . . . . . . . . . . . . . . . . .A31, C17, C122
Parker, V . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B102, D47
Parson, P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D95
Parulekar, M . . . . . . . . . . . . . . . . . . . . . . . . . . .C2, C56, D127*
Pasquale, D A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A7
Pasquale, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D74
Patel, B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C5
Patel, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A96
Patel, N K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C17, C122
Patel, P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D160
Patel, R K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C35
Patel, T . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A119
Patrick, K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D65
Patrick, L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B162*
Patterson, C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C162
Paul, T . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C67
Paulk, M E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A60
Payne, C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B67
Pearman, B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A91
Pecanac, K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C103
Pecorella, L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C146
Peddagovindu, B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B5*
Peduzzi, P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A49
Pejovic, V . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D31
Pekmezaris, R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C57, C130
Pena, I . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P17*
Peña-Cruz, F . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B139
Pénard, N . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B72
Penfield, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B56
Peng, D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B105*
Peniston, J H . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A34
Penmetsa, G K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B10*
Penrod, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P43
Perahia, D G . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C36
Peralta, C A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D44
Pereira, F A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P17
Pereira, G . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B27
Pereira, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A117*, C57
Perera, S . . . . . . .B49, B79, B81, B94, B96, B156, B161, B163,
D28, D157, P24
Pereyra, N F . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B152
Perez, F . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B4, C8
Pergolizzi, J V . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A35
Periyakoil, V . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B147
Perjar, I . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B133*
Perkal, M F . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D126
Perkins, T . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A47
Peron, E P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B81*
Perry, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A74, A106
Peterson, C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B85
Peterson, D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D38
Peterson, E N . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D154
Peterson, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A78
Petit, C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C157*
Peto, T . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C37
Petrella, R J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B82
Petrovitch, H . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B122, B124
Pettinger, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P31
Petz, S D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C111
Pham, T . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A62
Phelan, E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D81
Phillips, A T . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P27*
Phillips, C D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C49
Philp, I . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C131*
Pickens, S L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B93*
Pickney, C M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C101
Piecre, J R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B88
Pierre-Jacques Williams, M . . . . . . . . . . . . . . . . . . . . . . . .C109
Pignone, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C107
Pillemer, K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C102, P42
Pina, I L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P22
Pinheiro, R S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C50
Pinheiro, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C74, D52
Pinidbunjerdkool, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A130
Pinkerton, R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B137
Pinto, E T . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C44
Planoutis, K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P16
Platts-Mills, T F . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B27
Poddig, B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D79
Polite, B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P4
Pomidor, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C65*
Poole, P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A38
Poon, I . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D83
Poorzand, P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A128
Porter, K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C74
Powell, D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D3
Prager, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D78*, D143*
Prakash, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D146
Prerost, F J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C62*
Previdi, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D127
Protas, E J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D139
*Indicates presenting author
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A UTHOR
I NDEX
Pschirer, J P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A71
Psillides, D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C2*
Pugh, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B38
Pugh, M J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A45
Pugnaire, M . . . . . . . . . . . . . . . . . . . .A64, A68, C81, D73, D74
Punjabi, N . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B59
Putnam, B D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C14*
Puymbroeck, M V . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C143
Quimbo, R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D42
Qureshi, W . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A161*
Rabinovitch, P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P19
Radeos, M S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D33
Radke, B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A53
Radwany, S M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D104
Raetz, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D53*
Ragsdale, L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B28*, D35*
Ragsdale, P S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D67
Rahbar, H . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A48, B35*
Rahgoshay, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A12, A20*
Rahman, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C115
Rahman, A S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A127
Raji, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D17, D99
Raju, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A166*
Ramasamy, B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A48, B35
Ramasamy, K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D146
Ramaswamy, R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A70*
Ramirez, K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B106
Ramirez-Rivera, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C152
Ramos, M E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D128
Ramsaroop, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A77*, P36
Ramsdale, E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P4*
Ramsden, R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P34
Ramsey, C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C48*
Ramsey, K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A146
Rana, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A13*, C85
Rana, S S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A13
Rand, C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C104
Rankin, K P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A128
Rao, N . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P14
Rashad, M A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A8*
Raskin, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C36
Rastogi, R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C121
Rasu, R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A100
Ratnarajah, G . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C30*, C40*
Rawl, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B130
Raymond, G L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C163
Raziano, D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P40
Reardon, G . . . . . . . . . . . . . . . . . . . . .C54*, C93*, D122, D123
Reckrey, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B18
Reckrey, J M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D101*
Recto, C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C112
Redding, J M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D7*
Reddy, A K . . . . . . . . . . . . . . . . . . . . . . . . . . .A62, C61, C149*
Reed, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P19
Regev, T . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B54
Rehm, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D56*, D60
Reichstadt, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A25
Reid, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C113, D45
*Indicates presenting author
S258
AGS 2012 ANNUAL MEETING
Reid, M C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D41, D116
Reidy, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D73
Reisner ( AGS-F ), M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D14
Renner, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B133
Renner, J B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B21
Rennke, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C108
Resnick, N M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B81, B94
Restrepo, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C150, D130
Resurreccion, I P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C31*
Reuben, D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B112, P8
Reuben, D B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B106*, P38
Rhodes, R L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A60*
Rianon, N . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A46*, A100*
Richardson, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D93
Richardson, J K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D80
Richter, H . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P25
Richter, H E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B132*
Riggs, H . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B130*
Rigler, S K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B66
Rimediotti, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C146
Rimler, E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B67
Rios, L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A51
Rios Rojas, L E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C100*
Rios-Bedoya, C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C90
Ritchie, C S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D62
Ritchie, E K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C38*
Rittman, M R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C143
Ritvo, P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C162
Rivara, F . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B131
Rivera, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P39*
Rivera, K B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D84*
Rizzoli, R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B58
Robben, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A74*, A106*
Roberts, E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D66
Roberts, J E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D41, D116*
Robertson, I H . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B72
Robinson, M J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C36
Robison, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B151
Roboz, G . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C38
Robuccio, B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C81
Robuccio, B L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D74
Rochat, E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D48
Rochat, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B84
Rockwood, K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A122
Rodgers, N . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A101*
Rodriguez, C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D106, D107
Roffe, E . . . . . . . . . . . . . . . . . . . . . . . . . . .A9, B12, C3, D1, D2
Rogers, G . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D120
Rogers, R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P25
Roggin, K K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B171
Rohan, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C38
Rohner, I . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D114, D136
Roiland, R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C103
Rommesser, C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D12
Rondina, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P20*
Roos, B A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D100
Rosano, C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B163, D157
Rose, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C76
Rosen, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C102*, P42
Rosen, H J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A128

A UTHOR
I NDEX
Rosenberg, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D109
Rosenberg, D E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C111
Rosenthal, R A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D126
Ross, G W . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C53
Ross, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C148, D130
Ross, W . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B122
Ross, W G . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B124
Rosso, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A78
Roth, C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B106
Roth, D L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P13
Rothenberg, L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B117*
Rothrock, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D62
Rowan, P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D83
Rowe, C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B63
Roy, C N . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B139
Ruby, C M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B81
Rudolph, J L . . . . . . . . . . . . . . . . . . . . . . . . . . . .B83, B97, C116
Rue, T . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B131
Ruiz, M A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D90*, D91*
Rummans, T . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D92
Rush, P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D59
Russell, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B102
Russell, M Q . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D131*
Russo, D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C14, D102
Russo, D J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A118
Russotto, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D109
Rustgi, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P12*
Rybar, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D65
Rye, D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B11
Saad, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A117, D129
Saad, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D8
Sabbagh, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D141
Sabillo, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A14*
Sachdeva, G . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C28*
Sachs, G . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B110
Sachs, G A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B144
Saczynski, J S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B46
Sadak, T . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A135*
Saengwanitch, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A130
Saifan, C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C40
Saito, K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C95
Sajid, S S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B3*
Sakely, H . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C85
Salem, R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C158
Salow, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B83, C116
Salter, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A63
Salzman, B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C73*
Samala, R V . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A14, D160
Samtani, K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D76
Sánchez G., E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B152
Sánchez Rodríguez, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C164
Sánchez Rodríguez, J L . . . . . . . . . . . . . . . . . . . . . . . . . . .D40*
Sanchez-Reilly, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D130
Sanders, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B36*
Sanders, L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B40
Sanders, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C62
Sanders, N . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A86*, B90*
Sanders, P W . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B127
Sanders, MD MS, A E . . . . . . . . . . . . . . . . . . . . . . . . . . . .C145
Sandhu, S K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C87
Sangarlangkarn, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B65*
Sanon, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D115
Santoro, G M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B41
Santos, K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D103
Santos-Modesitt, W . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A149
Sarkar, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C2, C56, D127
Sarkar, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A134
Sarzynski, E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C90*
Satchidanand, N . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B146*
Satterfield, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P30
Saunders, K T . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D141*
Sawyer, P . . . . . . . . . . . . . . . . . . . . . . . . . .A50, B92, B127, D62
Scarborough, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B170*
Schancupp, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D139*
Schapira, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D128*
Scheider, L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A120
Schein, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C54, C93
Schers, H . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A74, A106, D77
Schillerstrom, J E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B125
Schlaudecker, J D . . . . . . . . . . . . . . . . . . . .C118, D54*, D110*
Schmader, K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B40, D35
Schmotzer, B J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P22
Schneider, E B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A162
Schnittker, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D98
Schreiber, R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D109
Schubert, C C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P14*
Schwartz, A V . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P30
Schwartz, P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B144
Schwartz, R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B145, P6
Segal-Maurer, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D102
Seguin, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C27
Selvage, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D79*
Selwyn, B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A46
Seminara, D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C30, C40
Seminara, D P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C148
Serra, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C51, D39
Setters, B . . . . . . . . . . . . . . . . . . . .A24, C6, C9, C10, C20, C26
Severson, R . . . . . . . . . . . . . . . . . . . . . . . . . . . .A43, A44, C101
Sevilla, C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B80
Sewell, D D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A25
Shah, B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B18
Shah, K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D15*
Shah, N . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C115
Shah, N D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A127
Shah, R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D86
Shah, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A124, B59*
Shany-Ur, T . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A128
Sharma, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C129, P15
Sharma, H . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D18
Sharma, K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C19
Sharma, N . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B143, C29, C130
Sharma, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D16
Shawn, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A133
Shea, K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B48
Shega, J . . . . . . . . . . . . . . . . . . . . . . . . . . .B149*, B150*, D150*
Shega, J W . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B111
Sheikh, N . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A146
Shengelia, R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D41
Sheppard, E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C160*
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A UTHOR
I NDEX
Sheppard, K D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D62*
Sherer, R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A73
Sheridan, P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A129*
Sherman, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C112
Shertzer-Skinner, R . . . . . . . . . . . . . . . . . . . . . . . . . . .D36, P23
Sheyner, I . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C32*
Shi, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B133
Shi, S M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A73*
Shi, X . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B21
Shield, R R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A83
Shier, V . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C127
Shimonov, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D18
Shipley, A J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B154
Shirley, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B88*
Shirley, N . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A133
Shklar, V . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A165
Shorr, R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B49
Shorr, R I . . . . . . . . . . . . . . . . . . . . . . . . .B81, B109, D105, P32
Shreve, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A108
Siddique, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D133
Sideman, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B9
Sieber, F . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D161
Siebers, M J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D135*
Siegler, E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A77, P36
Silliman, R . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B102, B167, P9
Silliman, R A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P3
Silverstein, J H . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P27
Silvestre, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D8*
Simon, L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B117
Simon, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P32
Simonsick, E . . . . . . . . . . . . . . . . . . . . . . . . .B49, B99, P29, P30
Simonsick, E M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B81, B109
Simonson, W . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C79
Simpkins, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A134
Simpson, D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D56, D60
Simpson, K M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C74
Sims, R V . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A50
Singer, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D42
Singh, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A48, B35
Singh, K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A26, C72
Sinha, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A66
Sinha, S K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B70, P34
Sink, K M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A72, B48
Sinvani, L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D86*
Sirisha, P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D90
Sison, C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D129
Sissoko, M . . . . . . . . . . . . . . . . . . . . . . . . . . .A85, B138*, D113
Sithinamsuwan, P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A130*
Siu, A L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P43
Skarf, L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B83
Skinner, J S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P7
Skopeljia, E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A88
Sloane, P D . . . . . . . . . . . . . . . . . . . . . . . . . .A38, B113*, B114
Sloane, R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A42
Smietniansky, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D128
Smiley-Oyen, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B161
Smith, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B98
Smith, A K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B31*, D46
Smith, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D146
Smith, K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C76
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Smith, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C117
Smith, S G . . . . . . . . . . . . . . . . . . . . . . . . .A75, A76, A79, B111
Smith, S M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D26
Smoller, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B120
Snyder, E A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B20*
Snyder, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D76
Snyderman, D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C73
Sobel, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A43, A44
Sobie, E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A140
Soch, K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A59
Solberg, L B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D154
Solberg, L M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D154*
Somogyi, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D27
Song, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C62
Sori, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B41
Soria, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C51, D39
Soryal, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D118
Soto, D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C77*
Speechley, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D88
Speice, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B62
Spencer, B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D48
Spencer, F A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B46
Spencer, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A113
Spini, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B41
Spira, A P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C48
Spritzler, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B141
Sreenivas, V . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A157
Stallard, E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C114
Staskin, D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C35
Stecher, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D110
Stecher, A M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C118*
Steel, K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C2, C56
Steimle, J A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D112*
Stein, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B67
Stein, T . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B96*
Steinman, M . . . . . . . . . . . . . . . . . . . . . . . . . . .B87, C108, D43*
Steinman, M A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B85
Stephens-Kelly, C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D114
Stessman, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B134, D145*
Steven, D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D60
Stevens, A B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D111
Stevens, K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D85
Stevens, N . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D53
Stewart, J T . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C32
Stieglitz, H . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A60
Stijacic-Cenzer, I . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P1
Stoll, D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D149
Stone, N . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C49
Stotts, A L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D26
Stover, K T . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C32
Strauss, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D122, D123
Strauss, M E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D42*
Streiner, D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C162
Strohmaier, C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D27
Strong, R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B123
Strotmeyer, E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B49
Strotmeyer, E S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B109, P30
Studenski, S . . . . . . . . . . . . . . . . . . . . . . . . . . . .B96, B166, P24
Studenski, S A . . . . . . . .A158, A159, B79, B156, B163, B165,
C133, D28, D157, D159, P30

A UTHOR
I NDEX
Stump, T . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B110
Styer, T . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D65
Subak, L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P25
Sudore, R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D6
Sudore, R L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P5*
Suelzer, C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P14
Suemoto, C K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A81
Suen, W . . . . . . . . . . . . . . . . . . . . . . . . .A85*, D47, D54, D113
Suh, T . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D114
Suh, T T . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A23*, B9
Sulapas, I . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D5*
Sullivan, D H . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B159*, B164
Sun, F . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C34
Sun, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A165*
Sunday, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A117, C63
Supiano, M A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A82
Suraj, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A133*
Suriyaarachchi, P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P15
Sustakoski, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B156*
Sutter, B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P14
Suzuki, T . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C95
Swami, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A53*
Swanson, K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B161, C115
Swanson, K M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A127
Sweeney, C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P39
Sy, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D1
Sychangco, P D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D102
Syed, H . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A127, C115*
Syed, Q . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A10*, C55
Szerszen, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C30, C40, C148
Szychowski, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B132
Szydlowski, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P40
Tadd, K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C131
Taffet, G . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D83
Taffet, G E . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A62, C61, C149
Taffet, J D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C61
Tai, C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A124
Takahashi, P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C115
Takahashi, P Y . . . . . . . . . . . . . . . . . . . . . . . . . .A127, B23, B24
Takenaka, C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B157
Talati, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A69
Talebreza, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D54
Talsania, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A1
Tamblyn, R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B77
Tamura, B K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B68
Tan, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B107
Tan, K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D121*
Tan, R S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C22
Tan, T . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D121, D132
Tancredi, D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C88
Tank, L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C2, C56, D127
Tannenbaum, C . . . . . . . . . . . . .B25, B77*, C35*, C137*, D87
Tanner, C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B124
Tariot, P N . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D141
Tay, L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D132
Taylor, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B162
Taylor, W . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A37, C41
Tegeler, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A99*, B64
Temkin-Greener, H . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P40
Tena-Nelson, R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D103
Teng, E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A136
Teodoro, C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A6
Teodoro, C D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C18*
Teresi, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C102, P42
Terrien, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C81
Terrin, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B168
Terriquez, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A145
Thai, J N . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D46*, D96*
Thaipisuttikul, P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A139
Thembani, E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C129
Thomas, K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B121
Thomas, L M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D146*
Thomas, N . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A117
Thompson, H J . . . . . . . . . . . . . . . . . . . . . . . . . . . .B131*, C94*
Thompson, K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D59*
Thornton, K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B7
Thorpe, R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B99
Thorud, J L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D111*
Tian, F . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B160
Tidwell, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D130
Tillou, A K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A57
Tilsley, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C163*
Tims, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A48, B35
Tingus, K D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A136
Tiwari, S C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A157
Tjia, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B22*, C106, D38
Tocco, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D31*
Toffanello, G . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C146
Tomlinson, G . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C162
Tong, W . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C35
Tooze, J A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B48, D36, P23
Toscano, C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A54, A55
Toussi, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C133*
Towle, V . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B52
Towle, V R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D140
Trahan, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D142
Trieu, E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C127*
Trochimowicz, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C132
Troke, A M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B144*
Trotti, L M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B76
True, G . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D72
Truong, T N . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D140
Tryzelaar, L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D16*
Tsai, E C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P18
Tseng, T J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A93*
Tu, W . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B110, P44
Tubach, F . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A33
Tucker, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C9*
Tulsky, J A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D97
Tumosa, N . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C142
Tuqan, A T . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P38*
Turker, D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P16*
Turner, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B75*
Turner, B J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B38
Turner, M S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B129
Turpie, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D164
Twersky, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B118
Tyagi, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B94*
*Indicates presenting author
AGS 2012 ANNUAL MEETING
S261

A UTHOR
I NDEX
Ukritchon, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A130
Umland, E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C76
Unroe, K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B110*
Unverzagt, F . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A88
Uphold, C R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C143*
Urban, C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D102
Valades, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C51, D39
Valcour, V . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B87
Valley, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P6
Valone, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C62
Valoti, P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C146
van den Heuvel, E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B25
Van Hala, S N . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A82
van Kempen, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D77*
Van Ness, P H . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P2
van Nieuwenhuijzen, L . . . . . . . . . . . . . . . . . . . . . . . . . . . .A74
van Reenen, C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P40
Van Son, C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A151
Van Son, C R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C155*
Van Swearingen, J M . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B163
van Zuilen, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D69*
Vanguri, V . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A68
vanLondon, G . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B96
VanSwearingen, J . . . . . . . . . . . . . . . . . . . . . .B79, B161, B166
VanSwearingen, J M . . . . . . . .A158, B156, D157*, D159, P24
Varma, R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A9
Vassar, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B105
Vassar, S D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A98
Vasudev, B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D60
Vaughan, C P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B76*, C84*
Vaynshteyn, V . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C40
Vela, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D18
Vernon, R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P19
Verrall, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C158, D158
Verrall, A M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D156
Verscheure, L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P34
Vest, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P22
Vickrey, B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B105
Vidal, E I . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C50*
Vidán, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D39
Vidan - Astiz, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C51
Vidán A., M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B152
Vig, E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B51*
Vij, B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B143
Villareal, V . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A78
Villarreal, D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D130
Villas Boas, P J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C50
Vitale, C A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C59
Voisine, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A2
Volbrecht, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C99
von Humboldt, S . . . . . . . . . . . . . . . . . . . . . . . . .A152*, A153*
Wagle, K C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D83*
Waite, H . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A138
Walder, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A155
Walke, L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D11
Walke, L M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D126*
Walker, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A7*
Walston, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B55, B61
*Indicates presenting author
S262
AGS 2012 ANNUAL MEETING
Walter, B K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P18
Walter, L C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D46, P1
Wan, Z . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C1
Wang, K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B56
Wang, P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P41
Ward, K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C119
Washington, F . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A115
Wasilenko, K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B155
Wasmund, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B90
Wasmund, S L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A86
Wasserman, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D33
Waters, K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A112
Waters, T M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P32
Watkins, F S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D61
Watson, G S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P18
Wayne, P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B86
Webb, T . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D60
Weber, T . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P45
Wee, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P41*
Wei, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D147
Wei, W . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A102, B153
Weiner, D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B149, D150
Weiner, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B130
Weingast, E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D103
Weintraub, N T . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P38
Weir, C R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A82
Wellens, N . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D32
Wenger, N . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B112, P8
Wenger, N S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B106
Wert, D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B166, P24
Wessel, B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D56, D60
Wessell, K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B63
Westmoreland, G R . . . . . . . . . . . . . . . . . . . . . . . . . . .A84, B64
Westphal, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D37*
Wetle, T . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A83
Wey, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B123
Weyrich, A S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P20
Wheaton, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D16
White, R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C45
White, S E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D46
White-Chu, E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C78*
Whitehead, W E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B129
Whitehouse, C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D71
Whitson, H E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A42, B40
Wieland, G D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C114*
Wieman, M S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A34*, A35*
Wierman, H . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C165*
Wiggins, J E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D125
Wilkinson, C W . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P18
Williams, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A70
Williams, B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C105*
Williams, D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D91
Williams, G . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A37
Williams, G R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C41*
Williams, L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A121
Williams, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A75, A76, A79*
Williams, PhD, S W . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A36
Williamson, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B48, D61
Williamson, J D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D36, P23
Willmore, C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D119

A UTHOR
I NDEX
Wilson, L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D66*
Wilson, N L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B54
Wilson, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B171
Wilson, V . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B48*
Windham, B G . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P29
Winter, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B102, P9
Winzelberg, G . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B63, D66
Wirt, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D22*
Wirtz, H S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P31*
Witt, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D60
Wo, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A132*
Wolf-Klein, G . . . .A117, B143, C57, C130, D86, D129, D155
Wolmark, Y . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A33*
Wong, C L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B136
Wong, J W . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B135*, D144*
Wong, P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A129
Wong, W . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C86
Wongvarcharoen, L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B122
Wood, R C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C47
Woods, N F . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A150*, B44
Wright, H . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C132
Wright, R M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A71*
Wroe, P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B91*
Wu, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C43*
Wu, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C52
Wyman, J F . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C34
Xuan, L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A60
Yadlosky, L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A132
Yaffe, K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A149
Yamaguchi, T . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B60
Yan, T . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A98
Yanamadala, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B118
Yang, H . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B55
Yang, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P30
Yang, Z . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A40
Yao, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B126
Yazdani, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D73
Ye, Y . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A31*, A115
Yechoor, P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A62
Yeh, C S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C161
Yeh, V . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A160*
Yeo, C Y . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C86*
Yeung, K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C27
Yin, P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B70*
Yorkston, K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D158*
Yoshida, H . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C95
Yoshida, Y . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C95
Young, B A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C159, D152
Young, K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A101
Young, L J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C143
Young, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A85, D113
Young, M E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D47*
Yuasa, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B68*
Yuen, J K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D6*
Yulico, H . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A165
Zaas, D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B40
Zafar, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A80
Zaffarana, N . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C146
Zafirau, W . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D108
Zaldana, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D159*
Zamrini, E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B10
Zanetti, M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A64, C81, D73
Zaslavsky, O . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A150, B44*
Zeballos, P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A66
Zelaya, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D63
Zerah, T . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A33
Zhang, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C1, P18
Zhang, W . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A154
Zhang, X . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C1
Zheng, Y . . . . . . . . . . . . . . . . . . . . . .B49, B81, B96, B109, D28
Zhou, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C90
Zickmund, S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B79
Zierath, D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B131
Zimmerman, G A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P20
Zimmerman, K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B83*
Zimmerman, S . . . . . . . . . . . . . . . . . . . . . . . .A38, B113, B114*
Zirker, W . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B73
Zitnay, R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B15*
Zitnay, R M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A85, D113
Zmudka, J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D25*
Zone, J J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B135
Zulifiqar, A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B75
Zweig, Y . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A139*
*Indicates presenting author
AGS 2012 ANNUAL MEETING
S263

K EYWORD
25-hydroxyvitamin D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P23
30 day readmission . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B102
α-synuclein . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B123
AAMC Geriatric Competencies . . . . . . . . . . . . . . . .A75, A79
Accelerometer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B165
Access . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A108, A127
Accidental Falls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P32
ACE inhibitors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B85
Ace unit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D114
Acetylcholinesterase inhibitors . . . . . . . . . . . . . . . . . . . . .D82
ACGME Competencies . . . . . . . . . . . . . . . . . . . . . . . . . . .D61
ACGME competency . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A70
Achalasia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A7
Acinetobacter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C152
ACOVE measures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D35
Actinomyces israelli . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D3
Action Potential Duration . . . . . . . . . . . . . . . . . . . . . . . .A140
Activity of Daily Living . . . . . . . . . . . . . . . . . . . . . . . . . . . .B33
Acupuncture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C2
Acute . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D118
Acute Care . . . . . . . . . . . . . . . . . . . . . . . . . . .C51, D115, D135
Acute Care consults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A120
Acute care transfers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A115
Acute coronary syndromes . . . . . . . . . . . . . . . . . . . . . . . . .B41
Acute illness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D39
Acute leukemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C38
Acute musculoskeletal pain . . . . . . . . . . . . . . . . . . . . . . . .B27
Adenocarcinoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C17
Adjustment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A152, A153
ADLs/IADLs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B98
Admission . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D33
ADR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C100
Adult Protective Services . . . . . . . . . . . . . . . . . . . . . . . . . .B93
Adult Still’s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B17
Advance care planning . . . .A80, B52, B53, B63, B101, B104,
C58, C75, P5
Advance directive . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C59
Advanced care planning . . . . . . . . . . . . . . . . . . . . . . . . . . .D21
Adverse health outcomes . . . . . . . . . . . . . . . . . . . . . . . . . .A93
Advocacy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C105
African American . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D95
Age . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D80
Age differences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A166
Aged . . . . . . . . . . . . . . . .A33, A54, A90, A96, B49, B109, C46
Aggression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P42
Aging . . . . . . . . .A49, A152, B55, B60, B79, C39, C158, D156,
D158, P5, P30
Aging research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P16
Alcohol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A57, D137
Aldosteronism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B8
ALLOPURINOL . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A11, C5
ALS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A13
Altered mental status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C16
Alzheimer’s disease . . . . . . . . .A129, A134, C141, C162, D25,
D27, D31, P18
Ambulatory Curriculum . . . . . . . . . . . . . . . . . . . . . . . . . . .A65
Amiodarone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D1
Amputation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C12
I NDEX
Amyloid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C3, P18
Amyloid-beta . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A131
Analgesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B27
Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A68
Anemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C87
Anemia of inflammation . . . . . . . . . . . . . . . . . . . . . . . . . .B139
Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C40
Anesthesiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P27
Anesthetics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C144
Angiodysplasia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A6
Angiomyolipoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C30
Animal model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B58
Anosognosia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A128
Antibiotic Resistance . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C101
Antibiotic resistant organisms . . . . . . . . . . . . . . . . . . . . . .B39
Antibiotic Stewardship . . . . . . . . . . . . . . . . . . . . . .C101, D102
Antibiotics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C150
Antibiotics use . . . . . . . . . . . . . . . . . . . . . . . . . .A43, A44, C49
Anticholinergic medications . . . . . . . . . . . . . . . . . . . . . . .B168
Anticholinergics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C35, P31
Anticoagulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C71
Antipsychotics . . . . . . . . . . . . . . . . . . . .A101, B22, C106, D37
Anxiety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A103, C20
Aortic impedance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C149
Apache score . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C152
Aphasia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A22
ApoE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B36
Apolipoprotein E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P18
Apoptosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A129
Appropriate documentation . . . . . . . . . . . . . . . . . . . . . . . . .A2
Arrhythmia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A17, A140
Arterial stiffness . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C61, C149
Arteriovenous malformation . . . . . . . . . . . . . . . . . . . . . . . .A9
Arthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B92, C25
Arthroplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D164
Asian . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A97
Aspergilloma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A23
Aspirin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D143
Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C77, D52
Assessment Tools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B70
Ataxia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D4
Atheroclerosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B36
Athlete . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A27
Atrial fibrillation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B12
Atrial Fibrillation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C45
Attention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D28
Atypical antipsychotic . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D79
AUSCAN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B21
Autoimmune skin disease . . . . . . . . . . . . . . . . . . . . . . . . .B135
Autoinmune . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C8
Automobile driving . . . . . . . . . . . . . . . . . . . . . . .A49, B145, P6
Autonomic dysfunction . . . . . . . . . . . . . . . . . . . . . . . . . . . .B90
Autophagy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P17
B 12 deficiency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A58
Babesiosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B14
Back Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P28
Balance confidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B96
Barriers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C57
Basal Insulin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A102
S264
AGS 2012 ANNUAL MEETING

K EYWORD
I NDEX
Behavioral intervention . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P9
Behavioral Symptoms of Dementia . . . . . . . . . . . . . . . . .B118
Benzodiazepines . . . . . . . . . . . . . . . . . . . . . . . . . . . .A101, B89
Bereavement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D130
Bilateral . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B9
Bilingualism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D11
Biomarker . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B21, B59
Biomarkers . . . . . . . . . . . . . . . . . . . . . . . . . . . .B133, C62, D93
Bipolar disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C48
Bisphosphonates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C27
Bladder dysfunction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C35
Blisters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C8
Blood pressure . . . . . . . . . . . . . . . . .A26, A132, C44, D44, P29
BMI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D75
Bone metastases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B126
Bone mineral density . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A51
Bone Mineral Desity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B23
BOO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B136
Botulinum toxin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A7
BPH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B136
BPSD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C42
Bradycardia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A62, D147
Brain imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D157
Brain mapping . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C141
Brain Tumors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A25, D23
Breast cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D91, P3
Breast Implant Herniation . . . . . . . . . . . . . . . . . . . . . . . . .D17
Built environment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C111
Bullous pemphigoid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B135
C-reactive protein . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C88
C.diff . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D14
CADASIL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A24
Calcium channel blocker . . . . . . . . . . . . . . . . . . . . . . . . . . .B60
Caloric-restriction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P19
Cancer . . . . . . . . . . . . . . . . . . . . . . . .A155, B51, B91, B96, C41
Cancer screening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B144
Capacity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B54
Capacity to consent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A159
Capgras syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A139
Cardiac . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A160
Cardiac aging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B142
Cardiac amyloidosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D8
Cardiac function . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D145
Cardiac surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A164
Cardiothoracic surgery . . . . . . . . . . . . . . . . . . . . . . . . . . .A166
Cardiovascular . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C61
Cardiovascular Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . .B48
Cardiovascular Medications . . . . . . . . . . . . . . . . . . . .B81, C43
Care coordination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P41
Care management . . . . . . . . . . . . . . . . . . . . . . . . . .A113, C109
Care transition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A127, P41
Care Transitions . .A126, B67, B103, C103, C115, C116, D111
Caregiver . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C143, D112
Caregiver burden . . . . . . . . . . . . . . . . .B151, C86, D101, D154
Caregiver experience . . . . . . . . . . . . . . . . . . . . . . . .B151, C113
Caregiver health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C113
Caregiver stress . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C91, D85
Caregivers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B98
Caregiving . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D85
Case Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A8, C17
Case study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D5
Case-based learning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B65
Catheter Directed Thrombolysis (CDT . . . . . . . . . . . . . .A18
Cause of death . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A56
Cellular senescence . . . . . . . . . . . . . . . . . . . . . . . . . . .B56, P21
Census Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D108
Cerebral . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C3
Cerebral cortical thickness . . . . . . . . . . . . . . . . . . . . . . . .A132
Charles Bonnet Syndrome . . . . . . . . . . . . . . . . . . . . . . . . .D92
Charlson index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B95
Chemotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C38
CHF . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C148
Chief resident . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P37
China . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A73
Cholinesterase inhibitor . . . . . . . . . . . . . . . . .D27, D83, D147
Cholinesterase inhibitors . . . . . . . . . . . . . . . . . . . . . . . . . . .C32
Chronic ankle pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D5
Chronic bronchiectasis . . . . . . . . . . . . . . . . . . . . . . . . . . . .A23
Chronic care model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A125
Chronic disease . . . . . . . . . . . . . .A108, B49, C104, D30, D106
Chronic disease management . . . . . . . . . . . . . . . . . . . . . .D100
Chronic hip pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C147
Chronic Illness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A154, B53
Chronic kidney disease . . . . . . . . . . .B111, B127, B128, D152
Chronic obstructive pulmonary disease . . . . . . . . . . . . . . .B45
Chronic pain . . . . . . . . . . . . . . . . . . . . . . . . . . .A166, B38, D45
Citalopram . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D7
Clinical . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C19
Clinical Course . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C150
Clinical Economics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P10
Clinical outcome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B137
Clinical trial . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A149, C34
Clinical Trials . . . . . . . . . . . . . . . . . . . . . . . . . . .A94, B25, D141
Clinics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P15
Clostridium difficile . . . . . . .B137, C37, D9, D42, D122, D123
CNS aging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A137
Co-management program . . . . . . . . . . . . . . . . . . . . . . . . .D126
Co-morbidity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B112, P8
Cochlear implantation . . . . . . . . . . . . . . . . . . . . . . . . . . . .B169
Code status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B65
Code Status Discussions . . . . . . . . . . . . . . . . . . . . . . . . . . .A59
Cognition . . . . . . . . . . . . . . . . . . . . . . . . .C136, D28, D31, D88
Cognitive Abilities Screening Instrument . . . . . . . . . . . . .D11
Cognitive assessment . . . . . . . . . . . . . . . . . . . . . . . .B108, D11
Cognitive Complications . . . . . . . . . . . . . . . . . . . . . . . . . .A163
Cognitive decline . . . . . . . . . . . . . . . . . . . . . . .C21, C133, C137
Cognitive Dysfunction . . . . . . . . . . . . . . . . . . . . . . . . . . . .D161
Cognitive function . . . . . . . . . . .A107, A159, B32, B122, B166
Cognitive impairment . . . . . .A47, A56, A88, A123, B46, B47,
B78, C89, D140
Cognitive screening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D119
Cognitive tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A50
Cognitive-motor interference . . . . . . . . . . . . . . . . . . . . . .C163
Collaboration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A74
Collaborative care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A114
Collagen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P19
Colon cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A28, B130
Colon cancer prevention . . . . . . . . . . . . . . . . . . . . . . . . . . .P16
Colorectal Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P4
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Colorectal cancer screening . . . . . . . . . . . . . . . . . . . . . . .C107
Communication . . . . . . . . . . . . . . . . . . . . . . . .A151, B100, C66
Communication skills . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A70
Community . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B54
Community dwelling elderly . . . . . . . . . . . . . . . . . . . . . . . .D43
Community Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C75
Community partnerships . . . . . . . . . . . . . . . . . . . . . . . . . .D111
Community programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D72
Community-dwelling elderly . . . . . . . . . . . . . . . . . . .B80, D36
Comorbidities . . . . . . . . . . . . . . . . . . . . .B45, B129, D38, D139
Comorbidity . . . . . . . . . . . . . . . . . . . . . . . . . . . .B42, B167, C82
Comorbidity index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B95
Competence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D57
Competency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C65
Complex patient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P43
Complexity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A84, C72
Complications of hospitalization . . . . . . . . . . . . . . . . . . . .D68
Comprehensive Geriatric Assessment . .C164, D40, D163, P4
Computational Models . . . . . . . . . . . . . . . . . . . . . . . . . . .A140
Computerized Cognitive Assessment . . . . . . . . . . . . . . .C140
Confusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D4
Congestive heart failure . . . . . . . . . . . . . . . . . . . . . . . . . .D140
Congnitive impairement . . . . . . . . . . . . . . . . . . . . . . . . . .C134
Conjoint analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C107
Constipation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A3
Consultation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A113
Consultation Service . . . . . . . . . . . . . . . . . . . . . . . .A116, A120
Consults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D135
Consumer-targeted information . . . . . . . . . . . . . . . . . . . . .B77
Continence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B25
COPD severity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B45
Copyright . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B108
Coronary Artery Disease . . . . . . . . . . . . . . . . . . . . . . . . . .D17
Cost . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A108
Cost-effectiveness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P45
COVE-PIM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A64
CPOE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C100
Creutzfeldt-Jakob disease . . . . . . . . . . . . . . . . . . . . . . . . . .B10
Cryptococcal Meningoencephalitis . . . . . . . . . . . . . . . . . .C31
CSF protein 14.3.3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B10
CT scan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B140
Curriculum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A69, B68, C68
Curriculum evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P35
Curriculum in skin and wound care . . . . . . . . . . . . . . . . . .C78
Deacetylase . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P17
Death at home . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D107
Decision making . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B144
Decision making capacity . . . . . . . . . . . . . . . . . . . . . . . . . .C60
Decision-making . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B20, P5
Decision-making capacity . . . . . . . . . . . . . . . . . . . . . . . . . . .D6
Deep vein thrombosis (DVT . . . . . . . . . . . . . . . . . . . . . . .A18
Delirium . . . . .A165, B83, B119, B168, C23, C80, C146, D40,
D57, D66, D83, D115, D127, D132
Delirium screening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B29
Demented Parents, Stress . . . . . . . . . . . . . . . . . . . . . . . . .D154
Dementia . . . .A22, A39, A40, A99, A107, A130, A135, A138,
A157, B20, B50, B105, B121, B122, B125, B148, C5, C11,
C14, C18, C20, C21, C32, C42, C89, C91, C117, C138, C142,
C145, D2, D10, D20, D38, D83, D129, D142, D147, D148,
D150, D153
Dementia behaviors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C102
Dementia care . . . . . . . . . . . . . . . . . . . . . . . .B118, C119, D138
Dementia with Lewy Bodies . . . . . . . . . . . . . . . . . . . . . . .A139
Demetia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C19
Demyelinating . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A16
Dental care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A39
Dental residency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C68
Depression . . . . . . . . . .A114, C9, C18, C55, C88, C143, D128
Depressive symptoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B26
Design . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D95
Desire for hastened death . . . . . . . . . . . . . . . . . . . . . . . . . .D48
Diabetes . . . . . . . . . .A50, A102, B140, C112, D15, D94, D152
Diabetes mellitus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C159
Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A33, B136
Diastolic dysfunction . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B142
Diastolic function . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A62
Diclofenac . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A34
Dietary vitamin D intake . . . . . . . . . . . . . . . . . . . . . . . . . . .C53
Diffuse Lewy Body Dementia . . . . . . . . . . . . . . . . . . . . . .B13
Diphragmatic Hernia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D24
Direct observation . . . . . . . . . . . . . . . . . . . . . . . . . . . .C66, P36
Disability . . . .B31, B33, B158, B160, C52, C158, D156, D158
Discharge Communication . . . . . . . . . . . . . . . . . . . . . . . .C103
Disruptive Behavior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D142
Driving . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D155
Driving assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A133
Driving cessation . . . . . . . . . . . . . . . . . . . . . . . . . . . .A49, B145
Driving clinic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A133
Driving safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D65
Drug addiction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A10
Drug prescribing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D35
Drug Reaction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C7
Drug-induced stuttering . . . . . . . . . . . . . . . . . . . . . . . . . . .A14
Dual eligible population . . . . . . . . . . . . . . . . . . . . . . . . . .A125
Dual Stiffness flooring . . . . . . . . . . . . . . . . . . . . . . . . . . . .B162
Dual-tasks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D89
Duloxetine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C36
Duodenum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D146
Dynapenia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B2
Dysphagia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B18, C25
E-learning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C80
Early intervention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C131
Early Onset Dementia . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A24
Early readmission . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D43
Earthquiake . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C42
Echocardiography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D145
Economic burden . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D42
ECT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C18
Education . . . .A67, A72, A73, A81, B67, B69, B70, C64, C71,
C72, C74, C77, C98, C106, D57, D66, P34
Education in nursing home care . . . . . . . . . . . . . . . . . . . .A115
Education of med. students, residents and fellows . . . . .D110
Educational assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . .D64
Educational innovation . . . . . . . . . . . . . . . . . . . . . . . . . . . .D56
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Educational intervention . . . . . . .B101, D56, D60, D85, D136
Effectiveness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D50
Elder abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . .B125, C156, P42
Elder mistreatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C102
Elder Self Neglect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B75
Elder Self-Neglect . . . . . . . . . . . . . . . . . . . . . . . . . . . .B93, D26
Elderly . . . . . .A5, A27, A31, A34, A95, A147, B14, B73, C15,
C40, C71, C98, C112, C160, D42, D90, D91, D121, D124
ElderQuest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C65
Elective joint replacement . . . . . . . . . . . . . . . . . . . . . . . .D143
Electronic Medical Record . . . . . . . . . . . . . . .B23, B24, C123
Electronic medical records . . . . . . . . . . . . . . . . . . . . . . . .B104
Emergencies . . . . . . . . . . . . . . . . . . . . . . . . . . . .A54, A55, D34
Emergency . . . . . . . . . . . . . . . . . . . . . . . . . . . .B170, C122, D33
Emergency department . . . . . . . . .A40, A41, B29, B30, D115
Emergency medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A42
Emotion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D153
Emotionalism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D84
EMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D34
Encepalitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A17
Encephalopathy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B11, D12
End of life . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B98, C57
End of life care . . . . . . . . . . . . . . . . . . . . . . . . .A151, B52, D97
End of life decision making . . . . . . . . . . . . . . . . . . . . . . . . . .P2
End of life pain control . . . . . . . . . . . . . . . . . . . . . . . . . . . .C28
End stage renal disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A9
End-of-life . . . . . . . . . . . . . . . . . . . . . . . . .A19, B31, C13, D46
End-of-life care . . . . . . . . . . . . . . . . . . . . . . . .B154, C14, D134
Endothelial senescence . . . . . . . . . . . . . . . . . . . . . . . . . . . .B60
Enrollment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B150
Epidemiology . . . . . . . . . . . . . . . . . .B46, B127, D37, D44, P32
Epidural abscess . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C16
Erythroid maturation . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B139
Ethical conflicts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C14
Ethics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A19, C60
Ethnic/Racial . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A46
Ethnogeriatrics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A32
Evacuation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B121
Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D51
Evaluation of fellowship programs . . . . . . . . . . . . . . . . . . .P38
Evidence Based Medicine . . . . . . . . . . . . . . . . . . . . . . . . . .D69
Evidence based practice . . . . . . . . . . . . . . . . . . . . . . . . . . .C79
Excimer laser . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D144
Executive Dysfunction . . . . . . . . . . . . . . . . . . . . . . . . . . .A123
Executive Function . . . . . . . . . . . . . . . . . . . . . . . . . .B93, B163
Exercise . . . . . . . . . . . . . . . . . . . . .A149, A160, C95, D28, P24
Factitious disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D20
Factor Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C46
Faculty Development . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D74
Fail elderly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C10
Failure to thrive . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A8
Fall . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P33
Fall injury prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B162
Fall prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D114
Fall reduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D114
Fall Risk Assessment . . . . . . . . . . . . . . . . . . . . .A72, C94, D89
Falls . . . . . . .A138, A147, B28, B72, B82, B88, C36, C74, C77,
D76, D78, D81, D88, D139, P15, P23, P31, P45
Falls prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C79, C127
Falls risk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D36, P29
Family . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A151, C21
Family caregiver . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A61
Family members . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D155
Family members’ perceptions . . . . . . . . . . . . . . . . . . . . . .C155
Family-centered . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C118
Fear of falling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B166
Feeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B20
Fellow education . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A85, D64
Female urinary incontinence . . . . . . . . . . . . . . . . . . . . . . .D16
Ferritin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B138
Fever . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B5, B113
Finger-stick burden . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B153
Focus Groups . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D158
Foley Catheter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A146
Food access . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C111
Foot . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C12
Foreign-born elders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A32
Fracture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A20, A51, D148
Fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C129, P15, P31
Fragility fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A156
Frail . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C34
Frail elderly . . . . . . . . . . . . . . . . . . . . . . . . . . . .A74, A106, D41
Frail older adults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D104
Fraility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C122
Frailty . . . . .A87, A93, A122, A164, B58, B61, B74, B78, B86,
C82, C83, D59, D75, D77, D90, D93, D94
Frontotemporal Dementia . . . . . . . . . . . . . . . . . . . . . . . .A128
Functional ability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C155
Functional Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . .A37
Functional assessment OSCE . . . . . . . . . . . . . . . . . . . . . . .A82
Functional decline . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D39
Functional disparities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B99
Functional gastrointestinal disorder . . . . . . . . . . . . . . . . .B129
Functional history taking . . . . . . . . . . . . . . . . . . . . . . . . . .A76
Functional Impairment . . . . . . . . . . . . . . . . . . . . . . . . . . . .B31
Functional Independence Measure . . . . . . . . . . . . . . . . .C138
Functional Performance . . . . . . . . . . . . . . . . . . . . . . . . . . .A93
Functional Reach Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D78
Functional Recovery . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C164
Functional status . . . . . . . . . . . . . . . . . . . . . . . . . . . .B39, B125
Functional test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B156
Gait . . . .A158, B82, B161, B163, C83, C136, C141, D80, D89,
D157, P24
Gait abnormality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P30
Gait analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C94
Gait Imbalance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B16
Gait speed . . . . . . . . . . . . . . . . . . . . . . . .B128, B156, C92, D44
Game . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C65
Gastrointestinal bleeding . . . . . . . . . . . . . . . . . . . . . . . . . . .A9
Gender . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D39
Gene polymorphism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C1
Geriatric . . . . . . . . . . . . .A34, A35, A71, B73, B135, C88, D79
Geriatric Emergency Medicine . . . . . . . . . . . . . . . . . . . . . .B28
Geriatric Assesment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B171
Geriatric assessment . . . . . . . . . .A165, C41, D162, D163, P14
Geriatric assessment skills . . . . . . . . . . . . . . . . . . . . .A75, A79
Geriatric competencies . . . . . . . . . . . . . . . . . . .A72, C73, D61
Geriatric conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P8
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Geriatric curriculum . . . . . . . . . . . . . . . . . . . . . . . . . .B64, D68
Geriatric Education . . . . . . . . . . . . . .B62, B66, C69, D67, P35
Geriatric Emergency Medicine . . . . . . . . . . . . . . . . . . . . .D35
Geriatric Medicine Clerkship . . . . . . . . . . . . . . . . . . . . . . .D69
Geriatric Oncology . . . . . . . . . . . . . . . . .A37, C38, C41, D163
Geriatric opd . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A89
Geriatric outpatient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C86
Geriatric outpatient clinic . . . . . . . . . . . . . . . . . . . . . . . . .C128
Geriatric outpatients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C85
Geriatric population . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D144
Geriatric service . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D134
Geriatric syndromes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A90
Geriatric Tool . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A66
Geriatric training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B71
Geriatric trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A120
Geriatrics . . . . . .A10, A39, A109, B102, C56, C67, C68, C115,
C157, D51, D96, D104, P1, P27
Geriatrics education . . . . . . . . . . . .A69, C124, D56, P37, P38
Geriatrics focus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C123
Geriatrics knowledge assessment . . . . . . . . . . . . . . . . . . . .P38
Geriatrics Population . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D14
Geriatrics/Frail Elders . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D46
Geropsychiatric . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D120
GI Bleed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C26
GI Bleeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A6
Glucocorticoids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A51
Goal-setting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A106
Goals of care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A2, B18
Goals-of-care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A19
Graduate medical education . . . . . . . . . . . . . . . . . . . . . . . .D60
Gray Matter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C133
Group visits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C91
Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B148
Hand off communications . . . . . . . . . . . . . . . . . . . . . . . . .B103
HBPC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P10
Health Care Expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P7
Health care utilization . . . . . . . . . . . . . . . . . . . . . .A125, D101
Health disparities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D98
Health economics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B115
Health Information Exchange . . . . . . . . . . . . . . . . . . . . .A126
Health Information Technology . . . . . . . . . . . . . . . . . . . . . .P9
Health literacy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C96
Health related outcomes . . . . . . . . . . . . . . . . . . . . . . . . . .D123
Health service use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A42
Health services research . . . . . . . . . . . . . . . . . . . . . . .B115, P7
Health services use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A96
Health status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C96, C156
Health-related quality of life . . . . . . . . . . . . . . . . . . . . . . .C159
Healthcare cost . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A104
Healthcare costs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P43
Healthy aging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D63
Hearing impairment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D70
Heart block . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C10
Heart failure . . . .A33, A161, B46, B47, B85, C15, D21, D151,
P2, P22
Heart rate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C44
HELP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D127
Hemodialysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D41
Hemorrhage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C3
Herpes Zoster . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A53
High dose statins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C125
Hip Fracture . . . . . . . . .B23, B24, B168, C40, C47, C50, D161
Hip prosthesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D3
Hippocampal sclerosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C19
Hispanics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C96
HIV . . . . . . . . . . . . . . . . . . . . . . . .A105, B87, B141, D15, D90
HIV-Aging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A63
HIV/AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A94
Hodgkin Lymphoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A15
Home and Community based care . . . . . . . . . . . . . . . . . . .B81
Home care . . . . . . . . . . . . . . . . . . . . . . .A61, C55, D106, D113
Home visit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C132
Home Visits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C124, D133
Homebound . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D101
Homecare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A121, D117
Homeless persons . . . . . . . . . . . . . . . . . . . . . . . . . . . .A90, A96
Homeostenosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A68
Hospice . . . . . . .A60, A97, A99, B102, B110, B148, C57, C63,
D47, D97
Hospice Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B117
Hospice quality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D138
Hospice/Palliative Care . . . . . . . . . . . . . . . . . . . . . . . . . . . .P12
Hospital . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A112, B88
Hospital care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A105
Hospital discharge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C108
Hospital Elder Life Program . . . . . . . . . . . . . . . . . . . . . . .B119
Hospital falls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D105, P32
Hospital readmission . . . . . . . . . . . . . . . . . . . . . . . . . .D32, P44
Hospital Readmissions . . . . . . . . . . . . . . . . . . . . . . . . . . . .C115
Hospital transfer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D103
Hospitalization . . . . . .A101, B116, C87, C92, D106, P13, P40
Hospitalized elderly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D129
House call . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B116
House calls program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C126
Housecalls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P10
Huddle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A112
Hygroma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D2
Hyperammonemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A3
Hypercalcemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A15, B6
Hypercoagulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A142
Hyperferritinemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B17
Hypernatremia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A12
Hypersensitivity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A30
Hypertension . . . . . . . . . . . . . . . . . . . . . . .A50, A95, B8, B134
Hypoactive Delirium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A4
Hypoglycemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C112
Hypomagnesemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A29
Hyponatremia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A147, D7
ICU . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C150
IEED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D84
IgG2 deficiency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A23
IL-6 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A63
Imipenem . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A4
Immigrant elders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A32
Immune activation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B141
Immune response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B141
Immunosenescence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B57
Implantable cardioverter defibrillator . . . . . . . . . . . . . . . . .P2
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Implantable Loop Recorders . . . . . . . . . . . . . . . . . . . . . . .A86
Improving Quality of Care . . . . . . . . . . . . . . . . . . . . . . . . .A38
In-hospital Mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C148
Inappropriate medication . . . . . . . . . . . . . . . . . . . . . . . . . .B77
Inappropriate Medications . . . . . . . . . . . . . . . . . . . .B34, C110
Inappropriate prescribing . . . . . . . . . . . . . . . . . . . .B113, B114
Incidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C54
Incontinence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B132
Infection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D3
Infection, antibiotic use, hospitalization . . . . . . . . . . . . . .C59
Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C56
Inflammation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A87, B131
Inflammatory arthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A89
Information exchange . . . . . . . . . . . . . . . . . . . . . . . . . . . .D108
Information systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C131
Injurious Falls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C45
Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A57, D105
Injury prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D65
Innovation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C69
Inpatient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C118, D118
Inpatient managment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B35
Inpatient palliative care . . . . . . . . . . . . . . . . . . . . . . . . . . .C157
Inpatient Stay . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D112
Insidious . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D18
Insomnia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A45, B89, B94
Integrated care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D77
Integrative Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A154
Intensive Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C146, D21
Interactive teaching . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D54
Interdisciplinary care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D59
Interdisciplinary team . . . . . . . . . . . . . . . . . . . . . . . . .A71, D71
Interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A69
Interleukin-6 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B139
Internal medicine residency . . . . . . . . . . . . . . . . . . . . . . . .A66
Internal Medicine Residents . . . . . . . . . . . . . . . . . . .D61, D72
Interprofessional . . . . . . . . . . . . . . .A78, A84, C81, C118, D67
Interprofessional communication . . . . . . . . . . . . . . . . . .D110
Interprofessional education . . . . . .A74, C73, C76, C79, C81,
D62, P39
Interprofessional teams . . . . . . . . . . . . . . . . . . . . . . . . . . .D110
Interprofessional Teamwork . . . . . . . . . . . . . . . . . . . . . . . .D55
Intervention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D116
Intracranial hemorrhage in Elder Fallers . . . . . . . . . . . . .C45
Intractable hallucinations . . . . . . . . . . . . . . . . . . . . . . . . . .D10
Irritable bowel syndrome . . . . . . . . . . . . . . . . . . . . . . . . .B129
ITP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A11
Japanese-American . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B124
JCAHO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D127
Journals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C56
Karnofsky Performance Status . . . . . . . . . . . . . . . . . . . . . .A37
Kidney tranplant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D162
Kidney transplant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A141
Knee Osteoarthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B82
Knee pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C95
Knowledge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C106
Knowledge assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . .D60
Knowledge Translation . . . . . . . . . . . . . . . . . . . . . . . . . . .B119
Laboratory test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D113
Lactobacillus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B15
Late onset rheumatoid arthritis . . . . . . . . . . . . . . . . . . . . .A89
Leadership . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P37
Learning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C144
Length of Stay . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A36, P12
Lens transparency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B36
Leukemia cutis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B7
Lichen Planus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C7
Life sustaining interventions . . . . . . . . . . . . . . . . . . . . . . .B154
Life-space . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B92
Life-sustaining treatment . . . . . . . . . . . . . . . . . . . . . . . . . . .D6
Lipedema . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A31
Lithium toxicity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A12, A14
Long Term Care . . . . . . . . . . . .A38, A102, B115, D122, D123
Long term care facility . . . . . . . . . . . . . . . . . . . . . .C101, D102
Long-term care . . . . . . . . . . . . . . . . . . . . .B153, C54, C78, C93
Long-term care financing . . . . . . . . . . . . . . . . . . . . .C114, D98
Long-term care insurance . . . . . . . . . . . . . . . . . . . . . . . . .A107
Longitudinal analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B44
Longitudinal cohort study . . . . . . . . . . . . . . . . . . . . .B134, C53
Longitudinal curriculum . . . . . . . . . . . . . . . . . .A75, A76, A79
Longitudinal study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C137
Longterm-care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A118
Loss of consciousness . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D20
Low bed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D105
Low income seniors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P44
Low-density lipoprotein receptor-related protein-1 . . .A131
Lower extremity function . . . . . . . . . . . . . . . . . . . . . . . . . .D94
Lung cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C4
Lung Transplantation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B40
Lupus anticoagulant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A91
Lymphoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C147, D8
Macrophage Activation Syndrome . . . . . . . . . . . . . . . . . . .B17
Malaise . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D18
Male osteoporosis . . . . . . . . . . . . . . . . . . . . . . . . . .A148, B143
Malignancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B6, B138, D146
Malnutrition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C39
Mammography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B107
Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D132
Mandated reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D65
Mania . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C48
Matrix Metalloproteinase . . . . . . . . . . . . . . . . . . . . . . . . .B142
May-Thurner syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . .A18
Measurement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B156
Mechanical ventilation . . . . . . . . . . . . . . . . . . . . . .A117, A118
Medical decision making . . . . . . . . . . . . . . . . . . . . . . . . . .B111
Medical decision-making . . . . . . . . . . . . . . . . . . . . . . . . . . .B51
Medical education . . . . . . . . . .A71, A83, C66, C67, C73, D59
Medical intensive care unit . . . . . . . . . . . . . . . . . . . . . . . .D130
Medical Interns . . . . . . . . . . . . . . . . . . . . . . . . .D51, D52, D68
Medical student education . . . . . . . . . . . . . . . . . . . . . . . . .D63
Medical Students . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D69
Medicare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D99
Medicare Part D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B109
Medication . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B109, C90, D87
Medication adherence . . . . . . . . . . . . . . . . . . . .A88, B49, B75
Medication compliance . . . . . . . . . . . . . . . . . . . . . . . . . . . .B75
Medication discontinuation . . . . . . . . . . . . . . . . . . . . . . . . .C85
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Medication discrepancy . . . . . . . . . . . . . . . . . .B97, D86, D121
Medication Errors . . . . . . . . . . . . . . . . . . . . . . . . . . . .A41, B34
Medication mismanagment . . . . . . . . . . . . . . . . . . . . . . . .D119
Medication reconciliation . . . . . . . . . . . . . . .C116, D86, D121
Medication Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B97
Medication safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B38
Medication titration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C10
Medications . . . . . . . . . . . . . . . . . . . . . . . . . . .B83, C108, D126
Memantine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D31
Memory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C35, C144
Memory loss . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A136, C89
Mentorship . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A83
Metabolic syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D79
Metformin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A29, A58
Mexican-American . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C47
Microglia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A137
MicroRNA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P21
Mild Cognitive Impairment . . . . . . . . . . . . . . . . . .A136, C142
Mild cognitive impairment (MCI . . . . . . . . . . . . . . . . . . .C139
Mini-mental state exam . . . . . . . . . . . . . . . . . . . . . . . . . . .B108
Mitochondria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B55, B61
MMP-9 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A87
MMSE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C134
MNA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C39
Mobile phones . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D100
Mobility . . . . . . . . . . . . . . . . . . . . . . . .B92, B127, C92, P3, P13
Mobility Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B79
Mobility disability . . . . . . . . . . . . . . . . . . . . . . . . . .B128, C111
MOCA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C134
Model of care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B118, D109
Mortality . . . . . .A95, A122, A162, B37, B42, B47, B78, B120,
B134, B149, B157, B170, C44, C47, C48, C50, C51, D32,
D40, D161
Motor learning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D159
Motor skill . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B161, D157
Multi-disciplinary team model . . . . . . . . . . . . . . . . . . . . .C132
Multimodal Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D55
Multimorbidity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C52, C104
Multiple Myeloma ( MM . . . . . . . . . . . . . . . . . . . . . . . . . . . .A5
Muscle biopsy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D30
Musculoskeletal pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C27
Myeloproliferative . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A142
Myeloproliferative syndrome . . . . . . . . . . . . . . . . . . . . . .A143
Myocardial infarction . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C146
NAMCS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A100
National survey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B71
Natural Disasters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C23
Navigator . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C81
Neighborhood socioeconomic status . . . . . . . . . . . . . . . . .A98
Neuropsychiatric symptoms . . . . . . . . . . . . . . . . . . . . . . . .A25
Neuropsychological Testing . . . . . . . . . . . . . . . . . . . . . . .A136
Nicastrin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A129
Nocturia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B76, B94
Non cancer pain . . . . . . . . . . . . . . . . . . . . . . . . . . . .B150, D150
Non-malignant pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A100
Non-prescribing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B85
Nonagenarians . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A55
Noncancer pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B149
Nonlinear . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C15
Nontuberculous mycobacterial infection . . . . . . . . . . . .A145
Nonverbal physician-patient communication . . . . . . . . .A103
Normal aging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A68
Normal Pressure Hydrocephalus . . . . . . . . . . . . . . . . . . . .D25
NOSOCOMIAL INFECTIONS . . . . . . . . . . . . . . . . . . .B137
NSAIDs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A100, C27
Number needed to treat . . . . . . . . . . . . . . . . . . . . . . . . . . .D50
Nurse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C129
Nurse Practitioner . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P11
Nursing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D120
Nursing education . . . . . . . . . . . . . . . . . . . . . . . . . . . .C80, D70
Nursing home . . . . . . .A99, B34, B39, B50, B68, B110, B121,
C49, C110, C120, D53, D58, D103, P33, P42
Nursing home admission . . . . . . . . . . . . . . . . . . . . . . . . . . .D98
Nursing home care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A115
Nursing home residents . . . . . . . . . . . . . . . . . . . . . . .C59, D43
Nursing homes . . . . . . . . . . . . . . . . . .B113, B114, C102, C135
Nutrition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B164
Nutritional deficiency . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C157
Obesity . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B32, B37, C1, C161
Observational study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B44
Obstructive sleep apnea . . . . . . . . . . . . . . . . . . . . . . . . . . .B158
Occupational Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . .A157
Octogenarians . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D155
Octreotide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A6
Older Adult . . . . . . . . . . . . . . . . . . . . . . . . .A57, B145, D87, P6
Older adult, lower urinary tract symptoms . . . . . . . . . . . .D87
Older adults . . . . . . . .B29, B96, B99, B130, B165, B169, D30,
D45, D137, D160
Older women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B25
Oldest old octagenarians nonagenarians . . . . . . . . . . . . .B147
Omeprazole . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C9
On-call . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B68
Opioids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A35
Oral chemotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B130
Oral Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A38, C159
Orthostatic Hyoptension . . . . . . . . . . . . . . . . . . . . . . . . . . .D76
Orthostatic hypotension . . . . . . . . . . . . . . . . . . . . . . .B90, P29
OSCE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A81
Osteoarthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . .B21, B133, C2
Osteochondritis dissecans . . . . . . . . . . . . . . . . . . . . . . . . . . .D5
Osteopontin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B59
Osteoporosis . . . . . . .A46, B1, B84, B132, C129, D148, D149
Osteoporosis related fractures . . . . . . . . . . . . . . . . . . . . .A156
Osteoporosis screening . . . . . . . . . . . . . . . . . . . . . . . . . . .A148
Osteosarcopenia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B1
Outcomes . . . . . . . . . . . . . . . . . . . . . . . . .A48, A118, B35, D91
Outcomes assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B22
Outdoor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B155
Outpatient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C90
Overuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B107
Oxidative stress . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A131
PACE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D142, P40
Paced respiration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C33
Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A155
Pain Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B30
Palliative care . . . . . .A60, A97, B83, C120, C132, C155, D41,
D47, D104, D107, D116, D130, D134
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Palliative care consult . . . . . . . . . . . . . . . . . . . . . . . . . . . .B147
Palliative care education . . . . . . . . . . . . . . . . . . . . . . .B71, D64
Palliative consult . . . . . . . . . . . . . . . . . . . . . . . . . . .A117, D129
Palliative surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C13
Pancreas cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B171
Pancreatic mass . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C4
Parasitic Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A8
Parasthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C6
Parkinson’s disease . . . . . . . . . . . . . . . .B76, B123, C84, D139
Parkinson’s Disease . . . . . . . . . . . . . . . . . . . . . . . . . . .B124
Patient adherence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B158
Patient engagement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D111
Patient preferences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C107
Patient Safety . . . . . . . . . . . . . . . . . . . . . .A41, B77, B88, B103
Patient Satisfaction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B30
Patient-centered . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C121
Patient-centered care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C76
PC-MRI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D25
Pelvic floor symptoms . . . . . . . . . . . . . . . . . . . . . . . . . . . .B132
Peripheral nerve . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P30
Peripheral Neuropathy . . . . . . . . . . . . . . . . . . . . . . . . . . . .B16
Personal Competency Rating Scale . . . . . . . . . . . . . . . . .A128
Perturbation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D80
Pharmacoepidemiology . . . . . . . . . . . . . . . . . . . . . .A45, A114
Pharmacokinetics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A35
Pharmacology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B69
Pharmacy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D82
Phenotypes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A150
Phone call . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C108
Physical activity . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A98, B155
Physical activity/Exercise . . . . . . . . . . . . . . . . . . . . . . .C98, P9
Physical function . . . . . .A158, B120, B146, B166, D15, D159
Physical Performance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P22
Physical restraint . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A61
Physical Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . .C138, C163
Physician assisted suicide . . . . . . . . . . . . . . . . . . . . . . . . . .B154
Pillbox skills . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D119
Pilot trial . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C33
Platelet Monocyte Aggregates . . . . . . . . . . . . . . . . . . . . . . .P20
Platelets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P20
Pneumonia . . . . . . . . . . . . . . . . . . . . . . . . .A48, B35, C43, D37
Pneumonitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A30
POEMS Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B16
POGOe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D54
Policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C105
Polycythemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A143
Polyneuropathy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A16
Polypharmacy . . . . . . . . . . . . . . . . . . . . .B87, B97, C116, C133
Polyuria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B12
Popliteal Vein Aneurysm . . . . . . . . . . . . . . . . . . . . . . . . . . . .B9
Positive aging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A150, B44
Post Acute care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B64
Post-acute care . . . . . . . . . . . . . . . . . . . . . . . .A52, A159, C164
Post-treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A155
Postmenopausal women . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C1
Postoperative . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A163
Postoperative mortality . . . . . . . . . . . . . . . . . . . . . . . . . . .A165
Posttraumatic stress disorder . . . . . . . . . . . . . . . . . . . . . . .C11
Postural complexity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B86
Potentially Inappropriate . . . . . . . . . . . . . . . . . . . . . . . . . .A45
PPA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A22
Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D120
Practice effects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C139
Practice redesign . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B106
Prediction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B33
Prediction of mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B95
Prehypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A132
Pressure ulcers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C50
Prevelance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D150
Preventing Delirium . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D136
Prevention . . . . . . . . . . . . . . . . . . . . . . . .C153, D131, D141, P1
Preventive . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C120
Preventive care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B144
Primary care . . . . . . . . . . . . . . .A113, A127, C109, C123, D77
Prisoner . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C105
Problem awareness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D70
Prognosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A122, D46
Program of All-inclusive Care for the Elderly . . . . . . . .C119
Propofol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P27
Prospective cohort . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P28
Prospective cohort study . . . . . . . . . . . . . . . . . . . . . . . . . .B131
Prostate cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A103, B126
Prostatic acid phosphatase . . . . . . . . . . . . . . . . . . . . . . . .B126
Prosthetic Joint Infection . . . . . . . . . . . . . . . . . . . . . . . . . . .B15
Protective factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C62
Proteinuria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B122
Proteomics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D93
Proton pump inhibitor . . . . . . . . . . . . . . . . . . . . . . . . . .C9, C85
Provider factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A124
Proxy decision making . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B50
Pruritus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B7
PSA screening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A110
Pseudoachalasia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B18
Psoas sign . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A92
Psoriasis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D144
Psychiatric . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D34
Psychiatric illness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D19
Psychological health . . . . . . . . . . . . . . . . . . . . . . . .A110, A130
Psychosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D4
Psychosocial . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D125
Psychotropic drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P33
PTSD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D82
Public policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C113
Pulmonary embolus . . . . . . . . . . . . . . . . . . . . . . . . . .A142, C30
Pulse wave velocity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C149
QoL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C158
Qualitative Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C127
Qualitative study . . . . . . . . . . . . . . . . . . . . . . . . . . . .D52, D112
Quality Improvement . . . . . . .A85, A104, A126, B104, B114,
D103, D113, D136, P34
Quality indicator . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C110
Quality Indicators . . . . . . . . . . . . . . . . . . . . . . .A109, B112, P8
Quality measure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B38
Quality of care . . . . . . . . . . . . . . . . . . . . . . . .B106, C104, D140
Quality of Life . . . . . . .A152, A153, A154, A157, B152, B155,
C22, C46, C156, C161, C162, D38, D109, D152
Quality-of-Life . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C13
Question Bank . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B66
AGS 2012 ANNUAL MEETING
S271

K EYWORD
I NDEX
Race . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A47, B99
Racial disparities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D97
Radial neuropathy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C135
Radiotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D23
Randomized Clinical Trial . . . . . . . . . . . . . . . . . . . . . . . . . .D26
Randomized controlled trial . . . . . . . . . . . . . . . . . .B150, D50
Rapamycin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B123, P19
Rash . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C8
RCT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P24
Re-hospitalization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C130
Reaction Time . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B124
Reactive Oxygen Species . . . . . . . . . . . . . . . . . . . . . . . . . .D49
Readmission . . . . . . . . . .A123, A161, B116, C165, D124, P14
Readmissions . . . . . . . . . . . . . . . . . . . . . . . . . .C99, C121, D125
Recognition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C12
Reconciliation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C90
Reconstructive surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . .D24
Recruitment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D95
Recurrence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D122
REDD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B4
Referral . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P12
Reflective journaling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A83
Regional . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D99
Regional Variation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P11
Registry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D141
Regulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P11
Rehabilitation . . . . . . . . . .A146, A160, A161, C84, C130, P13
Rehabilitation center . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A156
Reimbursement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C109
Relocation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C82
Remaining life expectancy . . . . . . . . . . . . . . . . . . . . . . . . .B111
Renal function . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D145
Renin-angiotensin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B55
Renin-angiotensin system . . . . . . . . . . . . . . . . . . . . . . . . . .B61
Reproductive hormone . . . . . . . . . . . . . . . . . . . . . . . . . . . .C22
Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D58
Research Participation . . . . . . . . . . . . . . . . . . . . . . . . . . . .A94
Residency training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A80
Resident Education . . . . . . . . . . . .A65, B66, D71, D133, P36
Responsiveness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C162
Resting metabolic rate . . . . . . . . . . . . . . . . . . . . . . . . . . . .B159
Restorative sleep . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C62
Restricting fatigue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B43
Resuscitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C63
Resveratrol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P16
Retroperitoneal bleed . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A92
Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A88
Revisit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D33
Rhabdomyolysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D1
Rheumatoid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C25
Rheumatological diseases . . . . . . . . . . . . . . . . . . . . . . . . .A145
Risk factor assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D88
Risk Factors . . . . . . . . . . . . . . . . . . . . . . . . .D76, D81, P28, P44
Risk Stratification . . . . . . . . . . . . . . . . . . . . . . . . . . . .B24, B41
Risks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A163
RITUXIMAB . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A11
Rivaroxaban complications . . . . . . . . . . . . . . . . . . . . . . . .D164
Rivastigmine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D27
Roles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A84
Rotation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D53
Rural Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D55
Rural older adults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C151
Safety awareness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A138
Safety net . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A60
Sandwich Generation . . . . . . . . . . . . . . . . . . . . . . . . . . . .D154
Sarcodynapenia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B2
Sarcoidosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B6
Sarcopenia . . . . . . . . . . . . . . . . . . . . . . . . . . . .B1, B2, B37, B58
Score . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C51
Screening . . . . . . . . . . . .B54, B105, B107, B143, D149, P1, P6
Screening tools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D32
Seeking help . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D151
Self care capacity competencies . . . . . . . . . . . . . . . . . . . . .A76
Self neglect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A111
Self-assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C131
Self-rated health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B105, P3
Self-Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B79
Seniors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C75
Sensitivity and specificity . . . . . . . . . . . . . . . . . . . . . . . . .A158
Sepsis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C16, P20
Septic arthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A1
Septuagenarian . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C22
Seriously ill inpatient . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B147
Serum anticholinergic activity . . . . . . . . . . . . . . . . . . . . . .C137
Service learning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D72
Shared decision making . . . . . . . . . . . . . . . . . . . . . . . . . . . .B27
Shingles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A53
Short Physical Performance Battery . . . . . . . . . . . . . . . . . .B3
Side effects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C29
Simulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D67
Simulation OSCE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D73
Sirtuin 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P17
Skilled Nursing Facilities . . . . . . . . . . . . . . . . . . . . . . . . . .C103
Skilled nursing facility . . . . . . . . . . . . . . . . . . . . . . . . . . . .C165
Skin cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C153
Sleep . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A149, B76
Sleep apnea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A143, B89
Sleep-disordered breathing (SDB . . . . . . . . . . . . . . . . . . .B59
Sliding-scale insulin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B153
SLUMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C140
SLUMS exam . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C142
Small bowel obstruction . . . . . . . . . . . . . . . . . . . . . . . . . . .D12
Small cell cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C4
Smoothness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B161
Social Isolation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D96
Social services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C126
Social support . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A105
Social Work . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D58
Socioeconomic status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B32
SPIKES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A70
Spironolactone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B8
Spontaneous tumor lysis . . . . . . . . . . . . . . . . . . . . . . . . . . . .A5
Standardized Patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D66
Statins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C43
Sternoclavicular joint . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A1
Stroke . . . . . . . . . . . . . . . . . . . . .A36, B120, C136, C143, C163
Student Attitudes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A73
Students . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P39
Sub-acute . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C87
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Sub-acute care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C130
Subclavian stenosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A26
Subcortical hyperintensities . . . . . . . . . . . . . . . . . . . . . . .B163
Subdural hematoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D84
Successful Aging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A153
Suicidal ideation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D6
Suicide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D131
Sunblock . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C153
Superior opthalmic vein thrombosis . . . . . . . . . . . . . . . . .A91
Surgery . . . . . . . . . . . . . . . . . . .A109, B167, B170, B171, D126
Surgical complications . . . . . . . . . . . . . . . . . . . . . . . . . . . .B169
Surgical inpatients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A116
Survey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C63, D156
Survival . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C17
Sustained attention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B72
Syncope . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D13, D22
Systematic review . . . . . . . . . . . . . . . . . . . . . .B22, C127, D116
Systems based practice . . . . . . . . . . . . . . . . . . . . . . . . . . . .A77
Systems-based practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P36
T cell . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B57
Tachycardia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C20
Tai chi . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B86
Taiwanese . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D137
Tamsulosin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D16
TB Meningitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D18
TBI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A162
Team care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B106
Team-based care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C76
Technology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D96
Telehealth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D100
Telemedicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D45
Terminal illness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C28
Terry’s nails . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A28
Tertiary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D118
Thai traditional music . . . . . . . . . . . . . . . . . . . . . . . . . . . .A130
Thermal therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C95
Timed Up & Go Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D78
TMP/SMX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D7
TNF-R1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A63
Topical clindamycin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D9
Total actual costs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D135
Total hip arthroplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . .D160
Total knee arthroplasty . . . . . . . . . . . . . . . . . . . . . . . . . . .D160
Total mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C53
Transcatheter aortic valve . . . . . . . . . . . . . . . . . . . . . . . . .B152
Transcriptome, mouse . . . . . . . . . . . . . . . . . . . . . . . . . . . .A137
Transfer of care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A116
Transition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A121
Transition of care . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B19, D86
Transitional Care . . . . . . . . . . . . . . . .C117, D108, D117, D133
Transitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A112, C121
Transitions of care . . . . . . . . .A119, A124, B157, C122, C124,
D47, D71
Traumatic brain injury . . . . . . . . . . . . . . . . . . . . . . .A27, B131
Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D14
Treatment refusal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C60
Triple Antithrombotic Therapy . . . . . . . . . . . . . . . . . . . . . .C26
TSS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B4
Tube feeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B157
Ulcer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D146
Unbefriended . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C11
Undergraduate medical education . . . . . . . . . . . . . . . . . . .P35
Underweight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C161
Unexplained Falls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A86
Unintentional weight loss . . . . . . . . . . . . . . . . . . . . . . . . . .D19
Unplanned . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D124
Unresponsiveness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C24
Unsteadiness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A52
Urinary Catheters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P34
Urinary incontinence . . . . . . .B80, B81, C33, C84, D151, P25
Urinary tract infection . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C49
Urinary tract infections . . . . . . . . . . . . . . . . . . . . . . . . . . .A146
Utilization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A121, B112
Vaccination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A53
Variability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C83
Venous thromboembolism . . . . . . . . . . . . . . . .B167, C54, C93
Vertebral fracture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D149
VES-13 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B91, P4
Veterans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B101
Veterans Health Administration . . . . . . . . . . . . . . . . . . . .C117
Video . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C69, D54
Visual hallucinations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D92
Visual impairment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D92
Vitamin D . . . . . . . . . .A104, B48, B140, C55, C148, P22, P45
Vitamin D deficiency . . . . . . . . . . . . . .A46, A144, C151, D36
Vitamin D Replacement . . . . . . . . . . . . . . . . . . . . . . . . . . .D26
Vitamin D supplement . . . . . . . . . . . . . . . . . . . . . . . . . . . .C151
Vitamin D supplementation . . . . . . . . . . . . . . . . . . .A144, P23
Volunteering . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C160
VTE prophylaxis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D143
Vulnerability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B91
Vulnerable elderly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C34
Waldenstrom’s macroglobulinemia . . . . . . . . . . . . . . . . . . .D8
Walking ability . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B146, D159
Warfarin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A92, C93, D99
Wear time . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B165
Weekend . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A162
Weight loss . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B73, C32
Wheelchair wrist drop . . . . . . . . . . . . . . . . . . . . . . . . . . . .C135
Wii Fit technology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B3
Wish to die . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D48
Withdrawal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A117
Wood . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B14
Work force . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D53
Wound dehiscence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .D24
Zarit Burden Inventory . . . . . . . . . . . . . . . . . . . . . . . . . . . .C86
Zoledronic Acid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B5
Zolpidem . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B11
Zoonoses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A21
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