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1.  Staff-Reported Strategies for Prevention and Management of Resident-to-Resident Elder Mistreatment in Long-Term Care Facilities 
Resident-to-resident elder mistreatment (R-REM) in nursing homes is frequent and leads to adverse outcomes. Nursing home staff responses may significantly mitigate R-REM's impact, but little is known about current practices.
To identify common staff responses to R-REM
We interviewed 282 certified nursing assistants (CNAs) in 5 urban nursing homes on their responses during the previous 2 weeks to R-REM behaviors of residents under their care.
97 CNAs (34.4%) reported actions responding to R-REM incidents involving 182 residents (10.8%), describing 22 different responses. Most common were: physically intervening/separating residents (51), talking calmly to settle residents down (50), no intervention (39), and verbally intervening to defuse the situation (38). Less common were notifying a nurse (13) or documenting in behavior log (4).
Nursing home staff report many varied responses to R-REM, a common and dangerous occurrence. CNAs seldom documented behaviors or reported them to nurses.
PMCID: PMC4615545  PMID: 25894206
nursing home; dementia-related behaviors; aggression
2.  Patterns of scheduled follow-up appointments following hospitalization for heart failure: insights from an urban medical center in the United States 
Clinical Interventions in Aging  2016;11:1325-1332.
Although postdischarge outpatient follow-up appointments after a hospitalization for heart failure represent a potentially effective strategy to prevent heart failure readmissions, patterns of scheduled follow-up appointments upon discharge are poorly described. We aimed to characterize real-world patterns of scheduled follow-up appointments among adult patients with heart failure upon hospital discharge.
Patients and methods
This was a retrospective cohort study performed at a large urban academic center in the United States among adults hospitalized with a principal diagnosis of congestive heart failure between January 1, 2013, and December 31, 2014. Patient demographics, administrative data, clinical parameters, echocardiographic indices, and scheduled postdischarge outpatient follow-up appointments were collected.
Of the 796 patients hospitalized for heart failure, just over half of the cohort had a scheduled follow-up appointment upon discharge. Follow-up appointments were less likely among patients who were white and had heart failure with preserved ejection fraction and more likely among patients with Medicaid and chronic obstructive pulmonary disease. In an adjusted multivariable regression model, age ≥65 years was inversely associated with a scheduled follow-up appointment upon hospital discharge, despite higher rates of several cardiovascular and noncardiovascular comorbidities.
Just half of the patients discharged home following a hospitalization for heart failure had a follow-up appointment scheduled, representing a missed opportunity to provide a recommended care transition intervention. Despite a greater burden of both cardiovascular and noncardiovascular comorbidities, older adults (age ≥65 years) were less likely to have a follow-up appointment scheduled upon discharge compared with younger adults, revealing a disparity that warrants further investigation.
PMCID: PMC5044983  PMID: 27713623
appointments; patient readmission; ageism; heart failure
3.  Emergency Department Placement and Management of Indwelling Urinary Catheters in Older Adults: Knowledge, Attitudes, and Practice 
Indwelling Urinary Catheters (IUCs) are placed frequently in older adults in the emergency department (ED). While often a critical intervention, IUCs carry significant risks, particularly for geriatric patients, including infection, delirium, and falls. In addition, once placed, IUCs are rarely removed in the ED and may remain for an extended period after transfer of care, leading to poor outcomes. The purpose of this research was to examine the current knowledge, attitudes, and practice of ED nurses and other providers regarding IUC placement and management in older adults.
We surveyed ED providers including nurses, attending physicians, Emergency Medicine (EM) residents, nurse practitioners (NPs), and physician assistants (PAs) at a large, urban, academic medical center. We developed comprehensive written questionnaires designed using items from previously validated instruments and questions created specifically for this study. In addition, we assessed providers' management of 25 unique clinical scenarios, each representing an established appropriate or inappropriate indication for IUC placement.
127 ED providers participated: 43 nurses, 21 attending physicians, 47 residents, and 17 NP/PAs. 91% of nurses and 88% of other providers reported comfort with appropriate indications for IUC placement. Despite this, in the clinical vignettes nurses correctly identified the appropriate approach for IUC placement in only 40% of cases and other providers in only 37%. Reported practices were most divergent from accepted standards in delirium, with 3% of nurses and 1% of other providers appropriately avoiding IUC placement. Practice varied widely between individual providers, with the nurse participants reporting appropriate practice in 16%–64% of clinical scenarios and other providers in 8%–68%. Few nurses or other providers reported reassessing their patients for IUC removal at transfer to the hospital upstairs (28% of nurses and 7% of other providers), admission (24% and 14%), or shift change (14% and 8%).
Although ED nurses and other providers report comfort with appropriate indications for IUC placement, their reported practice patterns showed inconsistencies with established guidelines. Wide practice variation exists between individual providers. Moreover, nurses and other providers infrequently consider IUC removal after placement. Future research should focus on development of educational interventions and protocols to assist ED nurses and other providers with appropriate indications for and management of IUCs in older adults.
PMCID: PMC4633299  PMID: 25872970
5.  Age-Associated Financial Vulnerability: An Emerging Public Health Issue 
Annals of internal medicine  2015;163(11):877-878.
PMCID: PMC4769872  PMID: 26458261
6.  Elder Mistreatment: Priorities for Consideration by the White House Conference on Aging 
The Gerontologist  2015;55(2):320-327.
Elder mistreatment is recognized internationally as a prevalent and growing problem, meriting the attention of policymakers, practitioners, and the general public. Studies have demonstrated that elder mistreatment is sufficiently widespread to be a major public health concern and that it leads to a range of negative physical, psychological, and financial outcomes. This article provides an overview of key issues related to the prevention and treatment of elder mistreatment, focusing on initiatives that can be addressed by the White House Conference on Aging. We review research on the extent of mistreatment and its consequences. We then propose 3 challenges in preventing and treating elder mistreatment that relate to improving research knowledge, creating a comprehensive service system, and developing effective policy. Under each challenge, examples are provided of promising initiatives that can be taken to eliminate mistreatment. To inform the recommendations, we employed recent data from the Elder Justice Roadmap Project, in which 750 stakeholders in the field of elder mistreatment were surveyed regarding research and policy priorities.
PMCID: PMC4542836  PMID: 26035609
Abuse/neglect; Crime; Public Policy; Organizational and Institutional issues
7.  Financial Exploitation of Older Adults: A Population-Based Prevalence Study 
Journal of General Internal Medicine  2014;29(12):1615-1623.
Financial exploitation is the most common and least studied form of elder abuse. Previous research estimating the prevalence of financial exploitation of older adults (FEOA) is limited by a broader emphasis on traditional forms of elder mistreatment (e.g., physical, sexual, emotional abuse/neglect).
1) estimate the one-year period prevalence and lifetime prevalence of FEOA; 2) describe major FEOA types; and 3) identify factors associated with FEOA.
Prevalence study with a random, stratified probability sample.
Four thousand, one hundred and fifty-six community-dwelling, cognitively intact adults age ≥ 60 years.
New York State.
Comprehensive tool developed for this study measured five FEOA domains: 1) stolen or misappropriated money/property; 2) coercion resulting in surrendering rights/property; 3) impersonation to obtain property/services; 4) inadequate contributions toward household expenses, but respondent still had enough money for necessities and 5) respondent was destitute and did not receive necessary assistance from family/friends.
One-year period FEOA prevalence was 2.7 % (95 % CI, 2.29–3.29) and lifetime prevalence was 4.7 % (95 % CI, 4.05–5.34). Greater relative risk (RR) of one-year period prevalence was associated with African American/black race (RR, 3.80; 95 % CI, 1.11–13.04), poverty (RR, 1.72; 95 % CI, 1.09–2.71), increasing number of non-spousal household members (RR, 1.16; 95 % CI, 1.06–1.27), and ≥ 1 instrumental activity of daily living (IADL) impairments (RR, 1.69; 95 % CI, 1.12–2.53). Greater RR of lifetime prevalence was associated with African American/black race (RR, 2.61; 95 % CI, 1.37–4.98), poverty (RR, 1.47; 95 % CI, 1.04–2.09), increasing number of non-spousal household members (RR, 1.16; 95 % CI, 1.12–1.21), and having ≥1 IADL (RR, 1.45; 95 % CI, 1.11–1.90) or ≥1 ADL (RR, 1.52; 95 % CI, 1.06–2.18) impairment. Living with a spouse/partner was associated with a significantly lower RR of lifetime prevalence (RR, 0.39; 95 % CI, 0.26–0.59)
Financial exploitation of older adults is a common and serious problem. Elders from groups traditionally considered to be economically, medically, and sociodemographically vulnerable are more likely to self-report financial exploitation.
PMCID: PMC4242880  PMID: 25103121
financial exploitation; elder financial abuse; elder abuse; elder mistreatment; economic abuse
8.  Exposure-Based CBT for Older Adults After Fall Injury: Description of a Manualized, Time-Limited Intervention for Anxiety 
Cognitive and behavioral practice  2014;21(4):432-445.
Fall accidents among older adults can be devastating events that, in addition to their physical consequences, lead to disabling anxiety warranting the attention of mental health practitioners. This article presents “Back on My Feet,” an exposure-based cognitive-behavioral therapy (CBT) protocol that is designed for older adults with posttraumatic stress disorder (PTSD), subthreshold PTSD, or fear of falling resulting from a traumatic fall. The protocol can be integrated into care once patients have been discharged from hospital or rehabilitation settings back to the community. Following a brief description of its development, the article presents a detailed account of the protocol, including patient evaluation and the components of the eight home-based sessions. The protocol addresses core symptoms of avoidance, physiological arousal/anxiety, and maladaptive thought patterns. Because older patients face different coping challenges from younger patients (for whom the majority of evidence-based CBT interventions have been developed), the discussion ends with limitations and special considerations for working with older, injured patients. The article offers a blueprint for mental health practitioners to address the needs of patients who may present with fall-related anxiety in primary care and other medical settings. Readers who wish to develop their expertise further can consult the online appendices, which include a clinician manual and patient workbook, as well as guidance on additional resources.
PMCID: PMC4214866  PMID: 25364226
prolonged exposure therapy; older adults; unintentional falls; anxiety
9.  Posttraumatic stress symptoms in older adults hospitalized for fall injury☆ 
General hospital psychiatry  2014;36(6):669-673.
Although unintentional falls may pose a threat of death or injury, few studies have investigated their psychological impact on older adults. This study sought to gather data on early posttraumatic stress symptoms in older adults in the hospital setting after a fall.
Participants in this study were 100 adults age 65 years or older admitted to a large urban hospital in New York City because of a fall. Men and women were represented approximately equally in the sample; most were interviewed within days of the fall event. The study's bedside interview included the Posttraumatic Stress Symptom Scale, which inquires about the presence and severity of 17 trauma-related symptoms.
Twenty-seven participants reported substantial posttraumatic stress symptoms (moderate or higher severity). Exploratory bivariate analyses suggested an association between posttraumatic stress symptom severity and female gender, lower level of education, unemployment, number of medical conditions, and back/chest injury.
A significant percentage of older patients hospitalized after a fall suffer substantial posttraumatic stress. Future investigations are needed to assess the association between the psychiatric impact of a fall and short-term inpatient outcomes as well as longer-term functional outcomes.
PMCID: PMC4252653  PMID: 25213226
Traumatic injury; Acute stress; Posttraumatic stress; Fall accidents; Older adults
10.  Development of an Instrument to Measure Staff-Reported Resident-to-Resident Elder Mistreatment (R-REM) Using Item Response Theory and Other Latent Variable Models 
The Gerontologist  2013;54(3):460-472.
Objectives: Although numerous studies have measured behaviors among individuals in congregate settings, few have focused on resident-to-resident elder mistreatment (R-REM). To our knowledge, there is no psychometrically developed measure of R-REM extant. The quantitative development of a measure of staff-reported R-REM is described. Methods: The design was a prevalent cohort study of residents of 5 long-term care facilities. The primary certified nursing assistant was interviewed about R-REM. Advanced measurement methods were used to develop a measure of R-REM. Results: The loadings on the general factor for the final 11-item scale were greater than those on the group factor except for the item “other physical behavior” (0.63 vs. 0.74), suggesting essential unidimensionality. Although the bifactor model fit was slightly better than that of the unidimensional model, the difference was trivial (bifactor comparative fit index [CFI] = 0.997, root mean square error of approximation [RMSEA] = 0.013, unidimensional CFI = 0.979, and RMSEA = 0.030). However, modest support was provided for use of verbal and physical subscales. The explained common variance statistics were 0.76 for the bifactor model compared with 0.63 for the unidimensional model. Discussion: The development of this R-REM measure will help to advance the measurement and ultimately evaluation of interventions associated with this important and under recognized problem facing residents in long-term care settings.
PMCID: PMC4013722  PMID: 23448960
Elder abuse; Mistreatment; Congregate care; Item response theory; Latent variable models; Scale development
11.  Using Qualitative Methods to Develop a Measure of Resident-to-Resident Elder Mistreatment in Nursing Homes 
International psychogeriatrics / IPA  2013;25(8):1245-1256.
Despite expansion of research on elder mistreatment, limited attention has been paid to the development of improved measurement instruments. This gap is particularly notable regarding measurement of mistreatment in long-term care facilities. This article demonstrates the value of qualitative methods used in item development of a Resident-to-Resident Elder Mistreatment (R-REM) measure for use in nursing homes and other care facilities. It describes the development strategy and the modification and refinement of items using a variety of qualitative methods.
A combination of qualitative methods was used to develop close-ended items to measure R-REM, including review by a panel of experts, focus groups, and in-depth cognitive interviews.
Information gathered from the multiple methods aided in flagging problematic items, helped to highlight the nature of the problems in measures, and provided suggestions for item modification and improvement.
The method employed is potentially useful for future attempts to develop better measures of elder mistreatment. The employment of previously established measurement items drawn from related fields, modified through an intensive qualitative research strategy, is an effective strategy to improve elder mistreatment measurement.
PMCID: PMC4178930  PMID: 23506835
qualitative methods; measure development; resident-to-resident elder mistreatment; long-term care
12.  Managing resident to resident elder mistreatment (R-REM) in nursing homes: the SEARCH approach 
This article describes an educational program to inform nursing and care staff in the management of resident-to-resident elder mistreatment (R-REM) in nursing homes, using the SEARCH approach. Although relatively little research has been conducted on this form of abuse, there is mounting interest in R-REM, as such aggression has been found to be extensive and can have both physical and psychological consequences for residents and staff. The aim of the SEARCH approach is to support staff in the identification and recognition of R-REM, and suggesting recommendations for management. The education program and the SEARCH approach are described. Three case studies from the research project are presented, illustrating how the SEARCH approach can be used by nurses and care staff to manage R-REM in nursing homes. Resident- and staff safety and well-being can be enhanced by the use of the evidence-based SEARCH approach.
PMCID: PMC4178932  PMID: 24548656
13.  Verbal and Physical Aggression Directed at Nursing Home Staff by Residents 
Little research has been conducted on aggression directed at staff by nursing home residents.
To estimate the prevalence of resident-to-staff aggression (RSA) over a 2-week period.
Prevalent cohort study.
Large urban nursing homes.
Population-based sample of 1,552 residents (80 % of eligible residents) and 282 certified nursing assistants.
Main Outcome Measures
Measures of resident characteristics and staff reports of physical, verbal, or sexual behaviors directed at staff by residents.
The staff response rate was 89 %. Staff reported that 15.6 % of residents directed aggressive behaviors toward them (2.8 % physical, 7.5 % verbal, 0.5 % sexual, and 4.8 % both verbal and physical). The most commonly reported type was verbal (12.4 %), particularly screaming at the certified nursing assistant (9.0 % of residents). Overall, physical aggression toward staff was reported for 7.6 % of residents, the most common being hitting (3.9 % of residents). Aggressive behaviors occurred most commonly in resident rooms (77.2 %) and in the morning (84.3 %), typically during the provision of morning care. In a logistic regression model, three clinical factors were significantly associated with resident-to-staff aggression: greater disordered behavior (OR = 6.48, 95 % CI: 4.55, 9.21), affective disturbance (OR = 2.29, 95 % CI: 1.68, 3.13), and need for activities of daily living morning assistance (OR = 2.16, 95 % CI: 1.53, 3.05). Hispanic (as contrasted with White) residents were less likely to be identified as aggressors toward staff (OR = 0.57, 95 % CI: 0.36, 0.91).
Resident-to-staff aggression in nursing homes is common, particularly during morning care. A variety of demographic and clinical factors was associated with resident-to-staff aggression; this could serve as the basis for evidence-based interventions. Because RSA may negatively affect the quality of care, resident and staff safety, and staff job satisfaction and turnover, further research is needed to understand its causes and consequences and to develop interventions to mitigate its potential impact.
PMCID: PMC3631060  PMID: 23225256
nursing home; dementia-related behaviors; elder abuse; staff mistreatment
14.  The CITRA Pilot Studies Program: Mentoring Translational Research 
The Gerontologist  2007;47(6):845-850.
We developed an innovative pilot studies program to foster partnerships between university researchers and agencies serving older people in New York City. The development of researchers willing to collaborate with frontline service agencies and service agencies ready to partner with researchers is critical for translating scientific research into evidence-based practice that benefits community-dwelling older adults.
Design and Methods
We adapted the traditional academic pilot studies model to include key features of community-based participatory research.
In partnership with a network of 265 senior centers and service agencies, we built a multistep program to recruit and educate scientific investigators and agencies in the principles of community-based research and to fund research partnerships that fulfilled essential elements of research translation from university to community: scientific rigor, sensitivity to community needs, and applicability to frontline practice. We also developed an educational and monitoring infrastructure to support projects.
Pilot studies programs developing community-based participatory research require an infrastructure that can supplement individual pilot investigator efforts with centralized resources to ensure proper implementation and dissemination of the research. The financial and time investment required to maintain programs such as those at the Cornell Institute for Translational Research on Aging, or CITRA, may be a barrier to establishing similar programs.
PMCID: PMC3981742  PMID: 18192638
Community-based participatory research; Investigator development; Research to practice
15.  Effects of Electronic Health Information Technology Implementation on Nursing Home Resident Outcomes 
Journal of aging and health  2011;24(1):92-112.
To examine the effects of electronic health information technology (HIT) on nursing home residents.
The study evaluated the impact of implementing a comprehensive HIT system on resident clinical, functional, and quality of care outcome indicators, as well as measures of resident awareness of and satisfaction with the technology. The study used a prospective, quasi-experimental design, directly assessing 761 nursing home residents in 10 urban and suburban nursing homes in the greater New York City area.
No statistically significant impact of the introduction of HIT on residents was found on any outcomes, with the exception of a significant negative effect on behavioral symptoms. Residents' subjective assessment of the HIT intervention were generally positive.
The absence of effects on most indicators is encouraging for the future development of HIT in nursing homes. The single negative finding suggests that further investigation is needed on possible impact on resident behavior.
PMCID: PMC3677697  PMID: 21646551
Long-Term Care; Technology; Quality of Care
16.  A staff intervention targeting resident-to-resident elder mistreatment (R-REM) in long-term care increased staff knowledge, recognition and reporting: Results from a cluster randomized trial 
Elder abuse in long term care has received considerable attention; however, resident-to-resident elder mistreatment (R-REM) has not been well researched. Preliminary findings from studies of R-REM suggest that it is sufficiently widespread to merit concern, and is likely to have serious detrimental outcomes for residents. However, no evidence-based training, intervention and implementation strategies exist that address this issue.
The objective was to evaluate the impact of a newly developed R-REM training intervention for nursing staff on knowledge, recognition and reporting of R-REM.
The design was a prospective cluster randomized trial with randomization at the unit level.
A sample of 1405 residents (685 in the control and 720 in the intervention group) from 47 New York City nursing home units (23 experimental and 24 control) in 5 nursing homes was assessed. Data were collected at three waves: baseline, 6 and 12 months. Staff on the experimental units received the training and implementation protocols, while those on the comparison units did not. Evaluation of outcomes was conducted on an intent-to-treat basis using mixed (random and fixed effects) models for continuous knowledge variables and Poisson regressions for longitudinal count data measuring recognition and reporting.
There was a significant increase in knowledge post-training, controlling for pre-training levels for the intervention group (p<0.001), significantly increased recognition of R-REM (p<0.001), and longitudinal reporting in the intervention as contrasted with the control group (p=0.0058).
A longitudinal evaluation demonstrated that the training intervention was effective in enhancing knowledge, recognition and reporting of R-REM. It is recommended that this training program be implemented in long term care facilities.
PMCID: PMC3677710  PMID: 23159018
Resident-to-resident elder mistreatment (R-REM); nursing homes; long term care; older people; elder abuse; staff education; staff training
17.  Sexual Aggression between Residents in Nursing Homes: Literature Synthesis for an Underrecognized Issue 
Evidence exists suggesting that most sexual aggression against older adults occurs in long-term care facilities. Fellow residents are the most common perpetrators, often due to inappropriate hypersexual behavior caused by dementing illness. This resident-to-resident sexual aggression (RRSA) is defined as sexual interactions between long-term care residents that in a community setting would likely be construed as unwelcome by at least one of the recipients and have high potential to cause physical or psychological distress in one or both of the involved. Although RRSA may be common and physical and psychological consequences for victims may be significant, this phenomenon has received little direct attention from researchers to date. We review the existing literature and relevant related research examining elder sexual abuse and hypersexual behavior to describe the epidemiologic features of this phenomenon, including risk factors for perpetrators and victims. Preventing and managing sexual aggression in nursing homes is made more challenging due to the legitimate and recognized need for nursing home residents, even those with advanced dementing illness, to sexually express themselves. We discuss the ethical dilemma this situation creates and the need to evaluate the capacity to consent to sexual activity among residents with dementing illness and to re-evaluate capacity as the diseases progress. We offer suggestions for managing RRSA incidents and for future research, including the importance of designing effective interventions.
PMCID: PMC3625650  PMID: 20840462
aggressive behavior; sexual abuse; nursing homes; sexual behavior; dementia
18.  Resident-to-Resident Aggression in Nursing Homes: Results from a Qualitative Event Reconstruction Study 
The Gerontologist  2011;52(1):24-33.
Despite its prevalence and negative consequences, research on elder abuse has rarely considered resident-to-resident aggression (RRA) in nursing homes. This study employed a qualitative event reconstruction methodology to identify the major forms of RRA that occur in nursing homes.
Design and methods:
Events of RRA were identified within a 2-week period in all units (n = 53) in nursing homes located in New York City. Narrative reconstructions were created for each event based on information from residents and staff who were involved as well as other sources. The event reconstructions were analyzed using qualitative methods to identify common features of RRA events.
Analysis of the 122 event reconstructions identified 13 major forms of RRA, grouped under five themes. The resulting framework demonstrated the heterogeneity of types of RRA, the importance of considering personal, environmental, and triggering factors, and the potential emotional and physical harm to residents.
These results suggest the need for person-centered and environmental interventions to reduce RRA, as well as for further research on the topic.
PMCID: PMC3265555  PMID: 22048811
Abuse/neglect; Behavior; Long-term care; Aggression
19.  Practitioners’ Views on Elder Mistreatment Research Priorities: Recommendations from a Research-to-Practice Consensus Conference 
Journal of elder abuse & neglect  2011;23(2):115-126.
This article presents recommendations from expert practitioners and researchers regarding future directions for research on elder abuse prevention. Using the Research-to-Practice Consensus Workshop model, participants critiqued academic research on the prevention of elder mistreatment and identified practice-based suggestions for a research agenda on this topic. The practitioners’ critique resulted in 10 key recommendations for future research that include the following priority areas: defining elder abuse, providing researchers with access to victims and abusers, determining the best approaches in treating abusers, exploiting existing data sets, identifying risk factors, understanding the impact of cultural factors, improving program evaluation, establishing how cognitive impairment affects legal investigations, promoting studies of financial and medical forensics, and improving professional reporting and training. It is hoped that these recommendations will help guide future research in such a way as to make it more applicable to community practice.
PMCID: PMC3076805  PMID: 21462046
elder mistreatment research; consensus workshop; research-practice collaboration
20.  Predicting Chemotherapy Toxicity in Older Adults With Cancer: A Prospective Multicenter Study 
Journal of Clinical Oncology  2011;29(25):3457-3465.
Older adults are vulnerable to chemotherapy toxicity; however, there are limited data to identify those at risk. The goals of this study are to identify risk factors for chemotherapy toxicity in older adults and develop a risk stratification schema for chemotherapy toxicity.
Patients and Methods
Patients age ≥ 65 years with cancer from seven institutions completed a prechemotherapy assessment that captured sociodemographics, tumor/treatment variables, laboratory test results, and geriatric assessment variables (function, comorbidity, cognition, psychological state, social activity/support, and nutritional status). Patients were followed through the chemotherapy course to capture grade 3 (severe), grade 4 (life-threatening or disabling), and grade 5 (death) as defined by the National Cancer Institute Common Terminology Criteria for Adverse Events.
In total, 500 patients with a mean age of 73 years (range, 65 to 91 years) with stage I to IV lung (29%), GI (27%), gynecologic (17%), breast (11%), genitourinary (10%), or other (6%) cancer joined this prospective study. Grade 3 to 5 toxicity occurred in 53% of the patients (39% grade 3, 12% grade 4, 2% grade 5). A predictive model for grade 3 to 5 toxicity was developed that consisted of geriatric assessment variables, laboratory test values, and patient, tumor, and treatment characteristics. A scoring system in which the median risk score was 7 (range, 0 to 19) and risk stratification schema (risk score: percent incidence of grade 3 to 5 toxicity) identified older adults at low (0 to 5 points; 30%), intermediate (6 to 9 points; 52%), or high risk (10 to 19 points; 83%) of chemotherapy toxicity (P < .001).
A risk stratification schema can establish the risk of chemotherapy toxicity in older adults. Geriatric assessment variables independently predicted the risk of toxicity.
PMCID: PMC3624700  PMID: 21810685
21.  Falls and Physical Performance Deficits in Older Patients With Prostate Cancer Undergoing Androgen Deprivation Therapy 
Urology  2008;72(2):422-427.
Men experience a decrease in lean muscle mass and strength during the first year of androgen deprivation therapy (ADT). The prevalence of falls and physical and functional impairment in this population have not been well described.
A total of 50 men aged 70 years and older (median 78) receiving ADT for systemic prostate cancer (80% biochemical recurrence) underwent functional and physical assessments. The functional assessments included Katz’s Activities of Daily Living (ADLs) and Lawton’s Instrumental Activities of Daily Living (IADLs). Patients completed the Vulnerable Elder’s Survey-13, a short screening tool of self-perceived functional and physical performance ability. Physical performance was assessed using the Short Physical Performance Battery. The history of falls was recorded. Of the 50 patients, 40 underwent follow-up assessment with the same instruments 3 months after the initial assessment.
Of the 50 men, 24% had impairment in the ADLs, 42% had impairment in the IADLs, 56% had abnormal Short Physical Performance Battery findings, and 22% reported falls within the previous 3 months. Within the Short Physical Performance Battery, deficits occurred within all subcomponents (balance, walking, and chair stands). On univariate analysis, age, deficits in ADLs and IADLs, and abnormal cognitive and functional screen findings were associated with an increased risk of abnormal physical performance. ADL deficits, the use of an assistive device, and abnormal functional screen findings were associated with an increased risk of falling.
The results of our study have shown that older men with prostate cancer receiving long-term ADT exhibit significant functional and physical impairment and are at risk of falls that is greater than that for similar-aged cohorts. Careful assessment of the functional and physical deficits in older patients receiving ADT is warranted.
PMCID: PMC3032402  PMID: 18561991
22.  Durable Responses with the Metronomic Regimen RT-PEPC in Elderly Patients with Recurrent Mantle Cell Lymphoma 
Cancer  2010;116(11):2655-2664.
Targeting the tumor microenvironment and angiogenesis is a novel lymphoma therapeutic strategy. We report safety, activity and angiogenic profiling with the RT-PEPC regimen (rituximab with thalidomide, and prednisone, etoposide, procarbazine and cyclophosphamide) in recurrent mantle cell lymphoma (MCL).
RT-PEPC includes induction (months 1–3) of weekly rituximab × 4, daily thalidomide (50 mg) and PEPC, then maintenance thalidomide (100 mg), oral PEPC titrated to neutrophil count, and rituximab every 4 months. Endpoints included safety, efficacy, quality of life (QoL), and translational studies including tumor angiogenic phenotyping, plasma VEGF and circulating endothelial cells.
Twenty-five pts were enrolled (22 evaluable) with median age 68 yrs (range 52–81), 24 (96%) stage III/IV, 18 (72%) IPI 3–5, 20 (80%) high risk MIPI, median 2 prior therapies (range 1–7), and 15 (60%) bortezomib progressors. At a median follow-up of 38 months, ORR was 73% (32% CR/CRu, 41% PR, n=22) and median PFS 10 months. Four CRs are ongoing (6+, 31+, 48+ and 50+ months). Toxicities included grade 1–2 fatigue, rash, neuropathy and cytopenias including grade 1–2 thrombocytopenia (64%) and grade 3–4 neutropenia (64%). Two thromboses and 5 grade 3–4 infections occurred. QoL was maintained or improved. Correlative studies demonstrated tumor autocrine angiogenic loop (expression of VEGFA and VEGFR1) and heightened angiogenesis and lymphangiogenesis in stroma. Plasma VEGF and circulating endothelial cells trended down with treatment.
RT-PEPC has significant and durable activity in MCL, with manageable toxicity and maintained QoL. Novel low-intensity approaches warrant further evaluation, potentially as initial therapy in elderly patients.
PMCID: PMC3004744  PMID: 20235190
23.  Distress in Older Patients With Cancer 
Journal of Clinical Oncology  2009;27(26):4346-4351.
To determine the predictors of distress in older patients with cancer.
Patients and Methods
Patients age ≥ 65 years with a solid tumor or lymphoma completed a questionnaire that addressed these geriatric assessment domains: functional status, comorbidity, psychological state, nutritional status, and social support. Patients self-rated their level of distress on a scale of zero to 10 using a validated screening tool called the Distress Thermometer. The relationship between distress and geriatric assessment scores was examined.
The geriatric assessment questionnaire was completed by 245 patients (mean age, 76 years; standard deviation [SD], 7 years; range, 65 to 95 years) with cancer (36% stage IV; 71% female). Of these, 87% also completed the Distress Thermometer, with 41% (n = 87) reporting a distress score of ≥ 4 on a scale of zero to 10 (mean score, 3; SD, 3; range, zero to 10). Bivariate analyses demonstrated an association between higher distress (≥ 4) and poorer physical function, increased comorbid medical conditions, poor eyesight, inability to complete the questionnaire alone, and requiring more time to complete the questionnaire. In a multivariate regression model based on the significant bivariate findings, poorer physical function (increased need for assistance with instrumental activities of daily living [P = .015] and lower physical function score on the Medical Outcomes Survey [P = .018]) correlated significantly with a higher distress score.
Significant distress was identified in 41% of older patients with cancer. Poorer physical function was the best predictor of distress. Further studies are needed to determine whether interventions that improve or assist with physical functioning can help to decrease distress in older adults with cancer.
PMCID: PMC2799049  PMID: 19652074
24.  Self-neglect in Older Adults: a Primer for Clinicians 
Journal of General Internal Medicine  2008;23(11):1841-1846.
Self-neglect in older adults is an increasingly prevalent, poorly understood problem, crossing both the medical and social arenas, with public health implications. Although lacking a standardized definition, self-neglect is characterized by profound inattention to health and hygiene. In light of the aging demographic, physicians of all specialties will increasingly encounter self-neglectors. We outline here practical strategies for the clinician, and suggestions for the researcher. Clinical evaluation should include attention to medical history, cognition, function, social networks, psychiatric screen and environment. The individual’s capacity is often questioned, and interventions are case-based. More research is needed in basic epidemiology and risk factors of the problem, so that targeted interventions may be designed and tested. The debate of whether self-neglect is a medical versus societal problem remains unresolved, yet as health sequelae are part of the syndrome, physicians should be part of the solution.
PMCID: PMC2585676  PMID: 18649111
self-neglect; older adults; clinical guidelines
25.  Resident-to-Resident Aggression in Long-Term Care Facilities: Insights from Focus Groups of Nursing Home Residents and Staff 
To more fully characterize the spectrum of RRA.
A focus group study of nursing home staff members and residents who could reliably self-report.
A large urban, not-for-profit long-term care facility in New York City
7 residents and 96 staff members from multiple clinical and non-clinical occupational groups.
16 focus groups were conducted. Content was analyzed with nVivo 7 software for qualitative data.
35 different types of physical, verbal and sexual RRA were described, with screaming and/or yelling being the most common. Calling out and making noise were the most frequent of 29 antecedents identified as instigating episodes of RRA. RRA was most frequent in dining and residents’ rooms, and in the afternoon, though it occurred regularly throughout the facility at all times. While no proven strategies exist to manage RRA, staff described 25 self-initiated techniques to address the issue.
RRA is a ubiquitous phenomenon in nursing home settings with important consequences for affected individuals and facilities. Further epidemiologic research is necessary to more fully describe the phenomenon and identify risk factors and preventative strategies.
PMCID: PMC2755096  PMID: 18637979
nursing home; dementia-related behaviors; focus groups

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