0581 Characteristics of US Women Veterans with Sleep Apnea: Results of a National Survey of VA Healthcare Users

Introduction

Sleep apnea (SA) is the most commonly diagnosed sleep disorder among patients in the US Veterans Administration (VA). The dramatic rise in women receiving VA care makes it essential to understand the presentation and treatment of SA in women Veterans. We performed a nationwide survey about sleep among US women Veterans and compared characteristics of respondents with and without a self-reported history of SA diagnosis and treatment.

Methods

A survey was mailed to a random sample of 4000 women VA healthcare users. The survey included demographics, Insomnia Severity Index (ISI), Patient Health Questionnaire-4 (PHQ-4 depression/anxiety), Primary Care-Post-Traumatic Stress Disorder (PC-PTSD), RLS symptom presence, SA symptoms (snore loudly, observed breathing pauses), diagnosis of SA, and use of PAP therapy (APAP, BPAP, CPAP). We compared women with and without SA, and (among those with SA) women who did and did not use PAP, using Chi-square and t-tests.

Results

1,498 completed surveys were returned (mean age 51.6 years, range 18-105 years, 62% non-Hispanic White). 200 respondents (13.4%) reported diagnosed SA. Women with SA were older (p<.001), likely to be employed (p=.013), more likely to snore loudly (p<.001) and to have breathing pauses while asleep (p<.001). They also had higher ISI (p<.001), were more like to report RLS (p<.001) nightmares (p=.027), and had higher PHQ-4 (p<.001) and PC-PTSD (p<.001) scores. Among women with SA, 130 (65%) used PAP. Loud snorers (p<.001) and those with observed breathing pauses were more likely to use PAP (p<.001).

Conclusion

One in 7 women who receive VA care report diagnosed SA. Women with SA had more mental health symptoms and comorbid sleep problems. Most reported using PAP therapy, although the amount of use is unknown. Those with SA symptoms were more likely to use PAP. Future work is needed to understand barriers to diagnosis and treatment of SA among women Veterans.

Support

Funding: VA Quality Enhancement Research Initiative RRP12-189 (Martin); NIH/NHLBI K24 HL143055 (Martin).

The influence of lower extremity joint torque on gait characteristics in elderly men

OBJECTIVE

To examine the relation between certain lower extremity isokinetic muscle torque capabilities and selected stride characteristics for a group of elderly, sedentary men.

STUDY DESIGN

Descriptive analysis of convenience sample.

SETTING

Veterans Administration (VA) ambulatory care center.

SUBJECTS

Eighty-one elderly men, capable of independent ambulation, were recruited from outpatient clinics and the local community (mean age, 74.7yr).

MAIN OUTCOME MEASURES

Maximal isokinetic torque in the sagittal plane of hip, knee, and ankle muscles; stride characteristics of speed, stride length, and cadence recorded during walking at a self-selected velocity.

RESULTS

Stepwise regression analysis revealed that hip extension torque was the only significant independent predictor for free walking speed, stride length, and cadence, and accounted for 37% (r = .611), 35% (r = .590), and 12% (r = .341) of the total variance, respectively. Other joint torques correlated with gait parameters but did not add significantly to the multivariate model.

CONCLUSIONS

Hip extension torque was the only significant independent predictor for free walking velocity, stride length, and cadence in this group. These results support the idea that strengthening the hip extensors may improve stride characteristics in elderly individuals.

Effects of a group exercise program on strength, mobility, and falls among fall-prone elderly men

OBJECTIVES

This randomized controlled trial studied the effects of a low- to moderate-intensity group exercise program on strength, endurance, mobility, and fall rates in fall-prone elderly men with chronic impairments.

METHODS

Fifty-nine community-living men (mean age = 74 years) with specific fall risk factors (i.e., leg weakness, impaired gait or balance, previous falls) were randomly assigned to a control group (n = 28) or to a 12-week group exercise program (n = 31). Exercise sessions (90 minutes, three times per week) focused on increasing strength and endurance and improving mobility and balance. Outcome measures included isokinetic strength and endurance, five physical performance measures, and self-reported physical functioning, health perception, activity level, and falls.

RESULTS

Exercisers showed significant improvement in measures of endurance and gait. Isokinetic endurance increased 21% for right knee flexion and 26% for extension. Exercisers had a 10% increase (p < .05) in distance walked in six minutes, and improved (p < .05) scores on an observational gait scale. Isokinetic strength improved only for right knee flexion. Exercise achieved no significant effect on hip or ankle strength, balance, self-reported physical functioning, or number of falls. Activity level increased within the exercise group. When fall rates were adjusted for activity level, the exercisers had a lower 3-month fall rate than controls (6 falls/1000 hours of activity vs 16.2 falls/1000 hours, p < .05).

DISCUSSION

These findings suggest that exercise can improve endurance, strength, gait, and function in chronically impaired, fall-prone elderly persons. In addition, increased physical activity was associated with reduced fall rates when adjusted for level of activity.

Development and testing of a five-item version of the Geriatric Depression Scale

OBJECTIVE

To develop and test the effectiveness of a 5-item version of the Geriatric Depression Scale (GDS) in screening for depression in a frail community-dwelling older population.

DESIGN

A cross-sectional study.

SETTING

A geriatric outpatient clinic at the Sepulveda VA Medical Center, Sepulveda, California.

PARTICIPANTS

A total of 74 frail outpatients (98.6% male, mean age 74.6) enrolled in an ongoing trial.

MEASUREMENTS

Subjects had a comprehensive geriatric assessment that included a structured clinical evaluation for depression with geropsychiatric consultation. A 5-item version of the GDS was created from the 15-item GDS by selecting the items with the highest Pearson chi2 correlation with clinical diagnosis of depression. Sensitivity, specificity, diagnostic accuracy, and positive and negative predictive values were calculated for the 15-item GDS and the new 5-item scale.

RESULTS

Subjects had a mean GDS score of 6.2 (range 0-15). Clinical evaluation found that 46% of subjects were depressed. The depressed and not depressed groups were similar with regard to demographics, mental status, educational level, and number of chronic medical conditions. Using clinical evaluation as the gold standard for depression, the 5-item GDS (compared with the 15-item GDS results shown in parentheses) had a sensitivity of .97 (.94), specificity of .85 (.83), positive predictive value of .85 (.82), negative predictive value of .97 (.94), and accuracy of .90 (.88) for predicting depression. Significant agreement was found between depression diagnosis and the 5-item GDS (kappa = 0.81). Multiple other short forms were tested, and are discussed. The mean administration times for the 5- and 15-item GDS were .9 and 2.7 minutes, respectively.

CONCLUSIONS

The 5-item GDS was as effective as the 15-item GDS for depression screening in this population, with a marked reduction in administration time. If validated elsewhere, it may prove to be a preferred screening test for depression.

The reliability and validity of an obstacle course as a measure of gait and balance in older adults

The use of an obstacle course to quantify gait, balance and functional mobility in elderly persons, particularly to assess objectively changes following exercise and rehabilitation interventions, has not been extensively developed or tested. In this study, we describe an 18-item obstacle course developed as an outcome measure for an exercise intervention among fall-prone elderly men. Reliability and validity of the obstacle course was tested in a group of 58 community-living elderly men (mean age = 75 years). Each subject's performance was videotaped and timed. The videotapes were scored by a physical therapist and a physician. Inter-rater reliability between the raters was high (Kappa = 0.96, p < 0.0001). Both the obstacle course score and time correlated significantly with gait velocity, a 6-minute walk test, and a performance-oriented instrument of gait and balance. Obstacle course scores showed significant improvement among the most impaired subjects, but not among higher functioning subjects following a 3-month exercise intervention. These results suggest that an obstacle course may be a useful and valid method for measuring outcomes related to mobility tasks in selected elderly populations. Further work is needed to determine in which populations, and for which outcomes, an obstacle course is better than simpler performance-based measures.

A randomized trial of walking versus physical methods for chronic pain management

We conducted a pilot study to evaluate a practical exercise program for elderly people with chronic musculo-skeletal pain. Thirty-three subjects (mean age, 73 years; 69% back pain; 24% knee pain; 9% hip pain) were randomly assigned to one of three groups. Group 1 received 6-week supervised program of walking. Group 2 received a pain education program that included instruction and demonstration of use of heat, cold, massage, relaxation and distraction. Group 3 received usual care. Outcomes including pain, self-reported health and functional status, and performance-based measures of functional status were evaluated at baseline, at two weeks and at eight weeks (end of study). Attendance was 100% for the education sessions and 93% for walking sessions. No injuries were sustained. Both intervention groups demonstrated significant improvements in pain (p < 0.05) and performance-based measures of functional status (p < 0.05), while the control group had no changes. These data suggest that patient education and fitness walking can improve overall pain management and related functional limitations among elderly people with chronic musculo-skeletal pain.

Falls and fall prevention in the nursing home

The mean incidence of falls in nursing homes is 1.5 falls per bed per year (range 0.2-3.6). The most common precipitating causes include gait and balance disorders, weakness, dizziness, environmental hazards, confusion, visual impairment, and postural hypotension. The most important underlying risk factors for falls and injuries include some of these same items as well as others: leg weakness, gait and balance instability, poor vision, cognitive and functional impairment, and sedating and psychoactive medications. A focused history and physical examination after a fall can usually determine the immediate underlying cause(s) of the fall and contributory risk factors. Many strategies for fall prevention have been tried with mixed success. The most successful take into account the multifactorial causes of falls, and include interventions to improve strength and functional status, reduce environmental hazards, and allow staff to identify and monitor high-risk residents. Regular evaluations in the nursing home can help identify patients at high risk who can then be targeted for specific treatment and prevention strategies. Strategies that reduce mobility through use of restraints have been shown to be more harmful than beneficial and should be avoided. A number of promising fall prevention strategies, involving both specific quality assurance programs and technologic devices, are being evaluated currently.

The Sepulveda GEU Study revisited: long-term outcomes, use of services, and costs

The randomized controlled trial of the Geriatric Evaluation Unit (GEU) at the Sepulveda Veterans Hospital was the first to document the clinical and cost-effectiveness of hospital-based comprehensive geriatric assessment (CGA). Frail elderly inpatients were assigned randomly to the GEU for CGA, therapy, rehabilitation, and placement (N = 63), or to standard hospital care (N = 60). At one year, GEU patients had much lower mortality (24% vs 48%) and were less likely to have been discharged to a nursing home (NH) (13% vs 30%), or to have spent any time in NHs (27% vs 47%). GEU patients were more likely to improve in personal self-maintenance and morale. Further, controls had substantially more acute-care hospital days, NH days, and hospital readmissions, resulting in higher direct institutional care costs, especially after survival adjustment. Here, we report the results of long-term follow-up. There was a significant survival effect through two years. Despite prolongation of life, there was no indication that quality of life was worse for survivors in the GEU group. In fact, the proportion of persons independent in > or = 2 ADLs at two years was somewhat higher for GEU patients (0.44) than controls (0.33) (z = 1.27; p = 0.056). By three years, 43% of GEU subjects and 38% of controls were still alive. Over the entire 3-year period, the per capita direct cost difference was not significant, either before or after survival adjustment (unadjusted: $37,091 GEU vs $34,205 control; survival-adjusted: $54,315 GEU vs $63,362 control; p = 0.17).(ABSTRACT TRUNCATED AT 250 WORDS)

Falls in the nursing home

OBJECTIVE

To review the epidemiology and causes of falls and fall-related injuries in nursing homes and to provide clinicians with a structured framework to evaluate and treat nursing home residents at risk for falls.

DATA SOURCES

All large-scale published studies documenting incidence, causes, risk factors, and preventive strategies for falls in nursing homes were reviewed.

RESULTS

The mean incidence of falls in nursing homes is 1.5 falls per bed per year (range, 0.2 to 3.6 falls). The most common precipitating causes include gait and balance disorders, weakness, dizziness, environmental hazards, confusion, visual impairment, and postural hypotension. The most important underlying risk factors for falls and injuries include some of these same items and others, such as lower-extremity weakness, gait and balance instability, poor vision, cognitive and functional impairment, and sedating and psychoactive medications. Many strategies for the prevention of falls have been tried, with mixed success. The most successful consider the multifactorial causes of falls and include interventions to improve strength and functional status, reduce environmental hazards, and allow staff to identify and monitor high-risk residents. Strategies that reduce mobility through use of restraints have been shown to be more harmful than beneficial and should be avoided.

CONCLUSIONS

A focused history and physical examination after a fall can usually determine both the immediate underlying causes of the fall and contributing risk factors. In addition, regular evaluations in the nursing home can help identify patients at high risk who can then be targeted for specific treatment and prevention strategies.

Multidimensional risk assessment versus age as criterion for retirement of airline pilots

OBJECTIVE

To determine whether airline pilots over the age of 60 pose a hazard to aviation safety and whether risk assessment could replace age-based retirement.

DATA SOURCES

A computer-assisted literature search (MEDLINE), expert consultation, and government reports.

STUDY SELECTION

Original studies on flight performance and pilot age; sudden incapacitation, neuropsychological testing, and/or medication use in pilots; and/or non-invasive testing for predicting sudden death or stroke in asymptomatic subjects.

DATA EXTRACTION

Pertinent results and methods data were abstracted from the 49 included studies.

DATA SYNTHESIS

No study on aircraft accidents or pilot performance has shown an increased accident risk for over-60-year-old pilots. Normal age-related cognitive changes probably have minimal impact on aviation safety up to age 70, given above average health, education, and experience in airline pilots. Cognitive tests have not been validated for predicting flight performance safety, but they can detect early stages of cognitive disease. Cardiovascular incapacitation risk increases with age, but risk factor profiles and non-invasive tests could identify pilots with non-acceptable risk.

CONCLUSIONS

An improved medical certification test could identify those pathologic conditions that might occur more frequently in older subjects. If pilots also underwent adequate performance testing, a gradual increase of the retirement age to approximately age 70 would seem justified. In the future, a longitudinal database should be established to validate medical tests for their ability to predict a pilot's accident risk. Using individual pilots as their own controls might be more sensitive than using population-based norm values. Progress in this field would advance medical assessment for other groups such as air traffic controllers or automobile drivers.

Home safety and fall prevention

In conclusion, the majority, or at least a large proportion, of accidental injuries in the elderly are preventable with careful medical and environmental evaluation and intervention. A vigorous diagnostic, therapeutic, and preventive approach is appropriate in all older patients who fall in addition to those at a high risk of falling. Any intervention that can make inroads on this major cause of death and disability in the elderly population will clearly have major impact.

The value of assessing falls in an elderly population. A randomized clinical trial

OBJECTIVE

To measure the effects of a specialized postfall assessment intended to detect causes and underlying risk factors for falls, and to recommend preventive and therapeutic interventions.

DESIGN

Randomized, controlled trial.

SETTING

A long-term residential care facility for elderly persons.

SUBJECTS

Within 7 days of a fall, 160 ambulatory subjects (mean age, 87 years) were randomly assigned to receive either a comprehensive postfall assessment (intervention group, n = 79) or usual care (control group, n = 81).

INTERVENTION

The postfall assessment included a detailed physical examination and environmental assessment by a nurse practitioner; laboratory tests; electrocardiogram; and 24-hour Holter monitoring. Probable cause or causes for the fall, identified risk factors, and therapeutic recommendations were given to the patient's primary physician.

MEASUREMENTS AND MAIN RESULTS

Through use of the assessment, many remediable problems (for example, weakness, environmental hazards, orthostatic hypotension, drug side effects, gait dysfunction) were detected. At the end of the 2-year follow-up period, the intervention group had 26% fewer hospitalizations (P less than 0.05) and a 52% reduction in hospital days (P less than 0.01) compared with controls. Patients in the intervention group had 9% fewer falls and 17% fewer deaths than controls by 2 years, but these trends were not statistically significant.

CONCLUSIONS

Our study suggests that falls are a marker of underlying disorders easily identifiable by a careful postfall assessment, which in turn can reduce disability and costs.

Predictors of falls among elderly people. Results of two population-based studies

A study was performed to identify and rank risk factors for falling among populations of institutionalized (fallers, N = 79, nonfallers, N = 70) and noninstitutionalized (fallers, N = 34, nonfallers, N = 34) elderly persons. Fallers were matched by age, sex, and living location to nonfaller control subjects. A nurse practitioner performed a comprehensive physical assessment in all subjects using a standardized protocol and physician consultation. Fallers in both populations were significantly more physically and functionally impaired than control subjects. Logistic regression identified hip weakness, poor balance, and number of prescribed medications as factors most strongly associated with falling among institutionalized subjects. A fall prediction model was developed from these findings yielding 76% overall predictive accuracy (89% sensitivity, 60% specificity). Using the model, the predicted 1-year risk of falling ranged from 12% for persons with none of the three risk factors to 100% for persons with all three risk factors. Findings among noninstitutionalized subjects were similar. These data support the concept of performing focused fall risk assessments to identify elderly patients at high risk for falling.

The value of Holter monitoring in evaluating the elderly patient who falls

Ambulatory cardiac (Holter) monitoring is often recommended in the routine evaluation of patients who fall; however, the prevalence of arrhythmias in old people is high, and the usefulness of such monitoring is unproven. As part of a large study of institutionalized elderly fallers, we compared Holter findings of fallers (N = 51) with a group of nonfallers (N = 27) having similar medical and demographic characteristics. Prevalence of ventricular arrhythmias was 82% in each group, and all patients had supraventricular arrhythmias. The mean number of ventricular and supraventricular couplets and runs did not differ between groups. There was no difference in severity of arrhythmias between fallers and nonfallers; in fact, fallers had slightly fewer Lown 4B arrhythmias than nonfallers (10% vs 18%, NS). Prevalence of heart disease was 78% in both groups and was associated with increased ventricular ectopy in the form of runs and couplets (P less than .05). No symptoms were reported during the Holter monitoring. We conclude that Holter monitoring should not be a routine part of the work-up of the patient who falls.

Improved survival for frail elderly inpatients on a geriatric evaluation unit (GEU): who benefits?

Previously reported data from a randomized controlled trial showed that admission to the geriatric evaluation unit (GEU) and follow-up clinic at the Sepulveda VA Medical Center leads to significantly improved outcomes for frail elderly hospital patients--including a 50% reduction of one-year mortality (p less than 0.005). In the present paper, two-year survival curves for GEU and control groups are reported. In addition, we subdivided the population by potential baseline risk factors (both patient- and treatment-related) and examined one-year survival using 12-month survival curves and odds ratios. There is evidence for GEU-related survival effects in specific subgroups of patients (e.g. patients with heart and pulmonary disease, patients with low baseline scores in functional status and mental status, and patients with high baseline morale scores). Finally, employing stepwise logistic regression, we determined the predictors of one-year survival in the pooled study population. These factors were: assignment to the GEU (adjusted odds ratio = 2.45; p less than 0.001); not having a heart diagnosis (2.24; p less than 0.001); and having primarily "geriatric/rehabilitation" problems (1.95; p less than 0.005). A predictive model derived from the regression defines patient subgroups likely to survive only when assigned to the GEU: cardiac patients with primarily "geriatric" or "rehabilitation" problems, and non-cardiac patients whose problems are primarily "medical". The dramatic effect of the GEU on survival appears to be concentrated on certain identifiable subgroups of patients who might be targeted to maximize program cost-effectiveness.

Impact of computerized drug profiles and a consulting pharmacist on outpatient prescribing patterns: a clinical trial

The effects of computerized drug profiles and clinical pharmacist consultation in the internal medicine clinics at a Veterans Administration hospital were studied. Population included patients (n = 512) and physicians (n = 35) of three internal medicine clinics during an eight-week period. The first four weeks were the preintervention period. The second four weeks were the intervention period in which a clinical pharmacist attended one clinic (A) and provided drug profiles on all patients. Two other clinics (B and C) served as controls. During the intervention, patients in clinic A experienced a significant reduction in prescribing problems as identified by the pharmacist: 49 percent of patients before the intervention versus 9.4 percent after the intervention (p less than 0.001). Patients in clinic B had no significant change in prevalence in the number of problems identified (39 versus 40 percent; NS), and patients in clinic C had a significant but less dramatic decrease (35 versus 22 percent; p less than 0.05). The proportion of patients in clinic A with net decrease in the number of prescribed medications rose from 7.1 to 34.9 percent (p less than 0.001), with a mean decrease of 0.3 medications per patient. No significant differences in number of prescribed medications were noted in clinics B or C. Accuracy of physician medication charting improved for patients in clinic A from 54 percent of charts with accurate drug lists before the intervention to 78.3 percent after the intervention (p less than 0.001). No significant improvements were noted for clinics B and C. These results suggest that computerized drug profiles together with clinical pharmacist consultation can improve prescribing practices in a hospital outpatient department.

Low prevalence of postural hypotension among community-dwelling elderly

Postural hypotension (PH) has a prevalence of about 20% in most large studies of elderly individuals; however, these studies do not exclude subjects with diseases and medications known to cause PH. We sought to determine the prevalence of PH in healthy, community-living, elderly individuals in contrast to those with known risk factors for the condition. We measured supine and one-minute standing blood pressures in 300 independently living elderly persons who visited a senior citizen health screening program. Subjects were divided into two groups: those with known risk factors (n = 175) and those without (n = 125). The prevalence of PH (systolic decrease, greater than or equal to 20 mm Hg) for for the entire population was 10.7%. In the group with risk factors, the prevalence was 13.7% (24/175), compared with 6.4% in the group without risk factors (8/125). Supine hypertension was associated with PH, but there was no relationship between the presence of PH and age, history of falls, symptoms on standing, or recent meal. These data suggest that PH is a relatively uncommon finding in healthy elderly, its prevalence is significantly related to risk factors, and its association with falls or symptoms may be less than previously reported.

Comprehensive health screening of well elderly adults: an analysis of a community program

We examined the yield of a health screening program in a free-standing community senior citizen center and identified factors associated with patient compliance with referral recommendations. Of elderly individuals screened, 94% had some positive finding requiring advice or intervention, and 54% were referred to a physician for further evaluation. The most prevalent findings were skin disorders (52%), genitourinary disorders (44%), and eye-ear-nose-throat disorders (33%). Of individuals referred to a physician, 70% complied with the referral. Of those who complied, 38% reported receiving treatment for the referred condition--15% of the entire group of clients screened. Factors positively associated with compliance with physician referral included the specific type of referred problem, the perceived seriousness of the problem, and absence of financial barriers to medical care. Though controlled trial data are lacking, this and other published studies indicate that many remediable problems can be identified among apparently healthy elderly individuals in community geriatric screening programs.

Differential prognosis and utilization patterns among clinical subgroups of hospitalized geriatric patients

While screening elderly inpatients on acute Veterans Administration (VA) hospital wards for a special geriatric program, we prospectively classified all patients age 65 and over, who had been hospitalized at least a week, into five clinical subgroups using specific diagnostic, prognostic, and functional criteria. These five subgroups were "geriatric evaluation unit (GEU) candidate", "severely demented", "medical", "terminal", and "independent". Medical record data from the initial admission and a full year of follow-up were collected from random samples of each subgroup and of nonscreened patients who had been hospitalized for less than a week. Analysis revealed that each subgroup had a distinctive pattern of survival, living location, and use of institutional services during the follow-up period. For one major subgroup ("GEU candidate"), a specific intervention (the GEU) has proved very effective in reducing mortality, increasing patient functioning, improving placement, and decreasing use of institutional services. Moreover, there are specific treatment and intervention strategies appropriate for each of the other subgroups (e.g., hospital-based home care, hospice, respite, and day treatment programs), although these services are not universally available nor clearly proved effective. The process of identifying patient subgroups illustrated in this study may be useful in needs assessment, in planning new intervention programs for frail elderly patients, and for identifying appropriate patients for these programs.

Effectiveness of a geriatric evaluation unit. A randomized clinical trial

We randomly assigned frail elderly inpatients with a high probability of nursing-home placement to an innovative geriatric evaluation unit intended to provide improved diagnostic assessment, therapy, rehabilitation, and placement. Patients randomly assigned to the experimental (n = 63) and control (n = 60) groups were equivalent at entry. At one year, patients who had been assigned to the geriatric unit had much lower mortality than controls (23.8 vs. 48.3 per cent, P less than 0.005) and were less likely to have initially been discharged to a nursing home (12.7 vs. 30.0 per cent, P less than 0.05) or to have spent any time in nursing home during the follow-up period (26.9 vs. 46.7 per cent, P less than 0.05). The control-group patients had substantially more acute-care hospital days, nursing-home days, and acute-care hospital readmissions. Patients in the geriatric unit were significantly more likely to have improvement in functional status and morale than controls (P less than 0.05). Direct costs for institutional care were lower for the experimental group, especially after adjustment for survival. We conclude that geriatric evaluation units can provide substantial benefits at minimal cost for appropriate groups of elderly patients, over and above the benefits of traditional hospital approaches.