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Aging in Place
JAMDA 13 (2012) 489e492
JAMDA journal homepage: www.jamda.com
Editorial
Aging in Place John E. Morley MB, BCh * Division of Geriatric Medicine, Saint Louis University School of Medicine, St. Louis, MO
Most older persons do not live in nursing homes, but manage to stay in the community with help from friends and relatives.1 When middle-aged persons are asked where they wish to stay as they age, 78% choose to stay in their own home; however, in the old-old, deterioration in neighborhood quality and living with others in the community decreased life satisfaction.2 White et al3 found that there is wide variation in preferences of older persons and their family members, with some seeing items that had a high value, for others as being undesirable. Although persons who are disabled or severely demented often have little choice but to move to an institution, even among this group, most manage to stay in the community.4,5 The long term care spectrum includes understanding the resources needed to allow older persons to “age in place” or to choose living facilities that are different from nursing homes and how to prevent further deterioration in their health. In Denmark, for instance, since 1984 new nursing homes have not been built but rather there has been a focus on “elderly housings” (“Aelderboliges”). These are handicapped accessible homes allowing the older person to remain in the community as they become disabled. In the United States, “The Green House” is an equivalent development.6 These are small units serving 10 to 12 residents with private rooms, including a bathroom, kitchen, and dining and living room. In a small study, the quality of life was equal to that of nursing homes and showed an improved functional status.7 Although there are a number of articles on these small, homelike care environments at present, studies have not clearly demonstrated an advantage or that they are cost effective.8 The International Association of Gerontology and Geriatrics position statement strongly supported older persons having the choice to live at home.9 Aging in place is the ability to live in one’s own home and community safely and independently as one ages. In the United States, this concept was first created in the Beacon Hill Village in Boston where a group of older persons came together in 2001 to provide mutual support to enable them to remain independent in their own home as long as possible. This has led to the “Village Model,” a consumer-driven approach to allow aging in place.10 Commercially, a number of continuing care retirement communities have been developed that offer housing associated with an assisted living facility and a nursing home on the same campus. To allow older persons to live maximally in their own living space requires the development of
* Address correspondence to John E. Morley, MB, BCh, Division of Geriatric Medicine, Saint Louis University School of Medicine, 1402 S. Grand Boulevard, M238, St. Louis, MO 63104. E-mail address: [email protected].
“smart houses.”11e14 The individuals in these communities tend to have multiple comorbidities, be on large numbers of medicines (mean of 10 in one study) and frequently need access to medical care.15 This means that these individuals need a high level of psychosocial and medical support to continue to live in these communities. Nurse-led case management and preventive and health promotion programs can greatly increase function in older persons living in the community.16e21 In Holland, the EASY care study provides a nurse driven geriatric assessment program in the home.18 In the Kochi prefecture in Japan, the “Field Medicine” project provides yearly health assessment for persons older than 75 years and then targeted interventions to maintain independence in activities of daily living. In this issue of the Journal, there is a report on the highly successful exercise program introduced as one of their targeted interventions.22 A highly successful home intervention program in the United States has been the Program for All-Inclusive Care (PACE).23e25 The program started with the “On-Lok” program for the Chinese community in San Francisco in 1979. The program provides coordinated community care with a central day care center providing health care. This program is cost-effective with residents living longer, having a better quality of life, and being twice as likely to die at home. Assisted living facilities blossomed throughout the 1990s in the United States as an alternative to nursing home admission.26e29 In general, they offer limited services with a low level of true privacy. Physicians on the whole are somewhat confident in the level of care available30; however, many of the facilities were perceived as lacking the ability to assess problems or to provide vital signs. The industry is private pay, making most assisted living unaffordable to low- to moderate income families. Overall, it would seem that many assisted living facilities are questionably worth the money spent on them, although for private-pay individuals they are cheaper than nursing homes and thus save money. The major predictors of institutionalization are inability to use the toilet, balance problems, and dementia.31e35 Fecal incontinence is particularly predictive of nursing home placement,36 as are behavioral disorders.37e46 Having more children is protective of needing to go to a nursing home. For a physician to successfully maintain an older person living in the community, early recognition of frailty is essential.47e55 Frailty is a treatable geriatric syndrome. The first focus in a frail person should be on increasing his or her exercise program. 56e65 Singh et al 66 demonstrated dramatic improvements in remaining at home in older persons post hip fracture. Exercise programs are a key to decreasing sarcopenia,67e74 reducing falls, and hip fracture.75e85 Pain needs to be aggressively treated to allow older persons to exercise.45,86e89
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Editorial / JAMDA 13 (2012) 489e492
Fatigue is another component of the frailty syndrome. Although exercise is an excellent treatment for fatigue, other causes, such as depression,90e93 anemia,94,95 and sleep disturbances, such as sleep apnea,96e98 are common factors in producing fatigue. Polypharmacy can aggravate fatigue by causing hypotension and sleepiness.99e107 Weight loss is a key to the frailty syndrome.98,108e115 Early screening for anorexia and malnutrition with the Simplified Nutrition Assessment Questionnaire and the MiniNutritional Assessment can lead to early treatment.92,94e97 An essential amino acideenriched protein supplement given between meals can improve muscle mass.114 An important component of allowing persons to age-in-place is to have high-quality palliative and hospice care services available in the community.116e124 Failure to receive adequate home health care nearly doubles the chances of a person dying in the nursing home.115 Aging in place takes a “family of caregivers” and appropriate medical care to allow it to occur. Acceptance of appropriate medical treatment as opposed to aggressive treatment that may or may not extend life125 and the realization that high-quality rehabilitation in a skilled nursing facility126 are both essential to allow an older person to age successfully in his or her own home.127 References 1. Katz PR. An international perspective on long-term care: Focus on nursing homes. J Am Med Dir Assoc 2011;12. 487e492.e1. 2. Oswald F, Jopp D, Rott C, Wahl HW. Is aging in place a resource for or risk to life satisfaction? Gerontologist 2011;51:238e250. 3. White HK, Corazzini K, Twersky J, et al. Prioritizing culture change in nursing homes: Perspectives of residents, staff, and family members. J Am Geriatr Soc 2012;60:525e531. 4. Morley JE. Clinical practice in nursing homes as a key for progress. J Nutr Health Aging 2010;14:586e593. 5. Henderson EJ, Caplan GA. Home sweet home? Community care for older people in Australia. J Am Med Dir Assoc 2008;9:88e94. 6. Rabig J, Thomas W, Kane RA, et al. Radical redesign of nursing homes: Applying the green house concept in Tupelo, Mississippi. Gerontologist 2006; 46:533e539. 7. Kane RA, Lum TY, Cutler LJ, et al. Resident outcomes in small-house nursing homes: A longitudinal evaluation of the initial green house program. J Am Geriatr Soc 2007;55:832e839. 8. Verbeek H, van Rossum E, Zwakhalen SM, et al. Small, homelike care environments for older people with dementia: A literature review. Int Psychogeriatr 2009;21:252e264. 9. Tolson D, Rolland Y, Andrieu S, et al, The International Association of Gerontology and Geriatrics/World Health Organization/Society Française de Gérontologie et de Gériatrie Task Force. International Association of Gerontology and Geriatrics: a global agenda for clinical research and quality of care in nursing homes. J Am Med Dir Assoc 2011;12:184e189. 10. Scharlach A, Graham C, Lehning A. The “Village” Model: A consumer-driven approach for aging in place. Gerontologist 2011;52:418e427. 11. Morley JE. High technology coming to a nursing home near you. J Am Med Dir Assoc 2012;13:409e412. 12. Marek KD, Rantz MJ. Aging in place: A new model for long-term care. Nurs Adm Q 2000;24:1e11. 13. Bemelmans R, Gelderblom GJ, Jonker P, de Witte L. Socially assistive robots in elderly care: A systematic review into effects and effectiveness. J Am Med Dir Assoc 2012;13. 114e120.e1. 14. Oswald F, Wahl HW, Schilling O, et al. Relationships between housing and healthy aging in very old age. Gerontologist 2007;47:96e107. 15. McDermott R, Gillespie SM, Nelson D, et al. Characteristics and acute care use patterns of patients in a senior living community medical practice. J Am Med Dir Assoc 2012;13:260e263. 16. Fabacher D, Josephson K, Pietruszka F, et al. An in-home preventive assessment program for independent older adults: A randomized controlled trial. J Am Geriatr Soc 1994;42:630e638. 17. Duke C. The frail elderly community-based case management project. Geriatr Nurs 2005;26:122e127. 18. Hallberg IR, Kristensson J. Preventive home care of frail older people: A review of recent case management studies. J Clin Nurs 2004;13:112e120. 19. Gloth FM 3rd, Gloth MJ. A comparative effectiveness trial between a postacute care hospitalist model and a community-based physician model of nursing home care. J Am Med Dir Assoc 2011;12:384e386. 20. Thomas KE, Gassoumis ZD, Wilber KH. Conversion diversion: Participation in a social HMO reduces the likelihood of converting from short-stay to long-stay nursing facility placement. J Am Med Dir Assoc 2010;11: 333e337.
21. Philpot C, Tolson D, Morley JE. Advanced practice nurses and attending physicians: A collaboration to improve quality of care in the nursing home. J Am Med Dir Assoc 2011;12:161e165. 22. Yamada M, Arai H, Sonoda T, Aoyama T. Community-based exercise program is cost-effective by preventing care and disability in Japanese frail older adults. J Am Med Dir Assoc 2012;13:507e511. 23. Ginsburg IF, Eng C. On-site mental health services for PACE (Program for Allinclusive Care for the Elderly) centers. J Am Med Dir Assoc 2009;10:277e280. 24. Hirth V, Baskins J, Dever Bumba M. Program of all-inclusive care (PACE): Past, present, and future. J Am Med Dir Assoc 2009;10:155e160. 25. Rearden GL, McNabney MK, Bloom SM, Eng C. Should programs of allinclusive care for the elderly use community-based primary care physicians? J Am Med Dir Assoc 2008;9:275e278. 26. Hawes C, Phillips CD, Rose M, et al. A national survey of assisted living facilities. Gerontologist 2003;43:875e882. 27. Levenson SA. On assisted living: Are we hitting the mark or missing the boat? J Am Med Dir Assoc 2012;13:314e315. 28. Avery E, Kleppinger A, Feinn R, Kenny AM. Determinants of living situation in a population of community-dwelling and assisted living-dwelling elderly. J Am Med Dir Assoc 2010;11:140e144. 29. Stefanacci RG. First steps in improving physical activity in assisted living. J Am Med Dir Assoc 2010;11:383e385. 30. Sloane PD, Zimmerman S, Perez R, et al. Physician perspectives on medical care delivery in assisted living. J Am Geriatr Soc 2011;59:2326e2331. 31. Dramé M, Fierobe F, Lang PO, et al. Predictors of institution admission in the year following acute hospitalisation of elderly people. J Nutr Health Aging 2011;15:399e403. 32. Sourdet S, Abellan van Kan G, Soto ME, et al. Prognosis of an abnormal one-leg balance in community-dwelling patients with Alzheimer’s Disease: A 2-year prospective study in 686 patients of the REAL.FR Study. J Am Med Dir Assoc 2012;13:407. 33. Morley JE, Rolland Y, Tolson D, Vellas B. Increasing awareness of the factors producing falls: The mini falls assessment. J Am Med Dir Assoc 2012;13: 87e90. 34. Zekry D, Loures Valle BH, Graf C, et al. Prospective comparison of 6 comorbidity indices as predictors of 1-year post-hospital discharge institutionalization, readmission, and mortality in elderly individuals. J Am Med Dir Assoc 2012;13:272e278. 35. Guerini F, Frisoni GB, Morghen S, et al. Clinical instability as a predictor of negative outcomes among elderly patients admitted to a rehabilitation ward. J Am Med Dir Assoc 2010;11:443e448. 36. Nyrop KA, Grover M, Palsson OS, et al. Likelihood of nursing home referral for fecally incontinent elderly patients is influenced by physician views on nursing home care and outpatient management of fecal incontinence. J Am Med Dir Assoc 2012;13:350e354. 37. Morley JE. Dementia-related agitation. J Am Med Dir Assoc 2011;12. 611e612. e2. 38. Kerwin D, Claus TH. Severe Alzheimer’s disease: treatment effects on function and care requirements. J Am Med Dir Assoc 2011;12:99e104. 39. Morley JE. Alzheimer’s disease: Future treatments. J Am Med Dir Assoc 2011; 12:1e7. 40. Jones RN, Kiely DK, Marcantonio ER. Prevalence of delirium on admission to postacute care is associated with a higher number of nursing home deficiencies. J Am Med Dir Assoc 2010;11:253e256. 41. Cruz-Oliver DM, Morley JE. Early detection of cognitive impairment: Do screening tests help? J Am Med Dir Assoc 2010;11:1e6. 42. Volicer L. Is your nursing home a battlefield? J Am Med Dir Assoc 2012;13: 195e196. 43. Volicer L, Van der Steen JT, Frijters DH. Modifiable factors related to abusive behaviors in nursing home residents with dementia. J Am Med Dir Assoc 2009;10:617e622. 44. Flaherty JH, Shay K, Weir C, et al. The development of a mental status vital sign for use across the spectrum of care. J Am Med Dir Assoc 2009;10: 379e380. 45. Flaherty JH, Rudolph J, Shay K, et al. Delirium is a serious and underrecognized problem: Why assessment of mental status should be the sixth vital sign. J Am Med Dir Assoc 2007;8:273e275. 46. Ferretti M, Seematter-Bagnoud L, Martin E, Büla CJ. New diagnoses of dementia among older patients admitted to postacute care. J Am Med Dir Assoc 2010;11:371e376. 47. Gobbens RJ, van Assen MA, Luijkx KG, et al. Determinants of frailty. J Am Med Dir Assoc 2010;11:356e364. 48. Gobbens RJ, van Assen MA, Luijkx KG, et al. The Tilburg Frailty Indicator: Psychometric properties. J Am Med Dir Assoc 2010;11:344e355. 49. Morley JE. Anorexia, weight loss, and frailty. J Am Med Dir Assoc 2010;11: 225e258. 50. Morley JE. Frailty: Diagnosis and management. J Nutr Health Aging 2011;15: 667e670. 51. Abellan van Kan G, Rolland YM, Morley JE, Vellas B. Frailty: Toward a clinical definition. J Am Med Dir Assoc 2008;9:71e72. 52. Rockwood K, Abeysundera MJ, Mitnitski A. How should we grade frailty in nursing home patients? J Am Med Dir Assoc 2007;8:595e603. 53. Morley JE. Developing novel therapeutic approaches to frailty. Curr Pharm Des 2009;15:3384e3395.
Editorial / JAMDA 13 (2012) 489e492 54. Rolland Y, Czerwinski S, Abellan van Kan G, et al. Sarcopenia: Its assessment, etiology, pathogenesis, consequences and future perspectives. J Nutr Health Aging 2008;12:433e450. 55. Abellan van Kan G, Rolland Y, Bergman H, et al. The I.A.N.A. Task Force on frailty assessment of older people in clinical practice. J Nutr Health Aging 2008;12:29e37. 56. Reelick MF, Faes MC, Esselink RA, et al. How to perform a preplanned process evaluation for complex interventions in geriatric medicine: exemplified with the process evaluation of a complex falls-prevention program for communitydwelling frail older fallers. J Am Med Dir Assoc 2011;12:331e336. 57. Torpilliesi T, Bellelli G, Morghen S, et al. Outcomes of nonagenarian patients after rehabilitation following hip fracture surgery. J Am Med Dir Assoc 2012; 13:81.e1e81.e5. 58. Valenzuela T. Efficacy of progressive resistance training interventions in older adults in nursing homes: A systematic review. J Am Med Dir Assoc 2012;13: 418e428. 59. Snyder A, Colvin B, Gammack JK. Pedometer use increases daily steps and functional status in older adults. J Am Med Dir Assoc 2011;12:590e594. 60. Fox T, Sloves G. Fostering a culture of exercise in assisted living. J Am Med Dir Assoc 2010;11:605. 61. Stefanacci RG. First steps in improving physical activity in assisted living. J Am Med Dir Assoc 2010;11:383e385. 62. Aman E, Thomas DR. Supervised exercise to reduce agitation in severely cognitively impaired persons. J Am Med Dir Assoc 2009;10:271e276. 63. Fox T, Jacobs M. The magic of exercise [Letter]. J Am Med Dir Assoc 2008;9:689. 64. Morley JE. The magic of exercise. J Am Med Dir Assoc 2008;9:375e377. 65. Rolland Y, Abellan van Kan G, Vellas B. Physical activity and Alzheimer’s disease: From prevention to therapeutic perspectives. J Am Med Dir Assoc 2008;9:390e405. 66. Singh NA, Quine S, Clemson LM, et al. Effects of high-intensity progressive resistance training and targeted multidisciplinary treatment of frailty on mortality and nursing home admissions after hip fracture: A randomized controlled trial. J Am Med Dir Assoc 2012;13:24e30. 67. Landi F, Liperoti R, Fusco D, et al. Sarcopenia and mortality among older nursing home residents. J Am Med Dir Assoc 2012;13:121e126. 68. Spruit MA, Polkey MI, Celli B, et al. Predicting outcomes from 6-minute walk distance in chronic obstructive pulmonary disease. J Am Med Dir Assoc 2012; 13:291e297. 69. Morley JE, Abbatecola AM, Argiles JM, et al, Society on Sarcopenia, Cachexia and Wasting Disorders Trialist Workshop. Sarcopenia with limited mobility: An international consensus. J Am Med Dir Assoc 2011;12:403e409. 70. Fielding RA, Vellas B, Evans WJ, et al. Sarcopenia: An undiagnosed condition in older adults. Current consensus definition: Prevalence, etiology, and consequences. International working group on sarcopenia. J Am Med Dir Assoc 2011;12:249e256. 71. Fox T, Sloves G. Fostering a culture of exercise in assisted living. J Am Med Dir Assoc 2010;11:605. 72. Morley JE. Sarcopenia in the elderly. Fam Pract 2012;29:i44ei48. 73. Van Kan GA, Cderbaum JM, Cesari M, et al. Sarcopenia: Biomarkers and imaging (International Conference on Sarcopenia Research). J Nutr Health Aging 2011;15:834e846. 74. Rolland Y, Czerwinski S, Abellan van Kan G, et al. Sarcopenia: Its assessment, etiology, pathogenesis, consequences and future perspectives. J Nutr Health Aging 2008;12:433e450. 75. Nyrop KA, Zimmerman S, Sloane PD, Bangdiwala S. Fall prevention and monitoring of assisted living patients: An exploratory study of physician perspectives. J Am Med Dir Assoc 2012;13:429e433. 76. Rapp K, Becker C, Cameron ID, et al. Epidemiology of falls in residential aged care: Analysis of more than 70,000 falls from residents of Bavarian nursing homes. J Am Med Dir Assoc 2012;13:187.e1e187.e6. 77. Choi M, Hector M. Effectiveness of intervention programs in preventing falls: A systematic review of recent 10 years and meta-analysis. J Am Med Dir Assoc 2012;13:188.e13e188.e21. 78. Morley JE. Osteoporosis and fragility fractures. J Am Med Dir Assoc 2011;12: 389e392. 79. Faes MC, Reelick MF, Melis RJ, et al. Multifactorial fall prevention for pairs of frail community-dwelling older fallers and their informal caregivers: A dead end for complex interventions in the frailest fallers. J Am Med Dir Assoc 2011; 12:451e458. 80. Adunsky A, Lerner-Geva L, Blumstein T, et al. Improved survival of hip fracture patients treated within a comprehensive geriatric hip fracture unit, compared with standard of care treatment. J Am Med Dir Assoc 2011;12:439e444. 81. Wagner LM, Dionne JC, Zive JR, Rochon PA. Fall risk care processes in nursing home facilities. J Am Med Dir Assoc 2011;12:426e430. 82. Neyens JC, van Haastregt JC, Dijcks BP, et al. Effectiveness and implementation aspects of interventions for preventing falls in elderly people in long-term care facilities: A systematic review of RCTs. J Am Med Dir Assoc 2011;12:410e425. 83. Morley JE. Hip fractures. J Am Med Dir Assoc 2010;11:81e83. 84. von Haehling S, Morley JE, Anker SD. An overview of sarcopenia: facts and numbers on prevalence and clinical impact. J Cachexia Sarcopenia Muscle 2010;1:129e133. 85. Landi F, Liperoti R, Fusco D, et al. Sarcopenia and mortality among older nursing home residents. J Am Med Dir Assoc 2012;13:121e126. 86. Morley JE. Paind“God’s megaphone”. J Am Med Dir Assoc 2012;13:316e318.
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87. Lapane KL, Quilliam BJ, Chow W, Kim M. The association between pain and measures of well-being among nursing home residents. J Am Med Dir Assoc 2011;13:344e349. 88. Onen SH, Onen F, Albrand G, et al. Pain tolerance and obstructive sleep apnea in the elderly. J Am Med Dir Assoc 2010;11:612e616. 89. Hanlon JT, Perera S, Sevick MA, et al. Pain and its treatment in older nursing home hospice/palliative care residents. J Am Med Dir Assoc 2010;11: 579e583. 90. Harris T, Carey IM, Shah SM, et al. Antidepressant prescribing in older primary care patients in community and care home settings in England and Wales. J Am Med Dir Assoc 2012;13:41e47. 91. Morley JE. Depression in nursing home residents. J Am Med Dir Assoc 2010; 11:301e303. 92. Rolland Y, Perrin A, Gardette V, Filhol N, Vellas B. Screening older people at risk of malnutrition or malnourished using the Simplified Nutritional Appetite Questionnaire (SNAQ): A comparison with the Mini-Nutritional Assessment (MNA) tool. J Am Med Dir Assoc 2012;13:31e34. 93. Engin S, Ozturk M, Engin N, Kulaksizoglu IB. Dark side of the town: Depressive symptoms in disadvantages senior citizens. J Nutr Health Aging 2010;14: 483e487. 94. Wilson MM, Thomas DR, Rubenstein LZ, et al. Appetite assessment: simple appetite questionnaire predicts weight loss in community-dwelling adults and nursing home residents. Am J Clin Nutr 2005;82:1074e1081. 95. Vellas B, Villars H, Abellan G, et al. Overview of the MNAdits history and challenges. J Nutr Health Aging 2006;10:456e463. 96. Thomas DR, Zdrowski CD, Wilson MM, et al. Malnutrition in subacute care. Am J Clin Nutr 2002;75:308e313. 97. Morley JE. Assessment of malnutrition in older persons: A focus on the Mini Nutritional Assessment. J Nutr Health Aging 2011;15:87e90. 98. Vikstedt T, Suominen MH, Joki A, et al. Nutritional status, energy, protein, and micronutrient intake of older service house residents. J Am Med Dir Assoc 2011;12:302e307. 99. Bronskill SE, Gill SS, Paterson JM, et al. Exploring variation in rates of polypharmacy across long term care homes. J Am Med Dir Assoc 2012;13:309. e15e309.e21. 100. Lattanzio F, Laino I, Pedone C, et al. Geriatric conditions and adverse drug reactions in elderly hospitalized patients. J Am Med Dir Assoc 2012;13: 96e99. 101. Lang PO, Vogt-Ferrier N, Hasso Y, et al. Interdisciplinary geriatric and psychiatric care reduces potentially inappropriate prescribing in the hospital: Interventional study in 150 acutely ill elderly patients with mental and somatic comorbid conditions. J Am Med Dir Assoc 2012;13:406. 102. Fitzgerald SP, Bean NG. An analysis of the interactions between individual comorbidities and their treatmentsdimplications for guidelines and polypharmacy. J Am Med Dir Assoc 2010;11:475e484. 103. Miles RW. A conversation: Polypharmacy in the nursing home. J Am Med Dir Assoc 2010;11:296e297. 104. Morley JE. Hypertension: Is it overtreated in the elderly? J Am Med Dir Assoc 2010;11:147e152. 105. Garcia-Gollarte F, Baleriola-Júlvez J, Ferero-López I, Cruz-Jentoft AJ. Inappropriate drug prescription at nursing home admission. J Am Med Dir Assoc 2012;13. 83.e9e15. 106. Bronskill SE, Gill SS, Paterson JM, et al. Exploring variation in rates of polypharmacy across long-term care homes. J Am Med Dir Assoc 2012;13:309. e15e309.e21. 107. Gokce Kutsal Y, Barak A, Atalay A, et al. Polypharmacy in the elderly: A multicenter study. J Am Med Dir Assoc 2009;10:486e490. 108. Morley JE. Undernutrition: A major problem in nursing homes. J Am Med Dir Assoc 2011;12:243e246. 109. Landi F, Russo A, Liperoti R, et al. Anorexia, physical function, and incident disability among the frail elderly population: Results from the ilSIRENTE study. J Am Med Dir Assoc 2010;11:268e274. 110. Argilés JM, Anker SD, Evans WJ, et al. Consensus on cachexia definitions. J Am Med Dir Assoc 2010;11:229e230. 111. Landi F, Laviano A, Cruz-Jentoft AJ. The anorexia of aging: Is it a geriatric syndrome? J Am Med Dir Assoc 2010;11:153e156. 112. Bourdel-Marchasson I. How to improve nutritional support in geriatric institutions. J Am Med Dir Assoc 2010;11:13e20. 113. Yang Y, Brown CJ, Burgio KL, et al. Undernutrition at baseline and health services utilization and mortality over a 1-year period in older adults receiving Medicare home health services. J Am Med Dir Assoc 2011;12:287e294. 114. van Wetering CR, Hoogendoorn M, Broekhuizen R, et al. Efficacy and costs of nutritional rehabilitation in muscle-wasted patients with chronic obstructive pulmonary disease in a community-based setting: A prespecified subgroup analysis of the INTERCOM trial. J Am Med Dir Assoc 2010;11:179e187. 115. Nanda A, Bourbonniere M, Wetle T, Teno J. Home care in the last year of life: Family member perceptions of unmet need associated with last place of care. J Am Med Dir Assoc 2010;11:21e25. 116. Dobbs D, Meng H, Hyer K, Volicer L. The influence of hospice use on nursing home and hospital use in assisted living among dual-eligible enrollees. J Am Med Dir Assoc 2012;13:189.e9e189.e13. 117. Hirschman KB, Abbott KM, Hanlon AL, et al. What factors are associated with having an advance directive among older adults who are new to long-term care services? J Am Med Dir Assoc 2012;13. 82.e7e11.
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118. Parker Oliver D, Kapp JM, Tatum P, Wallace A. Hospice medical directors: A survey of one state. J Am Med Dir Assoc 2012;13:35e40. 119. Wong RY. Improving end-of-life care for patients with noncancer illnesses: The time is now. J Am Med Dir Assoc 2011;12:86e87. 120. Morley JE. End-of-life care in the nursing home. J Am Med Dir Assoc 2011;12: 7e83. 121. Gheorghe C, Vazquez R, Casanegra AI, et al. Elders’ environs and their end-oflife preferences. J Am Med Dir Assoc 2011;12:22e28. 122. Famakinwa AB. End-of-life care in a PACE program: Respecting the patient’s wishes while supporting the caregiver. J Am Med Dir Assoc 2010;11:528e530.
123. Cruz-Oliver DM, Sanford AM, Paniagua MA. End-of-life care in the nursing home. J Am Med Dir Assoc 2010;11:462e464. 124. Biola H, Sloane PD, Williams CS, et al. Preferences versus practice: Lifesustaining treatments in last months of life in long-term care. J Am Med Dir Assoc 2010;11:42e51. 125. Dominguez LJ, Barbagallo M, Morley JE. The paradigm of life extension. J Am Med Dir Assoc 2010;11:457e458. 126. Caplan GA. Rehabilitation. J Am Med Dir Assoc 2011;12:8. 127. Morley JE. Successful aging or aging successfully. J Am Med Dir Assoc 2009; 10:85e86.
JAMDA journal homepage: www.jamda.com
Editorial
Aging in Place John E. Morley MB, BCh * Division of Geriatric Medicine, Saint Louis University School of Medicine, St. Louis, MO
Most older persons do not live in nursing homes, but manage to stay in the community with help from friends and relatives.1 When middle-aged persons are asked where they wish to stay as they age, 78% choose to stay in their own home; however, in the old-old, deterioration in neighborhood quality and living with others in the community decreased life satisfaction.2 White et al3 found that there is wide variation in preferences of older persons and their family members, with some seeing items that had a high value, for others as being undesirable. Although persons who are disabled or severely demented often have little choice but to move to an institution, even among this group, most manage to stay in the community.4,5 The long term care spectrum includes understanding the resources needed to allow older persons to “age in place” or to choose living facilities that are different from nursing homes and how to prevent further deterioration in their health. In Denmark, for instance, since 1984 new nursing homes have not been built but rather there has been a focus on “elderly housings” (“Aelderboliges”). These are handicapped accessible homes allowing the older person to remain in the community as they become disabled. In the United States, “The Green House” is an equivalent development.6 These are small units serving 10 to 12 residents with private rooms, including a bathroom, kitchen, and dining and living room. In a small study, the quality of life was equal to that of nursing homes and showed an improved functional status.7 Although there are a number of articles on these small, homelike care environments at present, studies have not clearly demonstrated an advantage or that they are cost effective.8 The International Association of Gerontology and Geriatrics position statement strongly supported older persons having the choice to live at home.9 Aging in place is the ability to live in one’s own home and community safely and independently as one ages. In the United States, this concept was first created in the Beacon Hill Village in Boston where a group of older persons came together in 2001 to provide mutual support to enable them to remain independent in their own home as long as possible. This has led to the “Village Model,” a consumer-driven approach to allow aging in place.10 Commercially, a number of continuing care retirement communities have been developed that offer housing associated with an assisted living facility and a nursing home on the same campus. To allow older persons to live maximally in their own living space requires the development of
* Address correspondence to John E. Morley, MB, BCh, Division of Geriatric Medicine, Saint Louis University School of Medicine, 1402 S. Grand Boulevard, M238, St. Louis, MO 63104. E-mail address: [email protected].
“smart houses.”11e14 The individuals in these communities tend to have multiple comorbidities, be on large numbers of medicines (mean of 10 in one study) and frequently need access to medical care.15 This means that these individuals need a high level of psychosocial and medical support to continue to live in these communities. Nurse-led case management and preventive and health promotion programs can greatly increase function in older persons living in the community.16e21 In Holland, the EASY care study provides a nurse driven geriatric assessment program in the home.18 In the Kochi prefecture in Japan, the “Field Medicine” project provides yearly health assessment for persons older than 75 years and then targeted interventions to maintain independence in activities of daily living. In this issue of the Journal, there is a report on the highly successful exercise program introduced as one of their targeted interventions.22 A highly successful home intervention program in the United States has been the Program for All-Inclusive Care (PACE).23e25 The program started with the “On-Lok” program for the Chinese community in San Francisco in 1979. The program provides coordinated community care with a central day care center providing health care. This program is cost-effective with residents living longer, having a better quality of life, and being twice as likely to die at home. Assisted living facilities blossomed throughout the 1990s in the United States as an alternative to nursing home admission.26e29 In general, they offer limited services with a low level of true privacy. Physicians on the whole are somewhat confident in the level of care available30; however, many of the facilities were perceived as lacking the ability to assess problems or to provide vital signs. The industry is private pay, making most assisted living unaffordable to low- to moderate income families. Overall, it would seem that many assisted living facilities are questionably worth the money spent on them, although for private-pay individuals they are cheaper than nursing homes and thus save money. The major predictors of institutionalization are inability to use the toilet, balance problems, and dementia.31e35 Fecal incontinence is particularly predictive of nursing home placement,36 as are behavioral disorders.37e46 Having more children is protective of needing to go to a nursing home. For a physician to successfully maintain an older person living in the community, early recognition of frailty is essential.47e55 Frailty is a treatable geriatric syndrome. The first focus in a frail person should be on increasing his or her exercise program. 56e65 Singh et al 66 demonstrated dramatic improvements in remaining at home in older persons post hip fracture. Exercise programs are a key to decreasing sarcopenia,67e74 reducing falls, and hip fracture.75e85 Pain needs to be aggressively treated to allow older persons to exercise.45,86e89
1525-8610/$ - see front matter Copyright Ó 2012 - American Medical Directors Association, Inc. doi:10.1016/j.jamda.2012.04.011
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Fatigue is another component of the frailty syndrome. Although exercise is an excellent treatment for fatigue, other causes, such as depression,90e93 anemia,94,95 and sleep disturbances, such as sleep apnea,96e98 are common factors in producing fatigue. Polypharmacy can aggravate fatigue by causing hypotension and sleepiness.99e107 Weight loss is a key to the frailty syndrome.98,108e115 Early screening for anorexia and malnutrition with the Simplified Nutrition Assessment Questionnaire and the MiniNutritional Assessment can lead to early treatment.92,94e97 An essential amino acideenriched protein supplement given between meals can improve muscle mass.114 An important component of allowing persons to age-in-place is to have high-quality palliative and hospice care services available in the community.116e124 Failure to receive adequate home health care nearly doubles the chances of a person dying in the nursing home.115 Aging in place takes a “family of caregivers” and appropriate medical care to allow it to occur. Acceptance of appropriate medical treatment as opposed to aggressive treatment that may or may not extend life125 and the realization that high-quality rehabilitation in a skilled nursing facility126 are both essential to allow an older person to age successfully in his or her own home.127 References 1. Katz PR. An international perspective on long-term care: Focus on nursing homes. J Am Med Dir Assoc 2011;12. 487e492.e1. 2. Oswald F, Jopp D, Rott C, Wahl HW. Is aging in place a resource for or risk to life satisfaction? Gerontologist 2011;51:238e250. 3. White HK, Corazzini K, Twersky J, et al. Prioritizing culture change in nursing homes: Perspectives of residents, staff, and family members. J Am Geriatr Soc 2012;60:525e531. 4. Morley JE. Clinical practice in nursing homes as a key for progress. J Nutr Health Aging 2010;14:586e593. 5. Henderson EJ, Caplan GA. Home sweet home? Community care for older people in Australia. J Am Med Dir Assoc 2008;9:88e94. 6. Rabig J, Thomas W, Kane RA, et al. Radical redesign of nursing homes: Applying the green house concept in Tupelo, Mississippi. Gerontologist 2006; 46:533e539. 7. Kane RA, Lum TY, Cutler LJ, et al. Resident outcomes in small-house nursing homes: A longitudinal evaluation of the initial green house program. J Am Geriatr Soc 2007;55:832e839. 8. Verbeek H, van Rossum E, Zwakhalen SM, et al. Small, homelike care environments for older people with dementia: A literature review. Int Psychogeriatr 2009;21:252e264. 9. Tolson D, Rolland Y, Andrieu S, et al, The International Association of Gerontology and Geriatrics/World Health Organization/Society Française de Gérontologie et de Gériatrie Task Force. International Association of Gerontology and Geriatrics: a global agenda for clinical research and quality of care in nursing homes. J Am Med Dir Assoc 2011;12:184e189. 10. Scharlach A, Graham C, Lehning A. The “Village” Model: A consumer-driven approach for aging in place. Gerontologist 2011;52:418e427. 11. Morley JE. High technology coming to a nursing home near you. J Am Med Dir Assoc 2012;13:409e412. 12. Marek KD, Rantz MJ. Aging in place: A new model for long-term care. Nurs Adm Q 2000;24:1e11. 13. Bemelmans R, Gelderblom GJ, Jonker P, de Witte L. Socially assistive robots in elderly care: A systematic review into effects and effectiveness. J Am Med Dir Assoc 2012;13. 114e120.e1. 14. Oswald F, Wahl HW, Schilling O, et al. Relationships between housing and healthy aging in very old age. Gerontologist 2007;47:96e107. 15. McDermott R, Gillespie SM, Nelson D, et al. Characteristics and acute care use patterns of patients in a senior living community medical practice. J Am Med Dir Assoc 2012;13:260e263. 16. Fabacher D, Josephson K, Pietruszka F, et al. An in-home preventive assessment program for independent older adults: A randomized controlled trial. J Am Geriatr Soc 1994;42:630e638. 17. Duke C. The frail elderly community-based case management project. Geriatr Nurs 2005;26:122e127. 18. Hallberg IR, Kristensson J. Preventive home care of frail older people: A review of recent case management studies. J Clin Nurs 2004;13:112e120. 19. Gloth FM 3rd, Gloth MJ. A comparative effectiveness trial between a postacute care hospitalist model and a community-based physician model of nursing home care. J Am Med Dir Assoc 2011;12:384e386. 20. Thomas KE, Gassoumis ZD, Wilber KH. Conversion diversion: Participation in a social HMO reduces the likelihood of converting from short-stay to long-stay nursing facility placement. J Am Med Dir Assoc 2010;11: 333e337.
21. Philpot C, Tolson D, Morley JE. Advanced practice nurses and attending physicians: A collaboration to improve quality of care in the nursing home. J Am Med Dir Assoc 2011;12:161e165. 22. Yamada M, Arai H, Sonoda T, Aoyama T. Community-based exercise program is cost-effective by preventing care and disability in Japanese frail older adults. J Am Med Dir Assoc 2012;13:507e511. 23. Ginsburg IF, Eng C. On-site mental health services for PACE (Program for Allinclusive Care for the Elderly) centers. J Am Med Dir Assoc 2009;10:277e280. 24. Hirth V, Baskins J, Dever Bumba M. Program of all-inclusive care (PACE): Past, present, and future. J Am Med Dir Assoc 2009;10:155e160. 25. Rearden GL, McNabney MK, Bloom SM, Eng C. Should programs of allinclusive care for the elderly use community-based primary care physicians? J Am Med Dir Assoc 2008;9:275e278. 26. Hawes C, Phillips CD, Rose M, et al. A national survey of assisted living facilities. Gerontologist 2003;43:875e882. 27. Levenson SA. On assisted living: Are we hitting the mark or missing the boat? J Am Med Dir Assoc 2012;13:314e315. 28. Avery E, Kleppinger A, Feinn R, Kenny AM. Determinants of living situation in a population of community-dwelling and assisted living-dwelling elderly. J Am Med Dir Assoc 2010;11:140e144. 29. Stefanacci RG. First steps in improving physical activity in assisted living. J Am Med Dir Assoc 2010;11:383e385. 30. Sloane PD, Zimmerman S, Perez R, et al. Physician perspectives on medical care delivery in assisted living. J Am Geriatr Soc 2011;59:2326e2331. 31. Dramé M, Fierobe F, Lang PO, et al. Predictors of institution admission in the year following acute hospitalisation of elderly people. J Nutr Health Aging 2011;15:399e403. 32. Sourdet S, Abellan van Kan G, Soto ME, et al. Prognosis of an abnormal one-leg balance in community-dwelling patients with Alzheimer’s Disease: A 2-year prospective study in 686 patients of the REAL.FR Study. J Am Med Dir Assoc 2012;13:407. 33. Morley JE, Rolland Y, Tolson D, Vellas B. Increasing awareness of the factors producing falls: The mini falls assessment. J Am Med Dir Assoc 2012;13: 87e90. 34. Zekry D, Loures Valle BH, Graf C, et al. Prospective comparison of 6 comorbidity indices as predictors of 1-year post-hospital discharge institutionalization, readmission, and mortality in elderly individuals. J Am Med Dir Assoc 2012;13:272e278. 35. Guerini F, Frisoni GB, Morghen S, et al. Clinical instability as a predictor of negative outcomes among elderly patients admitted to a rehabilitation ward. J Am Med Dir Assoc 2010;11:443e448. 36. Nyrop KA, Grover M, Palsson OS, et al. Likelihood of nursing home referral for fecally incontinent elderly patients is influenced by physician views on nursing home care and outpatient management of fecal incontinence. J Am Med Dir Assoc 2012;13:350e354. 37. Morley JE. Dementia-related agitation. J Am Med Dir Assoc 2011;12. 611e612. e2. 38. Kerwin D, Claus TH. Severe Alzheimer’s disease: treatment effects on function and care requirements. J Am Med Dir Assoc 2011;12:99e104. 39. Morley JE. Alzheimer’s disease: Future treatments. J Am Med Dir Assoc 2011; 12:1e7. 40. Jones RN, Kiely DK, Marcantonio ER. Prevalence of delirium on admission to postacute care is associated with a higher number of nursing home deficiencies. J Am Med Dir Assoc 2010;11:253e256. 41. Cruz-Oliver DM, Morley JE. Early detection of cognitive impairment: Do screening tests help? J Am Med Dir Assoc 2010;11:1e6. 42. Volicer L. Is your nursing home a battlefield? J Am Med Dir Assoc 2012;13: 195e196. 43. Volicer L, Van der Steen JT, Frijters DH. Modifiable factors related to abusive behaviors in nursing home residents with dementia. J Am Med Dir Assoc 2009;10:617e622. 44. Flaherty JH, Shay K, Weir C, et al. The development of a mental status vital sign for use across the spectrum of care. J Am Med Dir Assoc 2009;10: 379e380. 45. Flaherty JH, Rudolph J, Shay K, et al. Delirium is a serious and underrecognized problem: Why assessment of mental status should be the sixth vital sign. J Am Med Dir Assoc 2007;8:273e275. 46. Ferretti M, Seematter-Bagnoud L, Martin E, Büla CJ. New diagnoses of dementia among older patients admitted to postacute care. J Am Med Dir Assoc 2010;11:371e376. 47. Gobbens RJ, van Assen MA, Luijkx KG, et al. Determinants of frailty. J Am Med Dir Assoc 2010;11:356e364. 48. Gobbens RJ, van Assen MA, Luijkx KG, et al. The Tilburg Frailty Indicator: Psychometric properties. J Am Med Dir Assoc 2010;11:344e355. 49. Morley JE. Anorexia, weight loss, and frailty. J Am Med Dir Assoc 2010;11: 225e258. 50. Morley JE. Frailty: Diagnosis and management. J Nutr Health Aging 2011;15: 667e670. 51. Abellan van Kan G, Rolland YM, Morley JE, Vellas B. Frailty: Toward a clinical definition. J Am Med Dir Assoc 2008;9:71e72. 52. Rockwood K, Abeysundera MJ, Mitnitski A. How should we grade frailty in nursing home patients? J Am Med Dir Assoc 2007;8:595e603. 53. Morley JE. Developing novel therapeutic approaches to frailty. Curr Pharm Des 2009;15:3384e3395.
Editorial / JAMDA 13 (2012) 489e492 54. Rolland Y, Czerwinski S, Abellan van Kan G, et al. Sarcopenia: Its assessment, etiology, pathogenesis, consequences and future perspectives. J Nutr Health Aging 2008;12:433e450. 55. Abellan van Kan G, Rolland Y, Bergman H, et al. The I.A.N.A. Task Force on frailty assessment of older people in clinical practice. J Nutr Health Aging 2008;12:29e37. 56. Reelick MF, Faes MC, Esselink RA, et al. How to perform a preplanned process evaluation for complex interventions in geriatric medicine: exemplified with the process evaluation of a complex falls-prevention program for communitydwelling frail older fallers. J Am Med Dir Assoc 2011;12:331e336. 57. Torpilliesi T, Bellelli G, Morghen S, et al. Outcomes of nonagenarian patients after rehabilitation following hip fracture surgery. J Am Med Dir Assoc 2012; 13:81.e1e81.e5. 58. Valenzuela T. Efficacy of progressive resistance training interventions in older adults in nursing homes: A systematic review. J Am Med Dir Assoc 2012;13: 418e428. 59. Snyder A, Colvin B, Gammack JK. Pedometer use increases daily steps and functional status in older adults. J Am Med Dir Assoc 2011;12:590e594. 60. Fox T, Sloves G. Fostering a culture of exercise in assisted living. J Am Med Dir Assoc 2010;11:605. 61. Stefanacci RG. First steps in improving physical activity in assisted living. J Am Med Dir Assoc 2010;11:383e385. 62. Aman E, Thomas DR. Supervised exercise to reduce agitation in severely cognitively impaired persons. J Am Med Dir Assoc 2009;10:271e276. 63. Fox T, Jacobs M. The magic of exercise [Letter]. J Am Med Dir Assoc 2008;9:689. 64. Morley JE. The magic of exercise. J Am Med Dir Assoc 2008;9:375e377. 65. Rolland Y, Abellan van Kan G, Vellas B. Physical activity and Alzheimer’s disease: From prevention to therapeutic perspectives. J Am Med Dir Assoc 2008;9:390e405. 66. Singh NA, Quine S, Clemson LM, et al. Effects of high-intensity progressive resistance training and targeted multidisciplinary treatment of frailty on mortality and nursing home admissions after hip fracture: A randomized controlled trial. J Am Med Dir Assoc 2012;13:24e30. 67. Landi F, Liperoti R, Fusco D, et al. Sarcopenia and mortality among older nursing home residents. J Am Med Dir Assoc 2012;13:121e126. 68. Spruit MA, Polkey MI, Celli B, et al. Predicting outcomes from 6-minute walk distance in chronic obstructive pulmonary disease. J Am Med Dir Assoc 2012; 13:291e297. 69. Morley JE, Abbatecola AM, Argiles JM, et al, Society on Sarcopenia, Cachexia and Wasting Disorders Trialist Workshop. Sarcopenia with limited mobility: An international consensus. J Am Med Dir Assoc 2011;12:403e409. 70. Fielding RA, Vellas B, Evans WJ, et al. Sarcopenia: An undiagnosed condition in older adults. Current consensus definition: Prevalence, etiology, and consequences. International working group on sarcopenia. J Am Med Dir Assoc 2011;12:249e256. 71. Fox T, Sloves G. Fostering a culture of exercise in assisted living. J Am Med Dir Assoc 2010;11:605. 72. Morley JE. Sarcopenia in the elderly. Fam Pract 2012;29:i44ei48. 73. Van Kan GA, Cderbaum JM, Cesari M, et al. Sarcopenia: Biomarkers and imaging (International Conference on Sarcopenia Research). J Nutr Health Aging 2011;15:834e846. 74. Rolland Y, Czerwinski S, Abellan van Kan G, et al. Sarcopenia: Its assessment, etiology, pathogenesis, consequences and future perspectives. J Nutr Health Aging 2008;12:433e450. 75. Nyrop KA, Zimmerman S, Sloane PD, Bangdiwala S. Fall prevention and monitoring of assisted living patients: An exploratory study of physician perspectives. J Am Med Dir Assoc 2012;13:429e433. 76. Rapp K, Becker C, Cameron ID, et al. Epidemiology of falls in residential aged care: Analysis of more than 70,000 falls from residents of Bavarian nursing homes. J Am Med Dir Assoc 2012;13:187.e1e187.e6. 77. Choi M, Hector M. Effectiveness of intervention programs in preventing falls: A systematic review of recent 10 years and meta-analysis. J Am Med Dir Assoc 2012;13:188.e13e188.e21. 78. Morley JE. Osteoporosis and fragility fractures. J Am Med Dir Assoc 2011;12: 389e392. 79. Faes MC, Reelick MF, Melis RJ, et al. Multifactorial fall prevention for pairs of frail community-dwelling older fallers and their informal caregivers: A dead end for complex interventions in the frailest fallers. J Am Med Dir Assoc 2011; 12:451e458. 80. Adunsky A, Lerner-Geva L, Blumstein T, et al. Improved survival of hip fracture patients treated within a comprehensive geriatric hip fracture unit, compared with standard of care treatment. J Am Med Dir Assoc 2011;12:439e444. 81. Wagner LM, Dionne JC, Zive JR, Rochon PA. Fall risk care processes in nursing home facilities. J Am Med Dir Assoc 2011;12:426e430. 82. Neyens JC, van Haastregt JC, Dijcks BP, et al. Effectiveness and implementation aspects of interventions for preventing falls in elderly people in long-term care facilities: A systematic review of RCTs. J Am Med Dir Assoc 2011;12:410e425. 83. Morley JE. Hip fractures. J Am Med Dir Assoc 2010;11:81e83. 84. von Haehling S, Morley JE, Anker SD. An overview of sarcopenia: facts and numbers on prevalence and clinical impact. J Cachexia Sarcopenia Muscle 2010;1:129e133. 85. Landi F, Liperoti R, Fusco D, et al. Sarcopenia and mortality among older nursing home residents. J Am Med Dir Assoc 2012;13:121e126. 86. Morley JE. Paind“God’s megaphone”. J Am Med Dir Assoc 2012;13:316e318.
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87. Lapane KL, Quilliam BJ, Chow W, Kim M. The association between pain and measures of well-being among nursing home residents. J Am Med Dir Assoc 2011;13:344e349. 88. Onen SH, Onen F, Albrand G, et al. Pain tolerance and obstructive sleep apnea in the elderly. J Am Med Dir Assoc 2010;11:612e616. 89. Hanlon JT, Perera S, Sevick MA, et al. Pain and its treatment in older nursing home hospice/palliative care residents. J Am Med Dir Assoc 2010;11: 579e583. 90. Harris T, Carey IM, Shah SM, et al. Antidepressant prescribing in older primary care patients in community and care home settings in England and Wales. J Am Med Dir Assoc 2012;13:41e47. 91. Morley JE. Depression in nursing home residents. J Am Med Dir Assoc 2010; 11:301e303. 92. Rolland Y, Perrin A, Gardette V, Filhol N, Vellas B. Screening older people at risk of malnutrition or malnourished using the Simplified Nutritional Appetite Questionnaire (SNAQ): A comparison with the Mini-Nutritional Assessment (MNA) tool. J Am Med Dir Assoc 2012;13:31e34. 93. Engin S, Ozturk M, Engin N, Kulaksizoglu IB. Dark side of the town: Depressive symptoms in disadvantages senior citizens. J Nutr Health Aging 2010;14: 483e487. 94. Wilson MM, Thomas DR, Rubenstein LZ, et al. Appetite assessment: simple appetite questionnaire predicts weight loss in community-dwelling adults and nursing home residents. Am J Clin Nutr 2005;82:1074e1081. 95. Vellas B, Villars H, Abellan G, et al. Overview of the MNAdits history and challenges. J Nutr Health Aging 2006;10:456e463. 96. Thomas DR, Zdrowski CD, Wilson MM, et al. Malnutrition in subacute care. Am J Clin Nutr 2002;75:308e313. 97. Morley JE. Assessment of malnutrition in older persons: A focus on the Mini Nutritional Assessment. J Nutr Health Aging 2011;15:87e90. 98. Vikstedt T, Suominen MH, Joki A, et al. Nutritional status, energy, protein, and micronutrient intake of older service house residents. J Am Med Dir Assoc 2011;12:302e307. 99. Bronskill SE, Gill SS, Paterson JM, et al. Exploring variation in rates of polypharmacy across long term care homes. J Am Med Dir Assoc 2012;13:309. e15e309.e21. 100. Lattanzio F, Laino I, Pedone C, et al. Geriatric conditions and adverse drug reactions in elderly hospitalized patients. J Am Med Dir Assoc 2012;13: 96e99. 101. Lang PO, Vogt-Ferrier N, Hasso Y, et al. Interdisciplinary geriatric and psychiatric care reduces potentially inappropriate prescribing in the hospital: Interventional study in 150 acutely ill elderly patients with mental and somatic comorbid conditions. J Am Med Dir Assoc 2012;13:406. 102. Fitzgerald SP, Bean NG. An analysis of the interactions between individual comorbidities and their treatmentsdimplications for guidelines and polypharmacy. J Am Med Dir Assoc 2010;11:475e484. 103. Miles RW. A conversation: Polypharmacy in the nursing home. J Am Med Dir Assoc 2010;11:296e297. 104. Morley JE. Hypertension: Is it overtreated in the elderly? J Am Med Dir Assoc 2010;11:147e152. 105. Garcia-Gollarte F, Baleriola-Júlvez J, Ferero-López I, Cruz-Jentoft AJ. Inappropriate drug prescription at nursing home admission. J Am Med Dir Assoc 2012;13. 83.e9e15. 106. Bronskill SE, Gill SS, Paterson JM, et al. Exploring variation in rates of polypharmacy across long-term care homes. J Am Med Dir Assoc 2012;13:309. e15e309.e21. 107. Gokce Kutsal Y, Barak A, Atalay A, et al. Polypharmacy in the elderly: A multicenter study. J Am Med Dir Assoc 2009;10:486e490. 108. Morley JE. Undernutrition: A major problem in nursing homes. J Am Med Dir Assoc 2011;12:243e246. 109. Landi F, Russo A, Liperoti R, et al. Anorexia, physical function, and incident disability among the frail elderly population: Results from the ilSIRENTE study. J Am Med Dir Assoc 2010;11:268e274. 110. Argilés JM, Anker SD, Evans WJ, et al. Consensus on cachexia definitions. J Am Med Dir Assoc 2010;11:229e230. 111. Landi F, Laviano A, Cruz-Jentoft AJ. The anorexia of aging: Is it a geriatric syndrome? J Am Med Dir Assoc 2010;11:153e156. 112. Bourdel-Marchasson I. How to improve nutritional support in geriatric institutions. J Am Med Dir Assoc 2010;11:13e20. 113. Yang Y, Brown CJ, Burgio KL, et al. Undernutrition at baseline and health services utilization and mortality over a 1-year period in older adults receiving Medicare home health services. J Am Med Dir Assoc 2011;12:287e294. 114. van Wetering CR, Hoogendoorn M, Broekhuizen R, et al. Efficacy and costs of nutritional rehabilitation in muscle-wasted patients with chronic obstructive pulmonary disease in a community-based setting: A prespecified subgroup analysis of the INTERCOM trial. J Am Med Dir Assoc 2010;11:179e187. 115. Nanda A, Bourbonniere M, Wetle T, Teno J. Home care in the last year of life: Family member perceptions of unmet need associated with last place of care. J Am Med Dir Assoc 2010;11:21e25. 116. Dobbs D, Meng H, Hyer K, Volicer L. The influence of hospice use on nursing home and hospital use in assisted living among dual-eligible enrollees. J Am Med Dir Assoc 2012;13:189.e9e189.e13. 117. Hirschman KB, Abbott KM, Hanlon AL, et al. What factors are associated with having an advance directive among older adults who are new to long-term care services? J Am Med Dir Assoc 2012;13. 82.e7e11.
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118. Parker Oliver D, Kapp JM, Tatum P, Wallace A. Hospice medical directors: A survey of one state. J Am Med Dir Assoc 2012;13:35e40. 119. Wong RY. Improving end-of-life care for patients with noncancer illnesses: The time is now. J Am Med Dir Assoc 2011;12:86e87. 120. Morley JE. End-of-life care in the nursing home. J Am Med Dir Assoc 2011;12: 7e83. 121. Gheorghe C, Vazquez R, Casanegra AI, et al. Elders’ environs and their end-oflife preferences. J Am Med Dir Assoc 2011;12:22e28. 122. Famakinwa AB. End-of-life care in a PACE program: Respecting the patient’s wishes while supporting the caregiver. J Am Med Dir Assoc 2010;11:528e530.
123. Cruz-Oliver DM, Sanford AM, Paniagua MA. End-of-life care in the nursing home. J Am Med Dir Assoc 2010;11:462e464. 124. Biola H, Sloane PD, Williams CS, et al. Preferences versus practice: Lifesustaining treatments in last months of life in long-term care. J Am Med Dir Assoc 2010;11:42e51. 125. Dominguez LJ, Barbagallo M, Morley JE. The paradigm of life extension. J Am Med Dir Assoc 2010;11:457e458. 126. Caplan GA. Rehabilitation. J Am Med Dir Assoc 2011;12:8. 127. Morley JE. Successful aging or aging successfully. J Am Med Dir Assoc 2009; 10:85e86.