Health outcomes associated with polypharmacy in community-dwelling older adults: a systematic review.

Objectives: To summarize evidence regarding the health outcomes associated with polypharmacy, defined as number of prescribed medications, in older community-dwelling persons.

Design: Systematic review of MEDLINE (OvidSP 1946 to May, Week 3, 2014).

Setting: Community.

The effects of comorbidity on the benefits and harms of treatment for chronic disease: a systematic review.

Background: There are concerns about the potential for unintentional harms when clinical practice guidelines are applied to patients with multimorbidity. The objective was to summarize the evidence regarding the effect(s) of comorbidity on the outcomes of medication for an index chronic condition.

Methods: A systematic review was conducted of studies published in MEDLINE and Cochrane Trials before May 2012.

Association of experience with illness and end-of-life care with advance care planning in older adults.

Objectives: To examine whether experiences with illness and end-of-life care are associated with readiness to participate in advance care planning (ACP).

Design: Observational cohort study.

Setting: Community.

Innate Immune Responses in the Neutrophils of Community Dwelling and Nursing Home Elders.

Objective: To evaluate innate immune responses of older disabled nursing home residents that may contribute to infectious disease susceptibility, we compared surface markers and signaling efficiency of neutrophils from nursing home residents and community dwelling elders.

Design: Observational pilot study.

Setting: Five New Haven, CT area nursing homes and the greater New Haven community.

Considering the balance: development of a scale to assess patient views on trade-offs in competing health outcomes.

Objectives: To describe the development of a scale assessing participant attitudes regarding two commonly encountered trade-offs: quality versus quantity of life and present versus future health.

Design: Observational cohort study.

Setting: Community.

Cognitive impairment in older adults with heart failure: prevalence, documentation, and impact on outcomes.

Background: Despite the fact that 80% of patients with heart failure are aged more than 65 years, recognition of cognitive impairment by physicians in this population has received relatively little attention. The current study evaluated physician documentation (as a measure of recognition) of cognitive impairment at the time of discharge in a cohort of older adults hospitalized for heart failure.

Methods: We performed a prospective cohort study of older adults hospitalized with a primary diagnosis of heart failure.

A pilot randomized controlled trial of a decision support tool to improve the quality of communication and decision-making in individuals with atrial fibrillation.

Objectives: To design a tool for nonvalvular atrial fibrillation (NVAF) to inform individuals of their individual stroke and bleeding risks, assist in clarifying priorities, and promote communication.

Design: Clustered randomized controlled trial.

Setting: Primary care clinics.

Effects of benefits and harms on older persons' willingness to take medication for primary cardiovascular prevention.

Background: Quality-assurance initiatives encourage adherence to evidenced-based guidelines based on a consideration of treatment benefit. We examined older persons' willingness to take medication for primary cardiovascular disease prevention according to benefits and harms.

Methods: In-person interviews were performed with 356 community-living older persons.

Adverse outcomes in nursing home residents with increased episodes of observed bacteriuria.

We examined the association between an increase in episodes of observed bacteriuria and adverse clinical outcomes among nursing home residents without catheters. Although bacteriuria was not associated with hospitalization for urinary tract infection (UTI) or change in mental status, it was associated with use of antibiotics to treat UTI and with isolation of multidrug-resistant gram-negative rods from urine specimens, which suggested a causal relationship.

Increased TLR4 expression and downstream cytokine production in immunosuppressed adults compared to non-immunosuppressed adults.

Background: An increasing number of patients have medical conditions with altered host immunity or that require immunosuppressive medications. While immunosuppression is associated with increased risk of infection, the precise effect of immunosuppression on innate immunity is not well understood. We studied monocyte Toll-like receptor (TLR) expression and cytokine production in 137 patients with autoimmune diseases who were maintained on immunosuppressive medications and 419 non-immunosuppressed individuals.

Health outcome prioritization to elicit preferences of older persons with multiple health conditions.

Objective: To develop and test a simple tool to elicit the preferences of older persons based on prioritization of universal health outcomes.

Methods: Persons age ≥ 65 participating in a larger study were asked to rank 4 outcomes on a visual analogue scale: (1) maintaining independence, (2) staying alive, (3) reducing/eliminating pain, (4) reducing/eliminating other symptoms.

Results: Interviewers rated 73% of the 81 participants as having good to excellent understanding, and cognitive interviews demonstrated the tool captured how participants thought about trade-offs.

Age-associated decrease in TLR function in primary human dendritic cells predicts influenza vaccine response.

We evaluated TLR function in primary human dendritic cells (DCs) from 104 young (age 21-30 y) and older (> or =65 y) individuals. We used multicolor flow cytometry and intracellular cytokine staining of myeloid DCs (mDCs) and plasmacytoid DCs (pDCs) and found substantial decreases in older compared with young individuals in TNF-alpha, IL-6, and/or IL-12 (p40) production in mDCs and in TNF-alpha and IFN-alpha production in pDCs in response to TLR1/2, TLR2/6, TLR3, TLR5, and TLR8 engagement in mDCs and TLR7 and TLR9 in pDCs. These differences were highly significant after adjustment for heterogeneity between young and older groups (e.

Antimicrobial susceptibility of bacteria isolated from urine samples obtained from nursing home residents.

In our study of nursing home residents with clinically suspected urinary tract infection who did not require the use of an indwelling catheter, we identified bacteria isolated from urine samples, the resistance patterns of these isolated bacteria, and the antibiotic therapy prescribed to the residents. Escherichia coli, the predominant organism isolated, frequently was resistant to commonly prescribed oral antibiotics. Trimethoprim-sulfamethoxazole remains the best empiric antimicrobial therapy for a urinary tract infection, but nitrofurantoin should be considered if E.

CREB1/ATF1 activation in photoreceptor degeneration and protection.

Purpose: The cAMP response element binding protein 1 (CREB1) and activating transcription factor 1 (ATF1) are closely related members of the bZIP superfamily of transcription factors. Both are activated in response to a wide array of stimuli, including cellular stress. This study was conducted to assess the CREB1/ATF1 pathway in photoreceptor disease and protection.

Pilot testing of intervention protocols to prevent pneumonia in nursing home residents.

Objectives: To test intervention protocols for feasibility, staff adherence, and effectiveness in reducing pneumonia risk factors (impaired oral hygiene, swallowing difficulty) in nursing home residents.

Design: Prospective study.

Setting: Two nursing homes.

Clinical features to identify urinary tract infection in nursing home residents: a cohort study.

Objectives: To identify clinical features associated with bacteriuria plus pyuria in noncatheterized nursing home residents with clinically suspected urinary tract infection (UTI).

Design: Prospective, observational cohort study from 2005 to 2007.

Setting: Five New Haven, Connecticut area nursing homes.

Religion, risk, and medical decision making at the end of life.

Objective: The purpose of this study is to present empirical evidence about whether religious patients are more or less willing to undergo the risks associated with potentially life-sustaining treatment.

Methods: At least every 4 months 226 older community-dwelling persons with advanced cancer, congestive heart failure, or chronic obstructive pulmonary disease were asked questions about several dimensions of religiousness and about their willingness to accept potentially life-sustaining treatment.

Results: Results were mixed but persons who said that during their illness they grew closer to God (odds ratio [OR] = 1.

Interobserver variability in the assessment of clinical criteria for suspected urinary tract infection in nursing home residents.

We determined the interobserver variability in the assessment of clinical criteria for urinary tract infection (UTI) in nursing home residents. Pairs of nursing home staff caring for 30 residents were interviewed at the time UTI was suspected. At least one measure from each of 7 clinical criteria categories was reliably assessed by nursing home staff members.

Testing measurement reliability in older populations: methods for informed discrimination in instrument selection and application.

Objective: The authors recommend confidence intervals as measures of precision for reliability coefficients, regression modeling as supplements for such omnibus reliability statistics, and unreliability detection as a goal of reliability testing distinct from reliability inference.

Methods: Illustrative reliability analyses are conducted on measures selected from a study of clinical features associated with urinary tract infection in older nursing home residents.

Results: Standard methods for reliability testing (e.

Diagnostic accuracy of criteria for urinary tract infection in a cohort of nursing home residents.

Objectives: To prospectively evaluate nursing home residents with suspected urinary tract infection (UTI) to determine whether they met the McGeer, Loeb, or revised Loeb consensus-based criteria and whether any set of criteria was associated with laboratory evidence of UTI, namely bacteriuria (>100,000 colony forming units) plus pyuria (>10 white blood cells).

Design: Prospective cohort study.

Setting: Three New Haven-area nursing homes.

Role of dipstick testing in the evaluation of urinary tract infection in nursing home residents.

Among 101 nursing home residents with suspected urinary tract infection (UTI), we determined the negative predictive value of dipstick testing for leukocyte esterase and nitrite to be 100% (95% confidence interval, 74%-100%), compared with laboratory evidence of UTI (greater than 10 white blood cells/mm(3) on urinalysis and greater than 100,000 colony forming units/mL on urine culture). Nursing home dipstick testing effectively excluded the possibility of UTI.

Changes in preferences for life-sustaining treatment among older persons with advanced illness.

Background: There are conflicting assumptions regarding how patients' preferences for life-sustaining treatment change over the course of serious illness.

Objective: To examine changes in treatment preferences over time.

Design: Longitudinal cohort study with 2-year follow-up.