0208 The Effect of Mastication on Psychomotor Vigilance Performance

Introduction

Sustained attention is important for optimal neurobehavioral performance, but many biological and environment factors (e.g., circadian rhythm, distraction) may cause sustained attention deficits. Mastication (chewing) has been suggested to provide a countermeasure to sustained attention deficits. To investigate this, we conducted a randomized, within-subjects, cross-over study of sustained attention with a mastication condition and a control condition.

Methods

N=58 adults (ages 18–45; 38 females) completed a 5h in-laboratory study. Subjects entered the laboratory at 09:00. Following training on performance tasks, they had a 1h break before beginning the first of two test bouts at 11:00. Each test bout was 40min long and included subjective rating scales, the Sustained Attention to Response Task, and the Psychomotor Vigilance Test (PVT). Here we focus on PVT lapses of attention (RT > 500 ms), false starts, and mean reaction time (RT) as measures of sustained attention. In between test bouts, subjects had a 1h break inside the laboratory. During one of the two test bouts, subjects were instructed to chew a piece of gum at a steady, comfortable rate. Mastication activity was verified via electromyography (EMG). Half of the sample was assigned to the mastication condition during the first test bout, the other half during the second test bout.

Results

Controlling for order of conditions, there were no significant differences between conditions for PVT lapses (F1,56=0.40, P=0.54) or false starts (F1,56=0.10, P=0.80). Mean RT was higher in the mastication condition by 8.9±2.5ms (F1,56 =12.68, P<0.001).

Conclusion

Using this test paradigm, we were unable to detect any significant improvement in PVT performance, although mastication resulted in a very small increase in mean RT. However, subjects were not sleep-deprived, distracted, or otherwise perturbed. A follow-up study under conditions of sleep deprivation and/or with longer task duration may provide further insight into the countermeasure potential of mastication.

Support

Mars Wrigley Confectionery, U.S., LLC

0613 The Effects of Diabetes on Obstructive Sleep Apnea Severity and Progression: A Propensity Score Analysis

Introduction

Obstructive sleep apnea (OSA) is associated with increased glucose intolerance and insulin resistance, and commonly coexists with type 2 diabetes mellitus (T2DM). Research suggests an independent association between these two conditions. However, more research into the role of T2DM in the development of OSA, or vice versa, is needed.

Methods

Leveraging data from 139 participants with T2DM from the Sleep AHEAD cohort and 5,085 participants without T2DM from the Sleep Heart Health Study (SHHS), we conducted two complementary propensity score (PS) subclassification analyses to estimate the effect of T2DM on the oxygen desaturation index (ODI), both at baseline and over 4-5 years of follow-up. PS models included age, sex, race, body mass index, neck circumference, waist circumference, total cholesterol, HDL cholesterol, triglycerides, Epworth Sleepiness Scale, and comorbid hypertension or cardiovascular disease. Models evaluating ODI progression also included baseline ODI.

Results

The PS subclassification analysis identified 109 participants with T2DM and 480 without T2DM, balanced with respect to baseline covariates, for evaluation of the effect of T2DM on baseline ODI. On average, those with T2DM had a 9 events/hour greater ODI compared to those without (24.3 [20.8, 27.9] vs. 15.3 [13.6, 16.9] events/hour; p<0.0001). Among patients with baseline ODI≥5, a second PS subclassification identified 99 with T2DM and 227 without for evaluating the effect of T2DM on ODI progression. No difference in change in ODI was observed between those with and without T2DM (mean [95% CI] difference -0.25 [-10.7, 10.2] events/hour; p=0.963).

Conclusion

Using two robust PS subclassification designs to minimize selection bias, we evaluated the effect of T2DM on baseline ODI and ODI progression in adults with OSA after 4-5 years. Those with T2DM had more severe baseline ODI, but there were no meaningful differences in ODI progression. Results further our understanding of the association between these coexisting conditions.

Support

NIH grant HL070301

Identification of craniofacial risk factors for obstructive sleep apnoea using three-dimensional MRI

The alteration of craniofacial structures has been associated with obstructive sleep apnoea (OSA). We hypothesised that: 1) a smaller mandible is a risk factor for OSA; and 2) the previously observed inferiorly positioned hyoid bone in apnoeics is associated with enlarged tongue volume. This is a case-control study using three-dimensional magnetic resonance imaging cephalometry. 55 apneics and 55 controls were matched for age, sex and race. The analysis was stratified by sex and controlled for age, race, height, neck visceral fat, skeletal type and tongue volume. We found that a 1-sd increase in mandibular length and depth were associated with decreased risk of sleep apnoea (OR 0.52, 95% CI 0.28-0.99 and OR 0.46, 95% CI 0.23-0.91, respectively) in males but not in females. Greater hyoid-to-nasion (OR 2.64, 95% CI 1.19-5.89 in males and OR 5.01, 95% CI 2.00-12.52 in females) and supramentale-to-hyoid (OR 2.39, 95% CI 1.12-5.14) in males and OR 3.38, 95% CI 1.49-7.68 in females) distances were associated with increased risk of OSA. The difference for hyoid position between apnoeics and controls was lost after controlling for tongue volume. Enlargement of tongue is likely to be the pathogenic factor for inferior-posterior positioning of hyoid. A small and shallow mandible is an independent risk factor for OSA in males but not in females.

Predictors of body size in the first 2 y of life: a high-risk study of human obesity

OBJECTIVE

To ascertain the predictors of body size at 2 y of age.

DESIGN

: Prospective, longitudinal study of risk factors for weight gain of infants at high or low risk of obesity by virtue of their mothers' obesity or leanness.

SUBJECTS

A total of 40 infants of obese mothers and 38 infants of lean mothers, equally divided among boys and girls.

METHODS

Measurement of dependent variables: weight, length and skinfold thicknesses at 3, 6, 9, 12, 18 and 24 months and percent body fat at 3, 12 and 24 months. Measurement of independent variables: average daily caloric consumption at 3, 6, 9, 12, 18 and 24 months; and, at 3 months, nutritive sucking behavior during a test meal, total energy expenditure (TEE), sleeping energy expenditure (SEE), estimation of nonsleeping energy expenditure (TEE-SEE) and socioeconomic status. Parental weights and heights were obtained by self-report at the time of recruitment. Partial correlation and mixed effects linear regression analyses were performed.

RESULTS

Measures of body size (weight, length, skinfold thicknesses) and percent of body fat were almost identical between high- and low-risk groups at all times. Energy intake during six occasions over the 2 y, sucking behavior, family income and TEE predicted weight gain, controlling for body length. Parental body mass index was not associated with the child's body size during the first 2 y. During the first year, there were strong lagged correlations between energy intake and body weight and smaller correlations between protein intake and body weight.

CONCLUSION

Energy intake, and not energy expenditure, was the determinant of body size in these infants at 2 y of age, as it had been at 1 y. Sucking behavior and TEE (positively) and family income (negatively) also contributed to body weight at 2 y. The novel finding of a lagged correlation between energy intake and body weight early in life suggests that energy intake is programmed for future growth and development.

Breast cancer: education, counseling, and adjustment--a pilot study

The feasibility of a randomized clinical trial to implement and compare the effectiveness of three components of an intervention for women with breast cancer and their partners was tested. The intervention components, standardized education by videotape (SE), telephone counseling (TC), and education with telephone counseling (SE+TC), were designed with a complementary approach to disease management of breast cancer at each of four phases of the breast cancer experience: diagnostic, postsurgery, adjuvant therapy, and ongoing recovery. A standardized Telephone Counseling Training Manual was developed. A nonprobability sample of 12 patient-partner pairs was accrued. Four pairs were randomly assigned to each of the three intervention components. A set of questionnaires was completed by each patient and partner at baseline and following each intervention for assessment of emotional, physical, and social adjustment, and perceived support. Attrition was minimal and return rate for the completed questionnaires at all five data-collection points was high. Validation of the SE and the TC, one of the objectives, was by data from the preliminary descriptive study (Hoskins, 1990-1994), pretests and posttests for standardized education, audiotapes for each phase-specific telephone counseling session, and evaluation forms for each intervention session. The positive findings included significant changes from pre- to postmeasurement in patients' and partners' scores for the standardized education in each of the four phases. Even with the limited statistical power, the effects were marked, lending support for a full-scale randomized clinical trial, to understand better the relative treatment efficacy and differential benefit of one or some interventions over others.

An algorithm to stratify sleep apnea risk in a sleep disorders clinic population

Obstructive sleep apnea may lead to complications if not identified and treated. Polysomnography is the diagnostic standard, but is often inaccessible due to bed shortages. A system that facilitates prioritization of patients requiring sleep studies would thus be useful. We retrospectively compared the accuracy of a two-stage risk-stratification algorithm for sleep apnea using questionnaire plus nocturnal pulse oximetry against using polysomnography to identify patients without apnea (Objective 1) and those with severe apnea (Objective 2). Patients were those referred to a university-based sleep disorders clinic due to suspicion of sleep apnea. Subjects completed a sleep apnea symptom questionnaire, and underwent oximetry and two-night polysomnography. We used bootstrap methodology to maximize sensitivity of our model for Objective 1 and specificity for Objective 2. We calculated sensitivity, specificity, positive and negative predictive values, and rate of misclassification error of the two-stage risk-stratification algorithm for each of our two objectives. The model identified cases of sleep apnea with 95% sensitivity and severe apnea with 97% specificity. It excluded only 8% of patients from sleep studies, but prioritized up to 23% of subjects to receive in-laboratory studies. Among sleep disorders clinic referrals, a two-stage risk-stratification algorithm using questionnaire and nocturnal pulse oximetry excluded few patients from sleep studies, but identified a larger proportion of patients who should receive early testing because of their likelihood of having severe disease.

Magnetic resonance imaging of the upper airway structure of children with obstructive sleep apnea syndrome

The anatomical relationships between lymphoid, bony, and other tissues affecting the shape of the upper airway in children with obstructive sleep apnea syndrome (OSAS) have not been established. We therefore compared the upper airway structure in 18 young children with OSAS (age 4.8 +/- 2.1 yr; 12 males and 6 females) and an apnea index of 4.3 +/- 3.9, with 18 matched control subjects (age, 4.9 +/- 2.0 yr; 12 males and 6 females). All subjects underwent magnetic resonance imaging under sedation. Axial and sagittal T1- and T2-weighted sequences were obtained. Images were analyzed with image-processing software to obtain linear, area, and volumetric measurements of the upper airway and the tissues comprising the airway. The volume of the upper airway was smaller in subjects with OSAS in comparison with control subjects (1.5 +/- 0.8 versus 2.5 +/- 1.2 cm(3); p < 0.005) and the adenoid and tonsils were larger (9.9 +/- 3.9 and 9.1 +/- 2.9 cm(3) versus 6.4 +/- 2.3 and 5.8 +/- 2.2 cm(3); p < 0.005 and p < 0.0005, respectively). Volumes of the mandible and tongue were similar in both groups; however, the soft palate was larger in subjects with OSAS (3.5 +/- 1.1 versus 2.7 +/- 1.2 cm(3); p < 0.05). We conclude that in children with moderate OSAS, the upper airway is restricted both by the adenoid and tonsils; however, the soft palate is also larger in this group, adding further restriction.

Evaluation of the survival prediction index as a model of risk stratification for clinical research in dogs admitted to intensive care units at four locations

OBJECTIVE

To prospectively evaluate a survival prediction index (SPI) in dogs admitted to intensive care units (ICU) and to generate and test an improved SPI (ie, SPI2).

SAMPLE POPULATION

Medical records of 624 critically ill dogs admitted to an ICU.

PROCEDURE

Data were collected from dogs within 24 hours after admission to an ICU. Variables recorded reflected function of vital organ systems, severity of underlying physiologic derangement, and extent of physiologic reserve; outcome was defined as dogs that survived or did not survive until 30 days after admission to the ICU. Probabilities of survival were calculated, using an established model (SPI). We then performed another logistic regression analysis, thereby reestimating the variables to create the new SPI2. Cross-validation of the models obtained was performed by randomly assigning the total sample of 624 dogs into an estimation group of 499 dogs and validation group of 125 dogs.

RESULTS

Testing of SPI resulted in an area under the curve (AUC) of 0.723. Testing of SPI2 revealed an AUC of 0.773. A backwards-elimination procedure was used to create a model containing fewer variables, and variables were sequentially eliminated. The AUC for the reduced model of SPI2 was 0.76, indicating little loss in predictive accuracy.

CONCLUSIONS AND CLINICAL RELEVANCE

The new SPI2 objectively stratified clinical patients into groups according to severity of disease. This index could provide an important tool for clinical research.

Inpatient rehabilitation after stroke: a comparison of lengths of stay and outcomes in the Veterans Affairs and non-Veterans Affairs health care system

BACKGROUND

Patients have longer lengths of hospital stay (LOS) in VA medical centers than in the general health care system.

OBJECTIVE

The objective of this study was to determine whether resource use and outcome differences between VA and non-VA inpatient rehabilitation facilities remain after controlling for patient and medical care delivery differences.

DESIGN

This analysis involved 60 VA inpatient rehabilitation units and 467 non-VA rehabilitation hospitals and units. Multivariate adjusted resource use and patient outcome differences were compared across setting within patients grouped by severity of disability at admission through assignment to the Function Related Group (FRG) patient classification system.

SUBJECTS

The study included 55,438 stroke patients.

MEASURES

Study measures were LOS, functional status at discharge, and community discharge.

RESULTS

The VA serves a higher proportion of patients who are single, separated, or divorced; are unemployed or retired as a result of disability, and are not white (P < 0.0001). These traits tended to be associated with longer LOS, lower functional outcomes, and reduced rates of community discharge. After adjusting for these and other differences, depending on FRG, average LOS remained from 30% to 200% longer in the VA centers (P < 0.05); average functional outcomes were significantly higher in 8 and lower in 2 FRGs (P < 0.05); and community discharge rates were lower in 12 FRGs (P < 0.05).

CONCLUSIONS

While certain variables accounted for some of the observed differences in resource use and outcomes, differences remained after adjustment. Fewer incentives for cost containment and less support in patients' home environments may be among the most important unmeasured determinants of VA differences.

Repeated assessment of the endogenous 24-hour profile of blood pressure under constant routine

The impact of environmental and behavioral factors on the 24-h profile of blood pressure (BP) has been well established. Various attempts have been made to control these exogenous factors, in order to investigate a possible endogenous circadian variation of BP. Recently, we reported the results of the first environmentally and behaviorally controlled laboratory study with 24-h recordings of BP and heart rate (HR) during maintained wakefulness. In this constant-routine study, a pronounced endogenous circadian rhythm of HR was found, but circadian variation of BP was absent. This result suggested that the circadian rhythm of BP observed in earlier controlled studies, with sleep allowed, was evoked by the sleep-wake cycle as opposed to the endogenous circadian pacemaker. In order to verify our previous finding during maintained wakefulness, we repeated the experiment five times with six normotensive, healthy young subjects. Statistical analyses of the hourly measurements of BP and HR confirmed the replicable presence of an endogenous circadian rhythm of HR, as well as the consistent absence of an endogenous circadian variation of BP. Thus, this study provided additional evidence that the 24-h profile of BP--as observed under normal circumstances--is the sole result of environmental and behavioral factors such as the occurrence of sleep, and has no endogenous circadian component.

Nurse practitioner services: content and relative work value

The resource-based relative value scale is used to quantify work for reimbursement of services in the Medicare Fee Schedule. This pilot study explored use of the resource-based relative value scale for services provided by nurse practitioners. Estimation of relative work values for office visits by nurse practitioners was consistent with the Medicare Fee Schedule. Content analysis revealed that nurse practitioners provide additional services including comprehensive patient evaluation and education and attendance to social factors. Future research is needed to examine systems that identify and reimburse nurse practitioners for their services.

Physical findings and the risk for obstructive sleep apnea. The importance of oropharyngeal structures

In this study, we hypothesized that anatomic abnormalities of the oropharynx, particularly narrowing of the airway by the lateral pharyngeal walls, tonsils, and tongue, would be associated with an increased likelihood for obstructive apnea among patients presenting to a sleep disorders center. To test this hypothesis, we used data from a cohort of 420 patients presenting to the Penn Center for Sleep Disorders. Associations between individual variables in the clinical evaluation model and sleep apnea as defined by a respiratory disturbance index greater than or equal to 15 events per hour were characterized by odds ratios (ORs) with 95% confidence intervals (CIs). Multivariable logistic regression was used to simultaneously estimate ORs for multiple variables and to control for other relevant patient characteristics. Results showed that narrowing of the airway by the lateral pharyngeal walls (OR = 2.5; 95% CI, 1.6-3.9) had the highest association with obstructive sleep apnea (OSA) followed by tonsillar enlargement (OR = 2.0; 95% CI, 1.0-3.8), enlargement of the uvula (OR = 1.9; 95% CI, 1.2-2.9), and tongue enlargement (OR = 1.8; 95% CI, 1.0-3.1). Low-lying palate, retrognathia, and overjet were not found to be significantly associated with OSA. Controlling for BMI and neck circumference, only lateral narrowing and enlargement of the tonsils maintained their significant (OR = 2.0 and 2.6, respectively). A subgroup analysis examining differences between male and female subjects showed that no oropharyngeal risk factor achieved significance in women while lateral narrowing was the sole independent risk factor in men. These findings suggest that enlargement of the oropharyngeal soft tissue structures, particularly the lateral pharyngeal walls, is associated with an increased likelihood of OSA among patients presenting to sleep disorders centers.

Comparison of nurse practitioner and family physician relative work values

PURPOSE

With the enactment of the Balanced Budget Act of 1997, American nurse practitioners were granted direct Medicare reimbursement for Part B services. Payment structures in fee-for-service and managed care systems are physician-based, leading to difficulties in constructing payments for other health care professionals. The purpose of this pilot study was to examine the feasibility of using nurse practitioner data for specifying relative work values in the Medicare Fee Schedule for three office-visit codes.

DESIGN

An exploratory survey was designed to establish relative work values using magnitude-estimation scaling. Nurse practitioners (N = 43) responded to a structured questionnaire in a national mail survey. Physician data (N = 46) were obtained from a computerized database from the American Academy of Family Physicians.

METHODS

The methods used in this study were the same as the process used by the American Medical Association and the Health Care Financing Administration to establish relative work values in the Medicare Fee Schedule. Respondents established relative work values for three Current Procedural Terminology (CPT) codes for office visits (99203, 99213, 99215) commonly billed in primary care practice. Each CPT code descriptor and associated vignette were compared with reference services germane to the practice of nurse practitioners and family physicians, using magnitude-estimation scaling. To establish relative work values for each code, respondents were asked to consider the time to provide the service and intensity of the work involved for each CPT code.

FINDINGS

No significant differences between nurse practitioners and family physicians were found in the three CPT codes for relative work values and intensity. Nurse practitioners estimated significantly (p < .01) higher intraservice (face to face) time with patients than did family physicians, and family physicians estimated significantly (p < .05) higher pre-service time for two codes and significantly (p < .05) higher postservice times for three codes.

CONCLUSIONS

Nurse practitioner relative work values did not differ significantly from family physician relative work values. Although the sample sizes were small, the significance of the findings support the need for further research with large data sets and additional CPT codes. Such studies could then be used as a basis for decisions about Medicare payment and public policy.

A double-blind study comparing idazoxan and bupropion in bipolar depressed patients

BACKGROUND

There is a small body of evidence indicating that idazoxan, a potent and selective alpha-2 antagonist, may be effective in treating bipolar depressive disorder. The purpose of this prospective controlled study is to compare idazoxan to bupropion, an antidepressant which has been suggested to have some advantages over other antidepressants in treating bipolar depressed patients.

METHODS

Bipolar I depressed patients were randomly assigned in this 6-week double-blind out-patient study to receive either idazoxan, titrated to 240 mg/day and placebo bupropion, or bupropion, titrated to 450 mg/day and placebo idazoxan. These doses were achieved after 2 weeks. Depression severity was assessed with the Hamilton Depression Rating Scale and possible psychosis with the Brief Psychiatric Rating Scale. Side effects, heart rate, weight, and orthostatic blood pressure were also monitored.

RESULTS

Fourteen patients completed this study (seven in each group). Both idazoxan and bupropion demonstrated significant improvement over time with reductions in Hamilton scores of 50%.

LIMITATIONS

Limitations of this study include lack of a placebo group and small sample size.

CONCLUSION

In light of our preliminary findings suggesting the usefulness of idazoxan in bipolar depression, larger more rigorous studies are indicated.

A functional strategy for classifying patients after traumatic spinal cord injury

OBJECTIVES

To present a function-based strategy for classifying patients by expected functional outcomes measured as patients' performances at discharge on each of the 18 component items of the FIMtrade mark instrument (previously known as the Functional Independence Measure).

METHODS

Data included records from 3604 inpatients with traumatic spinal cord injury discharged from 358 rehabilitation units or hospitals in 1995. The function-based strategy assigned patients to four Discharge Motor-FIM-Function Related Groups defined by patients' admission performance on the motor-FIM items.

RESULTS

The majority of patients whose motor-FIM scores at admission were above 30 were able to groom, dress the upper body, manage bladder function, use a wheelchair, and transfer from bed to chair, either independently or with supervision, by the time of discharge from inpatient rehabilitation. Most patients whose scores were above 52 attained independence in all but the most difficult FIM tasks, such as bathing, tub transfers, and stair climbing.

CONCLUSIONS

This classification scheme can be used to determine the degree to which patients' actual FIM outcomes compare to other individuals who had similar levels of disabilities at the time of admission to rehabilitation. The clinician can apply these 'FIM item attainment benchmarks' retrospectively in quality improvement, in guideline development, and in anticipating the types of post-discharge care required by clinically similar groups.

Initiation of physical restraint in nursing home residents following restraint reduction efforts

In this pilot study a one group pretest posttest design was employed to identify resident characteristics and environmental factors associated with initiation of physical restraint. Predictors of restraint initiation for older adults were examined using secondary analysis of an existing data set of nursing home residents who were subjected to a federal mandate and significant restraint reduction efforts. Lower cognitive status (OR = 1.5 [for every 7-point decrease in Mini-Mental State Examination], 95% CI = 1.0, 2.1) and a higher ratio of licensed nursing personnel (OR = 3.7, 95% CI = 1.2, 11.9) were predictive of restraint initiation. Key findings suggest that restraint initiation occurs, despite significant restraint reduction efforts, when a nursing home resident is cognitively impaired or when more licensed nursing personnel (predominantly licensed practical nurses) are available for resident care. Achievement of restraint-free care in nursing homes requires specific and individualized approaches for residents who are cognitively impaired, as well as greater attention to staff mix of registered nurses, licensed practical nurses, and nursing aides.

Quantitative evaluation of the upper airway during nasopharyngoscopy with the Müller maneuver

OBJECTIVE

To quantitatively examine changes in the upper airway caliber of normal subjects at graded negative inspiratory pressures generated during nasopharyngoscopy with a Müller maneuver.

STUDY DESIGN

Eighteen normal subjects prospectively underwent nasopharyngoscopy with Müller maneuvers. Subjects performed graded and maximal effort Müller maneuvers while sitting upright, and maximal-effort Müller maneuvers in the supine position. Two regions of the upper airway--the retropalatal and retroglossal--were examined.

METHODS

Images from the endoscopic examination were objectively analyzed by adjusting manually traced airway contours using full-width, half-maximum edge detection algorithm software. The adjusted tracings' area and dimensions through the airway centroid were measured.

RESULTS

Müller maneuvers performed at -40 cm H2O resulted in a 64%+/-17% (P = .0001) reduction in upper airway area that consisted of a 51%+/-20% (P = .0001) reduction in the lateral dimension and a 21%+/-24% (P = .0026) reduction in antero-posterior dimension. Müller maneuvers in the retroglossal region did not significantly reduce airway area (P = .575), but demonstrated an altered airway conformation that consisted of lateral narrowing and an increase in antero-posterior dimension. Changes in body position did not result in significant differences in either airway caliber or airway dimension.

CONCLUSIONS

Airway caliber during forced inspiration is mediated primarily through changes in the lateral pharyngeal walls. This study has also shown that antero-posterior and lateral airway structures are largely independent in their response to Müller maneuvers. Similarly, the retropalatal and retroglossal regions of the upper airway respond differently to forced negative intraluminal pressure.

Vasodilator therapy for primary pulmonary hypertension in children

BACKGROUND

This report presents 13 years of experience with vasodilator therapy for primary pulmonary hypertension (PPH) in children. Two eras were involved: between 1982 and 1987, oral calcium channel blockers were the only agents available for long-term therapy; after 1987, prostacyclin (PGI2) has been available for long-term intravenous use.

METHODS AND RESULTS

Seventy-four children underwent short-term vasodilator testing with intravenous PGI2. Those who manifested pulmonary vasodilation ("acute responders") were treated with oral calcium channel blockers. Until 1987, "acute nonresponders" were treated in the same way as long as they had no serious side effects. When PGI2 became available for long-term administration, all nonresponders, as well as those who failed to improve clinically and hemodynamically on calcium channel blockers, were treated with long-term PGI2. In the 31 responders, calcium channel blockers improved survival compared with the 43 nonresponders (P=0.0002). Survival was also better in 24 PGI2-treated nonresponders compared with 22 nonresponders for whom PGI2 was unavailable (P=0.0005) as well as in all children who failed conventional therapy (n=31; P=0.002).

CONCLUSIONS

Long-term vasodilator therapy improves survival in children with PPH. In acute responders, oral calcium channel blockers generally suffice. In both nonresponders to short-term testing and responders who fail to improve on calcium channel blockers, continuous intravenous infusion of PGI2 improves survival.

Predictors of continued physical restraint use in nursing home residents following restraint reduction efforts

OBJECTIVES

To examine predictors of continued restraint use in nursing home residents following efforts aimed at restraint reduction.

DESIGN

Secondary analysis of data from a clinical trial using a one-group, pre-test post-test design.

SETTING

Three nonprofit, religion-affiliated nursing homes in a metropolitan area.

PARTICIPANTS

The sample consisted of 201 physically restrained nursing home residents. Following restraint reduction efforts, 135 of the sample were still restrained. Mean age of participants was 83.9 years.

MEASUREMENTS

Physical restraint use was measured by observation and included any chest/vest, wrist, mitt, belt, crotch, suit, or harness restraint plus any sheet used as restraint or a geriatric chair with fixed tray table. Nursing home residents were subjected to any one of three conditions aimed at restraint reduction, including adherence to the mandate of the Omnibus Budget Reconciliation Act of 1987 (OBRA '87), staff education, and education with consultation from a gerontological clinical nurse specialist. Resident characteristics including dependency, health status, mental status, depression, behavior, fall risk; presence of treatment devices and institutional factors were determined.

RESULTS

Physical dependency, lower cognitive status, behavior, presence of treatment devices, presence of psychiatric disorders, fall risk, and fall risk as staff rationale for restraint were associated (P < .10) with continued restraint use. Nursing hours, staff mix, prevalence of restraint use by unit, and site were also associated (P < .10) with continued use of physical restraints. Following bivariate analysis, associated resident characteristics were subjected to logistic regression. Lower cognitive status (OR = 2.4 (for every 7-point decrease in MMSE), 95% CI, 1.7, 3.3) and fall risk as staff rationale for restraint (OR = 3.5, 95% CI., 1.5, 8.0) were predictive of continued restraint use. Adding nursing hours, staff mix, and prevalence of restraint use by unit to the logistic regression model was not statistically significant (partial chi-square = 2.79, df = 6, P = .834). Nursing home site was added to the model without changing the significance (P < .05) of cognitive status or fall risk as a staff rationale for restraint use.

CONCLUSION

Continued restraint use in nursing home residents in this study most often occurred with severe cognitive impairment and/or when fall risk was considered by staff as a rationale for restraint. Efforts to reduce or eliminate physical restraint use with these groups will require greater efforts to educate staff in the assessment and analysis of fall risk, along with targeted interventions, particularly when cognition is also impaired.

Comparing consumer and clinician values for alternative functional states: application of a new feature trade-off consensus building tool

OBJECTIVE

To present the Features-Resource Trade-Off Game (Features Game) as a new method for comparing preferences for alternative outcomes among different groups of people.

DESIGN

The Features Game is illustrated by comparing preferences for recovery among the 18 functional status items making up the Functional Independence Measure. Methods involved trading levels of independence (resources) across the different items (features).

SETTING

Ten community-dwelling consumers with physical disabilities and 10 rehabilitation clinicians participated in four separate expert panels-two in Houston and two in Philadelphia.

MAIN OUTCOME MEASURES

Five sets of hierarchical stages defined by the four separate panels specifying the profiles of function believed to most foster independent living.

RESULTS

Cognitive and communication skills were selected preferentially over the recovery of physical tasks by all panels, but, in comparison to clinicians, consumers were more willing to accept mild deficits in cognitive skills as trade for realizing earlier recovery of physical abilities.

CONCLUSION

The overwhelming choice of cognitive and communication abilities over physical abilities suggests a need to enhance therapeutic efforts in those areas. More subtle differences in consumer and clinician preferences emphasize the importance of establishing consumer-oriented goals.

State-related changes in upper airway caliber and surrounding soft-tissue structures in normal subjects

State-dependent changes in upper airway caliber were studied with magnetic resonance imaging (MRI) techniques. We hypothesized that changes in airway caliber during sleep in normal subjects would result from positional and dimensional changes in upper airway soft-tissue structures, including the lateral pharyngeal walls, tongue, and soft palate. We used MRI to study 15 normal subjects during wakefulness and sleep. Sleep was facilitated by one night of sleep deprivation prior to MRI. During sleep, the volume of the retropalatal (RP) airway was reduced by 19% (p = 0.03). The volume of the retroglossal (RG) airway was not significantly reduced during sleep, suggesting that the RP region may be more likely to collapse. The mean minimal cross-sectional airway area was reduced by 228% (p = 0.004) in the RP and by 22% (p = 0.02) in the RG region during sleep as compared with values in anatomically matched axial images during wakefulness. Airway anteroposterior (AP) and lateral dimensions were also significantly reduced in the RP region. Airway narrowing in the RP region was associated with a 7% increase in thickness of the lateral pharyngeal walls (p = 0.04). In nine subjects, sagittal data showed significant posterior displacement of the soft palate during sleep as compared with wakefulness. Multiple linear regression analyses indicated that reduction in the RP airway area during sleep resulted from posterior movement of the soft palate, thickening of the lateral pharyngeal walls, and an increase in tongue oblique distance. We conclude that the lateral pharyngeal walls play an important role in upper airway narrowing during sleep in normal subjects.

Functional task benchmarks for stroke rehabilitation

OBJECTIVE

To determine typical outcome "benchmarks" for 18 functional tasks in patients undergoing stroke rehabilitation. The benchmarks are intended to serve as points of reference to which the outcomes of patients with similar impairments and degrees of disability can be compared.

SUBJECTS

Records from 26,339 stroke patients discharged from 252 inpatient facilities across the United States that submitted 1992 data to the Uniform Data System for Medical Rehabilitation.

METHODS

Stroke impairment was detailed as the presence or absence of hemiparesis resulting from stroke and the side(s) of involvement. Within each of five stroke impairment categories, patients were further classified by the Functional Independence Measure-Function-Related Groups (FIM-FRGs) into nine syndromes by degree of disability (admission motor and cognitive FIM scores) and by age. Outcomes were determined for each stroke syndrome at patients' discharge from medical rehabilitation.

MAIN OUTCOME MEASURES

Patients' median performance levels on each of the 18 items making up the FIM, length of stay, and community discharge rates.

RESULTS

The majority of patients whose admission motor FIM scores were above 37 were able to eat, groom, dress the upper body, and manage bladder and bowel functions independently by discharge. In addition to these tasks, most of those whose motor FIM scores were above 55 were able to dress the lower body, bathe, and transfer onto a chair/bed or toilet. The majority of patients whose initial motor FIM scores were above 62 points and whose cognitive FIM scores were above 30 gained independence in most tasks, including stair climbing and tub transfers. Community discharge rates ranged from 51.6% for the group of patients with the most severe disabilities to 99.2% for the group with the least severe disabilities.

CONCLUSION

The clinician can apply these benchmarks to guideline development and quality improvement, and in establishing patient goals.

Symptom distress and functional status changes during the first seven days after ambulatory surgery

In this study, we describe changes in symptom distress and functional status 24 h, 4 days, and 7 days after ambulatory surgery. Adult patients aged 18-64 yr, ASA physical status I-III, were studied. The General Symptom Distress Scale was used to score 11 general symptoms; scores range from 0 (no symptoms present) to 4 (symptoms present, constant, cannot be ignored, and, in a 24-h period, remained distressing for more than half the time). The Functional Status Questionnaire was used to evaluate basic and intermediate activities of daily living. Procedure-specific analyses of covariance were performed using multiple linear regression analyses. These models were used to obtain estimates of change while adjusting for preoperative index values of age, ASA physical status, type of anesthesia, and study site. Models for hernia (n = 41) and laparoscopy (n = 59) procedures used F statistics to test the overall significance of the model. Symptom distress persisted until the 7th postoperative day after ambulatory surgery. Patients experienced decreased functional status during the first 7 postoperative days, especially after hernia repair. Older laparoscopy patients tended to have more symptom distress and decreased functional status than younger patients. Only 22% of patients had returned to full- or part-time work by the 7th postoperative day. We conclude that although major morbidity is uncommon after ambulatory surgery, symptom distress and reduced functional status are common 7 days postoperatively.

IMPLICATIONS

Previous studies of patient status after ambulatory surgery have focused on mortality, major morbidity, and unanticipated hospitalization. In this study, we examined clinically significant but less life-threatening patient outcomes. Important problems in ambulatory surgery are posed by complications that occur at home. Careful assessment of discharge criteria is important to avoid these problems in this growing patient population.

The relationship between physical restraint removal and falls and injuries among nursing home residents

BACKGROUND

A major reason cited for continued restraint use in American nursing homes is the widely held belief that restraint reduction will lead to fall-related incidents and injuries.

METHODS

This study represents an analysis of data collected in a clinical trial of interventions aimed at reducing the use of restraints in nursing homes. Two different designs were employed to test the relationship between restraint reduction and falls/injuries. First, multiple logistic regression was used to compare fall/injury rates in subjects who had restraints removed (n = 38) to those who continued to be restrained (n = 88); second, survival analysis was employed to test the relationship between physical restraint removal and falls/injuries at the institutional level by comparing fall/injury rates among three nursing homes (n = 633) with varying rates of restraint reduction.

RESULTS

Based on the multiple logistic regression analysis, there was no indication of increased risk of falls or injuries with restraint removal. Moreover, restraint removal significantly decreased the chance of minor injuries due to falls (adjusted odds ratio: 0.3, 95% CI: 0.1, 0.9; p < .05). The survival analysis demonstrated that the nursing home that had the least restraint reduction (11%) had a 50% higher rate of falls (p < .01) and more than twice the rate of fall-related minor injuries (p < .001) when compared to the homes with 23% and 56% restraint reduction, respectively.

CONCLUSIONS

Physical restraint removal does not lead to increases in falls or subsequent fall-related injury in older nursing home residents.

An instrument to measure functional status outcomes for disorders of excessive sleepiness

This article reports the development of the functional outcomes of sleep questionnaire (FOSQ). This is the first self-report measure designed to assess the impact of disorders of excessive sleepiness (DOES) on multiple activities of everyday living. Three samples were used in the development and psychometric analyses of the FOSQ: Sample 1 (n = 153) consisted of individuals seeking medical attention for a sleep problem and persons of similar age and gender having no sleep disorder; samples 2 (n = 24) and 3 (n = 51) were composed of patients from two medical centers diagnosed with obstructive sleep apnea (OSA). Factor analysis of the FOSQ yielded five factors: activity level, vigilance, intimacy and sexual relationships, general productivity, and social outcome. Internal reliability was excellent for both the subscales (alpha = 0.86 to alpha = 0.91) and the total scale (alpha = 0.95). Test-retest reliability of the FOSQ yielded coefficients ranging from r = 0.81 to r = 0.90 for the five subscales and r = 0.90 for the total measure. The FOSQ successfully discriminated between normal subjects and those seeking medical attention for a sleep problem (T157 = -5.88, p = 0.0001). This psychometric evaluation of the FOSQ demonstrated parameters acceptable for its application in research and in clinical practice to measure functional status outcomes for persons with DOES. Thus, the FOSQ can be used to determine how disorders of excessive sleepiness affect patients' abilities to conduct normal activities and the extent to which these abilities are improved by effective treatment of DOES.

Impact of risperidone on the use of mental health care resources

OBJECTIVE

The effects of risperidone treatment on health care utilization and treatment costs were examined among patients with treatment-refractory schizophrenia or schizoaffective disorder.

METHODS

Data from the Santa Clara County Mental Health Department were used to measure inpatient and ambulatory services and outpatient medications related to the treatment of mental disorders. Data for 139 patients were analyzed for periods before and after initiation of risperidone treatment. A mean +/- SD of 14 +/- 2.1 months of data were available in both the before and after periods, for a mean total study period of 28 months.

RESULTS

The patients' mean age was 40 years (range, 18 to 78 years), and 46 percent were women. After the start of risperidone treatment, days in acute care inpatient facilities were reduced by 26 percent, and days in residential treatment were reduced by 57 percent. These reductions were accompanied by an increase in the use of lower-cost services, such as community living, treatment planning, and partial hospital-day treatment. There was a 3.4 percent increase in total psychiatric health care costs after initiation of treatment with risperidone.

CONCLUSIONS

Overall, risperidone treatment resulted in a shift or resource utilization from provider-delivered services to pharmaceutical care without a significant change in total health care cost.

Effects of a restraint reduction intervention and OBRA '87 regulations on psychoactive drug use in nursing homes

OBJECTIVES

To describe the changes in psychoactive drug use in nursing homes after implementation of physical restraint reduction interventions and mandates of the Omnibus Budget Reconciliation Act of 1987 (OBRA '87).

METHODS

A secondary analysis was conducted using data from a controlled clinical trial that took place in three nursing homes: a control home, one that received an educational intervention, and one that received an educational/consultation intervention. All three homes were influenced by the OBRA mandates. Complete pre- and 6 months' post-intervention data on use of psychoactive drugs and physical restraints were available for 446 resident subjects. Changes were first analyzed with the resident subjects as the unit of analysis and then using the nursing home ward (n = 16) as the unit of analysis.

RESULTS

While physical restraint use declined in the home that received the educational/consultation intervention, neither neuroleptic nor benzodiazepine use increased in any of the homes after the interventions. The percentage of residents taking neuroleptics declined in the control home (18.6% to 11.3%, P = .014). Benzodiazepine use, which was more prevalent than described previously in the literature, declined in all three homes (P < .001). Of those residents whose physical restraints were discontinued, only 2% were started on neuroleptics. When the effect of OBRA mandates on appropriateness of neuroleptic use was examined, the percentage of residents on neuroleptics who lacked an OBRA-approved indication declined from 21.3% to 14.6% in the total sample, and from 39.9% to 8% in the control home.

CONCLUSIONS

Interventions to reduce physical restraint did not lead to an increase in psychoactive drug use; further, reduction in both can occur simultaneously. OBRA mandates regarding psychoactive drug use were not uniformly effective, but appear, at minimum, to have increased awareness of the indications for neuroleptics.

A clinical trial to reduce restraints in nursing homes

OBJECTIVE

To investigate the relative effects of two experimental interventions on the use of physical restraints.

DESIGN

Prospective 12-month clinical trial in which three nursing homes were randomly assigned to restraint education (RE), restraint education-with-consultation (REC), or control (C).

SETTING

Three voluntary nursing homes in the Philadelphia area providing both skilled and intermediate care.

PARTICIPANTS

A total of 643 nursing home residents over the age of 60 were enrolled at baseline, and 463 remained to completion (1 year).

INTERVENTIONS

Both RE and REC homes received intensive education by a masters-prepared gerontologic nurse to increase staff awareness of restraint hazards and knowledge about assessing and managing resident behaviors likely to lead to use of restraints. In addition, the REC home received 12 hours per week of unit-based nursing consultation to facilitate restraint reduction in residents with more complex conditions.

MEASUREMENTS

Restraint status was observed systematically at baseline, immediately after the 6-month intervention, and again at 9 and 12 months. Staff levels, psychoactive drug use, and injuries were also determined.

RESULTS

Compared with baseline, the REC home had a statistically significant reduction in restraint prevalence, whereas RE and C homes did not. At 9 months (3 months post-intervention), absolute decline in the percents restrained were 7% RE, 7% C, and 20% REC; at 12 months (6 months post-intervention) declines were 4% RE, 6% C, and 18% REC. However, relative to baseline, these declines represent an average reduction in restraint use of 23% RE, 11% C, and 56% REC. The differences in changes over time were consistently significant (P = .01), whether considering survivors or those present at each time point, and also when controlling for differences between groups at baseline. Further, given any change in restraint use, REC-residents were between 25% and 40% more likely than either RE or C residents to experience decreased restraint use. Results were achieved without increased staff, psychoactive drugs, or serious fall-related injuries.

CONCLUSION

A 6-month-long educational program combined with unit-based, resident-centered consultation can reduce use of physical restraints in nursing homes effectively and safely. Whether extending the intervention will achieve greater reduction is not known from these results.

Risk factors for hip fracture in men. Hip Fracture Study Group

To identify risk factors for hip fracture in men, the authors conducted a case-control study involving 20 hospitals in Philadelphia, Pennsylvania, and 14 hospitals in Kaiser Permanente Medical Care Program of northern California. The 356 enrolled men had been admitted with a radiologically confirmed first hip fracture. The 402 control men either were from the Philadelphia area or were members of Kaiser Permanente and were frequency matched to the cases by age and ZIP code or telephone exchange. Information on potential risk factors was obtained through personal interviews. Men in the lowest quintile of body mass had a greatly increased risk of hip fracture compared with men in the heaviest quintile (odds ratio (OR) 3.8, 95% confidence interval (CI) 2.3-6.4). Premorbid lower limb dysfunction was associated with increased risks for hip fracture (OR 3.4, 95% CI 2.1-5.4). Increased risks were also observed with the use of cimetidine (OR 2.5, 95% CI 1.4-4.6) and psychotropic drugs (OR 2.2, 95% CI 1.4-3.3). Smoking cigarettes or a pipe increased the risk of hip fracture, and this association was independent of body mass. Finally, previous physical activity was markedly protective. Factors thought to affect bone density as well as factors identified as risk factors for falls appear to be important determinants of the risk of hip fracture in men. Physical activity may be a particularly promising preventive measure for men. Additional studies of the use of cimetidine on osteoporosis and osteoporotic fractures are indicated.

Night-to-night variability in CPAP use over the first three months of treatment

The purpose of this study was to examine the relationship between night-to-night variability and nightly duration of continuous positive airway pressure (CPAP) therapy over the first 9 weeks of treatment and to determine when patients begin to establish a nonadherent pattern of use. Data were analyzed from a study of daily CPAP use covertly monitored in 32 diagnosed patients with obstructive sleep apnea (OSA) using a microprocessor monitor encased in a CPAP machine. Patterns of CPAP use were bimodal, based on the frequency of nightly use. Approximately half the subjects were consistent users of CPAP, applying it > 90% of the nights for an average of 6.22 +/- 1.21 hours per night, while the other half comprised intermittent users who had a wide range of daily use averaging 3.45 +/- 1.94 hours per night on the nights CPAP was used. The percent of days skipped was significantly correlated with decreased nightly duration (rho = -0.73, p < 0.0001). Analysis of the night-to-night pattern of use revealed that the two groups differed significantly in the nightly duration of CPAP use by the fourth day of treatment (p = 0.001). Exploration of factors that potentially differentiate the two groups revealed no reliable predictors. However, intermittent users continued to report significantly greater OSA symptoms (snoring, snorting, and apnea) posttreatment, suggesting that they continued to experience sleep disordered breathing.

A prediction model for functional recovery in stroke

BACKGROUND AND PURPOSE

Stroke-related physical disability can diminish quality of daily living, place care burden on families, and increase need for long-term institutionalization. We developed a prognostic index for use in research and with potential for adaptation to clinical practice that establishes the likelihood of an individual achieving a specific stage of functional recovery after stroke rehabilitation.

METHODS

We constructed the index using logistic regression based on 3760 patient records from 96 rehabilitation facilities in 31 states. The stage, as measured by the Functional Independence Measure, includes achievement of the following: independence in eating, grooming, and dressing the upper body; continence in bowel and bladder; and transfer between a bed and chair with supervision only.

RESULTS

This stage was achieved by 26.1% of patients functioning below it at rehabilitation admission. Disability onset of less than 60 days was associated with more than a 3-fold increase in the likelihood of achieving the stage (adjusted odds ratio, 3.5; 95% confidence interval, 2.0 to 6.0). Each eight-point increase in an eight-item activities of daily living score, measured at admission to rehabilitation, increased the odds 2.5-fold (95% confidence interval, 2.3 to 2.8). For those living alone or employed before the stroke, the odds of achieving the stage increased by factors of 1.3 and 2.2, respectively. The index showed minimal shrinkage on cross validation. The achievement of this profile of function is important because 95.3% of stroke patients who achieved or exceeded it were discharged home, as opposed to only 66.8% of those who did not achieve it.

CONCLUSIONS

The index can be used to establish prognoses for individual stroke patients at admission to rehabilitation with regard to achieving this stage. Achievement of the stage is associated with a high likelihood of discharge to home.

Population and occupational screening for obstructive sleep apnea: are we there yet?

Several features of obstructive sleep apnea (OSA) suggest that it may be an appropriate disease for screening programs for general populations and more specific high-risk groups. Preliminary data suggest that OSA represents an important health problem in terms of high prevalence, increased levels of morbidity and mortality, and increased public safety risk. Furthermore, the chronicity of the disease and the relatively low levels of recognition of the disorder in the medical community suggest a potential for lead-time gains for screening programs. Specific groups that might be considered for screening programs include commercial vehicle operators, hazardous duty personnel, and certain groups of medical patients. The purpose of this clinical commentary is to consider the issues of population and specific group screening for OSA by reviewing the general principles of screening for chronic disease and then applying these principles specifically in the case of OSA. More extensive outcomes data relating levels of severity of the disorder to its potential adverse outcomes are needed and will assist in tailoring appropriate screening programs and determining the cost-effectiveness of screening various populations.

Suppression of herpes simplex virus infections with oral lithium carbonate--a possible antiviral activity

In vitro studies have shown an inhibitory effect of lithium salts on herpes simplex virus (HSV) replication by mechanisms that interfere with viral DNA synthesis. Moreover, clinical studies have shown that oral lithium carbonate and topical lithium succinate can suppress genital HSV infections in humans. We conducted a randomized, double-blind, placebo-controlled trial of oral lithium carbonate in 11 healthy subjects age 28-65 years (mean +/- SD age 38 +/- 11 years) who had at least four recurrent HSV infections in the year preceding the study. Six patients completed at least 5 months of lithium therapy at a mean (+/-SD) average daily lithium dose of 437 +/- 185 mg (range, 150-900 mg) and an average serum lithium level of 0.56 +/- 0.20 mmol/L. Overall, lithium treatment resulted in a consistent reduction in the mean number of episodes/month, the average duration of each episode, the total number of infection days/month, and the maximum symptom severity. In contrast, treatment with placebo resulted in an increase in three out of the four severity measures. Although the comparisons between the treatment groups did not achieve statistical significance due to the limited sample size, there was a clear "trend" for a reduction in the total monthly duration of all HSV infections with lithium (p = 0.08). Lithium treatment was well tolerated and produced no deleterious effects on renal or thyroid function. These observations lend support to prior observations of an antiviral activity of lithium, and suggest the possibility that oral lithium may represent a safe prophylactic agent in patients with recurrent HSV infections.

TRH stimulation test as a predictor of acute and long-term antidepressant response in major depression

We assessed the prognostic utility of the TRH stimulation test by examining (a) the relationship between pre-treatment delta TSH and acute response to fluoxetine treatment, and (b) the relationship between the change in delta TSH (delta delta TSH value) after repeated TRH testing at 6 weeks of fluoxetine treatment and long-term outcome during maintenance fluoxetine or placebo therapy. 43 MDD patients were studied with sequential TRH tests at 6-week intervals. Fluoxetine 'responders' were defined as patients with a Hamilton Depression Rating Scale score < or = 7 by week 9 of treatment and who remained in remission at least 3 additional weeks. These subjects were then randomized to one of four fluoxetine/placebo treatment groups and long-term outcome assessed. Overall, there was no difference in the mean pre-treatment delta TSH values between acute fluoxetine responders and nonresponders. Moreover, we observed similar delta delta TSH values in patients who maintained long-term remission compared to those who relapsed during maintenance with either fluoxetine or placebo. In contrast to prior reports of an higher delta delta TSH value in long-term remitters, the present observation of similar mean delta delta TSH values patients with long-term remission compared to those who relapsed suggest a limited prognostic utility for the TRH stimulation test in MDD.

Physical restraint use and falls in nursing home residents

OBJECTIVE

To examine the relationship between restraint use and falls while controlling for the effect of psychoactive drug use among nursing home residents, including subgroups of nursing home residents with high rates of restraint use and/or falls.

DESIGN

Secondary analysis of data from a longitudinal clinical trial designed to reduce restraint use.

SETTING

Three nursing homes.

PARTICIPANTS

Subjects (n = 322) were either restrained (n = 119) or never restrained (n = 203) at each observation point during a 9.5-month data collection period that preceded the intervention phase of the clinical trial.

MEASUREMENTS

We evaluated restraint status (independent variable) three times during the data collection period by direct observation over a 72-hour period. Incident reports documenting falls and fall-related injuries (dependent variables) were reviewed. Cognitive status was measured using the Folstein Mini-Mental State Exam and functional status (including ambulation status) by the Psychogeriatric Dependency Rating Scale. Psychoactive drug use profile was obtained through record review.

MAIN RESULTS

Using multiple logistic regression, we compared the effect of restraint use on fall risk between a confused ambulatory subgroup and the remaining sample and found a significant difference in the odds ratio for falls and recurrent falls (P = .02; chi-square = 5.24, df = 1; P = .003, chi-square = 9.12, df = 1). In the confused ambulatory subgroup, restraint use was associated with increased falls (odds ratio: 1.65, 95% CI: 0.69, 3.98) as well as recurrent fall risk (odds ratio: 2.46, 95% CI: 1.03, 5.88). Increased falls and recurrent fall risk was not observed in the remaining sample (falls odds ratio: 0.49, 95% CI: 0.28, 0.87; recurrent falls odds ratio: 0.42, 95% CI: 0.20, 0.91). One subgroup, the nonconfused ambulatory residents, were never restrained; after removing this subgroup, the confused ambulatory continued to be associated, though not significantly, with a higher risk of falls and injuries. Only nonconfused nonambulatory restraints were associated with a lower risk of all three outcomes: falls (odds ratio: 0.28, 95% CI: 0.05, 1.58), recurrent falls (odds ratio: 0.48, 95% CI: 0.05, 4.72), and injurious falls (odds ratio:0.42, 95% CI: 0.04, 4.01); these results, however, were not statistically significant. There was no evidence that the effect of restraint use on fall risk depended upon the use of psychoactive drugs (chi square = 4.43; df = 2, P = .11).

CONCLUSION

Restraints were not associated with a significantly lower risk of falls or injuries in subgroups of residents likely to be restrained. These findings support individualized assessment of fall risk rather than routine use of physical restraints for fall prevention. Researchers and clinicians should continue to focus efforts on developing a variety of approaches that reduce risk of falls and injuries and promote mobility rather than immobility.

Life-sustaining treatment decisions by spouses of patients with Alzheimer's disease

OBJECTIVE

To examine the anticipated decisions to consent to or to forgo life-sustaining treatment by spouses of patients with Alzheimer's disease and to describe the relationship of spouse and patient characteristics to predicted decisions.

DESIGN

Prospective quantitative study.

SETTING

The Aging and Dementia Research Center (ADRC), part of an Alzheimer's Disease Center Core Grant, at New York University Medical Center.

PARTICIPANTS

Fifty spouse caregivers of Alzheimer's disease patients, evaluated at the ADRC, who had a minimum Stage 4 on the Global Deterioration Scale.

MEASUREMENTS

Spouses were presented with two conditions (critical illness and irreversible coma) and rated their agreement with, certainty of, and comfort with four treatments (resuscitation, breathing machine, feeding tube, and antibiotics). Data were also obtained as to patients' current quality of life, spouses' standard of decision-making, and spouse burden.

RESULTS

Eighteen of 50 patients had a durable power of attorney for health care, 20 of 50 had a living will, and 26 of 50 had neither. In the face of critical illness, almost equal numbers of spouses would consent to or forgo CPR, 28 of 50 would forgo a breathing machine, 21 of 50 a would forgo a feeding tube, and 5 of 50 would forgo antibiotics. Five of 50 would forgo all four treatments, and 12 of 50 all but antibiotics. Spouses were significantly more likely to forgo treatment in the face of coma than for critical illness (P < .001). Spouses were more certain about decisions related to coma than to critical illness (P < .001), and there was a positive and significant correlation between certainty and comfort (P = .001). Those consenting to treatment were more comfortable than those forgoing treatment (for CPR and antibiotics P = .001). Spouses of patients with Stage 7 AD were more likely to forgo CPR than those with Stages 4 to 6 AD (P < .001). Only two of 50 spouses selected descriptors congruent with a purely substituted judgment standard of decision-making. An equal number of spouses rated patient quality of life as good, fair, or poor. For critical illness, the poorer the quality of life rating, the more likely the spouses were to forgo feeding tubes (P < .001). There was a trend for highly burdened spouses to consent to treatment.

CONCLUSIONS

The results provide evidence that spouses of patients with AD anticipate forgoing life-sustaining treatments in the face of coma but are less sure about choices for critical illness. Although preliminary in nature, findings suggest that doctors, nurses, and social workers need to provide additional support to spouses choosing to forgo rather than consent to treatment and need to inquire as to what spouses perceive as the factors that are important to them in making a decision.

Nursing home residents' preferences for life-sustaining treatments

OBJECTIVES

To determine life-sustaining treatment preferences among nursing home residents, whether information regarding cardiopulmonary resuscitation (CPR) affected these preferences, and with whom treatment preferences had been discussed, and to identify factors associated with CPR preferences.

DESIGN

In-person survey.

SETTING

Forty-nine randomly selected nursing homes.

SUBJECTS

Four hundred twenty-one randomly selected nursing home residents capable of making decisions.

MAIN OUTCOME MEASURES

Preferences regarding CPR, hospitalization, and enteral tube feedings, and individual factors associated with CPR preferences.

RESULTS

Of 1458 randomly selected nursing home residents assessed for the ability to participate in the study, 552 residents (38%) were eligible to participate and 421 agreed to be interviewed. Sixty percent of participants able to participate in the decision reported that they would elect CPR, 89% would choose hospitalization if seriously ill, and 33% would elect enteral tube feedings if no longer able to eat because of permanent brain damage. Individual factors associated with preferences for CPR included the following: African-American ethnicity, high self-reported physical mobility, belief that most important medical care decisions should be made by the doctor, moderate-to-severe impairment in daily decision-making skills, and not having a spouse. Fourteen percent changed their preference from preferring CPR to not preferring CPR after receiving additional information about CPR procedures. Twelve percent reported having discussed preferences with health care providers, and 31% discussed preferences with family members.

CONCLUSIONS

More than half of nursing home residents capable of making decisions preferred the use of CPR. Few had discussed their preferences with health care providers. Individual preferences should be assessed when considering the use of life-sustaining treatments.