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Biomedical subjects

W A Ray

Publications and source records attributed to W A Ray.

At least 55 records · Page 3Linked to original sources
PubMed1994

Risk factors for hip fractures occurring in the hospital.

Risk factors for in-hospital hip fractures among patients aged > or = 65 years were evaluated in a population-based case-control study conducted in the Canadian province of Saskatchewan from 1983 through 1985. There were 129 cases with confirmed in-hospital hip fractures and 234 controls, who were those controls from a previous study in this setting hospitalized on their assigned index date. Study variables were abstracted from the hospital chart. Six factors were independently associated with a significantly increased risk of in-hospital hip fracture: impaired vision (odds ratio = 1.97, 95% confidence interval (CI) 1.18-3.30), assisted ambulation (odds ratio = 2.12, 95% CI 1.25-3.59), confusion (odds ratio = 2.48, 95% CI 1.37-4.48), psychotropic drug use (odds ratio = 2.02, 95% CI 1.22-3.33), lowest weight tertile (odds ratio = 2.86, 95% CI 1.38-5.92), and prior in-hospital fall (odds ratio = 2.71, 95% CI 1.52-4.82). The risk increased substantially with the number of factors present, from an odds ratio of 4.08 (95% CI 1.56-10.67) for one factor (reference group, no factors) to 82.84 (95% CI 18.6-368.7) for four or more factors (p < 0.001, test for trend). These data underscore the multifactorial etiology of in-hospital hip fracture and suggest that prevention programs need to target multiple risk factors.

Aged↗
PubMed1994

Changes in antipsychotic drug use in nursing homes during implementation of the OBRA-87 regulations.

OBJECTIVES: To describe the changes in antipsychotic drug use in nursing homes during the period surrounding the implementation of federal legislation designed to reduce unnecessary use (the Omnibus Budget Reconciliation Act of 1987 [OBRA-87]) and to identify nursing home characteristics associated with such changes. DESIGN: Longitudinal study of 9432 Tennessee Medicaid enrollees 65 years of age or older who continuously resided in Tennessee from April 1, 1989, to September 30, 1991, a 30-month period surrounding implementation of OBRA-87. MAIN OUTCOME MEASURES: Changes in the use of antipsychotic and other psychotropic drugs. RESULTS: During the 30-month period, antipsychotic drug use decreased from 23.9 to 17.5 days per 100 days of residence, a 26.7% decline (P < .001), which resulted from both a decrease in new users (P < .001) and a reduction in long-term use of antipsychotic drugs (P < .001). There was no concomitant increase in other psychotropic drug use. A multivariate analysis revealed that changes in antipsychotic use were strongly associated with baseline antipsychotic use (P = .001) and third-shift staffing levels (P = .003). Nursing homes with baseline antipsychotic drug use and third-shift staffing above the median reduced antipsychotic drug use by 41%, compared with a 2% increase in nursing homes where both of these factors were below the median (P < .0001). CONCLUSIONS: A substantial decrease in antipsychotic drug use coincided with the implementation of OBRA-87. Although this decrease is consistent with an improvement in quality of nursing home care, further research is needed to determine the effects of this legislation on resident outcomes.

Aged↗
PubMed1994

Effects of antipsychotic withdrawal in elderly nursing home residents.

OBJECTIVE: To study the effects of antipsychotic withdrawal in elderly nursing home residents. DESIGN: Longitudinal prospective study. SETTING: 12 community nursing homes that participated in a randomized controlled trial of an educational program designed to reduce antipsychotic use. SUBJECTS: 271 residents receiving antipsychotics at baseline and remaining in the home for approximately 6 months thereafter. These were placed into two groups: those with continued use of antipsychotics at follow-up (n = 207) and those with drug discontinued (n = 64). MEASUREMENTS: Change between baseline and follow-up for several standard measurements. These included behavior problems, as reported by both regular care providers (Nursing Home Behavior Problem Scale) or a blinded study rater (items from the Brief Psychiatric Rating Scale), observer-rated psychiatric symptoms (subset of the Brief Psychiatric Rating Scale), and other standard tests of function (Activities of Daily Living, Mini-Mental State Examination, Geriatric Depression Scale, and Abnormal Involuntary Movements Scale). RESULTS: The frequency of behavior problems did not increase in residents with antipsychotics discontinued. For these residents, observer-rated psychiatric symptoms decreased by 21% (P = 0.003), which resulted from a 27% decrease in adverse affective symptoms (P = 0.0002). Residents with drug discontinued had no deterioration in any of the measures of function. CONCLUSION: In this sample, nursing home residents whose antipsychotics were discontinued had significantly improved affect and no discernable adverse effects.

Activities of Daily Living↗
PubMed1994

Comparison of clinical and biomechanical measures of balance and mobility in elderly nursing home residents.

OBJECTIVE: To compare biomechanics force platform measurements of postural sway with clinical measures of balance and mobility, in frail elderly residents of community nursing homes, in terms of feasibility, correlation with other known risk factors for falls, and intercorrelation with each other. DESIGN: Cross-sectional study. SETTING: Twelve Tennessee community nursing homes. SUBJECTS: Of 1315 residents 360 (> or = 65) could stand independently (> or = 10 seconds). Of these eligible subjects, 303 (84%) provided informed consent and were assessed. MEASUREMENTS: The biomechanics force platform measurements were postural sway during quiet standing characterized as elliptical area and mean velocity. The clinical measures were functional reach, mobility maneuvers (adapted from Tinetti's Mobility Index), timed chair stands, and 10-foot walk. Resident characteristics and function were also obtained. RESULTS: Balance measurements were obtained on most (100% for postural sway to 67% for chair stand) consenting residents and were reliable on test-retest (intraclass correlation from .56 to .98). Performance in both groups of balance measures deteriorated with increasing musculoskeletal disability. Functional reach and mobility maneuvers correlated with height, and mobility maneuvers with depressive symptoms. Elliptical area correlated with mean velocity of postural sway (Pearson's r = 0.72; P < 0.001), and the clinical measures of balance (functional reach, mobility maneuvers, timed chair stands and walk) were modestly intercorrelated (r from 0.35 to 0.65; all P values < or = 0.05). However, the biomechanical measures were not correlated with the clinical measures. CONCLUSIONS: Standard measures of balance were obtained reliably from nursing home residents who could stand independently for > or = 10 seconds. However, in this group, further research is needed to determine which measures best predict falls. Further research is also needed to identify predictors of falls in the majority of residents who were too frail to undergo these standard assessments.

Activities of Daily Living↗
PubMed1994

Presumptive eligibility for pregnant Medicaid enrollees: its effects on prenatal care and perinatal outcome.

OBJECTIVES: "Presumptive eligibility" permits pregnant prospective Medicaid enrollees to obtain services during the application period. The purpose of this study was to assess the effects of presumptive eligibility on the receipt of prenatal care and the occurrence of low-birthweight births and neonatal, perinatal, and infant mortality. METHODS: Outcome rates for pregnant women who enrolled in Tennessee Medicaid in the 6-month period before presumptive eligibility was enacted were compared with those obtained for pregnant women who enrolled in the 6-month period after presumptive eligibility had been in effect for 5 months. RESULTS: Women in the "after" group were 40% more likely to enroll and 30% more likely to obtain prenatal care in the first trimester. They were 300% more likely to fill a prescription for prenatal vitamins in the first trimester and 16% more likely to have begun prenatal care before the third trimester. However, they were similar to those enrolling in the "before" time period in terms of the occurrence of adverse perinatal outcomes. CONCLUSIONS: When barriers to prenatal care, including bureaucratic ones, are removed, low-income women will seek care earlier and more frequently.

Adolescent↗
PubMed1993

Concurrent use of nonsteroidal anti-inflammatory drugs and oral anticoagulants places elderly persons at high risk for hemorrhagic peptic ulcer disease.

BACKGROUND: Although joint use of nonsteroidal anti-inflammatory drugs (NSAIDs) and oral anticoagulants may increase the risk of gastrointestinal tract hemorrhage in elderly persons, no epidemiologic studies have been performed to quantify this risk. METHODS: We performed a retrospective cohort study of Tennessee Medicaid enrollees aged 65 years or older from 1984 through 1986. A total of 103,954 individuals contributed 209,066 person-years of follow-up, including 2203 person-years of current oral anticoagulant use, to the study. RESULTS: Of the cohort members, 1371 had confirmed hospitalizations for peptic ulcer disease. Of these, 661 (48%) presented with frank hematemesis or melena and thus met the definition for hemorrhagic peptic ulcer disease. Among current users of oral anticoagulants, the adjusted incidence of hospitalization for peptic ulcer disease was 14.3 per 1000 person-years, and the adjusted incidence of hospitalization for hemorrhagic peptic ulcer disease was 10.2 per 1000 person-years. Compared with nonusers, current anticoagulant users were at increased risk for hospitalization for ulcer disease (relative risk, 2.2; 95% confidence interval, 1.6 to 3.1), primarily due to the increased risk of hospitalization for hemorrhagic ulcers (relative risk, 3.3; 95% confidence interval, 2.3 to 4.9). Compared with nonusers of either drug, the relative risk of hemorrhagic peptic ulcer disease among current users of both anticoagulants and NSAIDs was 12.7 (95% confidence interval, 6.3 to 25.7). However, the prevalence of NSAID use among anticoagulant users was 13.5%, the same as in those who were not using anticoagulants. CONCLUSIONS: The nearly 13-fold increase in the risk of developing hemorrhagic peptic ulcer disease in concurrent users of oral anticoagulants and NSAIDs suggests that NSAIDs should be prescribed with extreme caution in patients undergoing anticoagulation therapy.

Administration, Oral↗
PubMed1993

Reducing antipsychotic drug use in nursing homes. A controlled trial of provider education.

OBJECTIVE: In the United States, 20% or more of nursing home residents receive antipsychotic drugs, primarily for the behavioral manifestations of dementia. This high level of use of drugs with substantial toxicity has engendered a strong and persistent controversy and recently has led to explicit regulatory measures to curtail use (Omnibus Budget Reconciliation Act of 1987). We developed and tested a comprehensive program to reduce antipsychotic use through education of physicians, nurses, and other nursing home staff. The primary elements of the program were instruction in use of behavioral techniques to manage behavior problems and encouragement of a trial of gradual antipsychotic withdrawal. DESIGN: In a nonrandomized controlled trial, the program was implemented (beginning in August 1990) in two rural Tennessee community nursing homes with elevated antipsychotic use; two other comparable homes were selected as concurrent controls. PATIENTS: Throughout the study 194 residents were in the education homes and 184 were in the control homes. Residents in both groups of homes had comparable demographic characteristics and functional status, and each group had a baseline rate of 29 days of antipsychotic use per 100 days of nursing home residence. MAIN OUTCOME MEASURES: The primary end points were postintervention changes in administration of antipsychotics and other psychotropic drugs, use of physical restraints, and frequency of behavior problems. RESULTS: Days of antipsychotic use decreased by 72% in the education homes vs 13% in the control homes (P < .001). No significant changes were noted in the use of other psychotropic drugs in either group. Days of physical restraint use decreased 36% in the education homes vs 5% in the control homes (P < .001). Behavior problem frequency did not increase in either group, even among the 48% of baseline antipsychotic users in the education homes who had antipsychotic drug regimens discontinued for 3 or more months. CONCLUSIONS: The educational program led to a substantial reduction in antipsychotic use with no increase in the frequency of behavior problems. This suggests that for many antipsychotic drug users benefits may be marginal and that programs to reduce such drug use among the 250,000 US nursing home residents receiving these drugs should have high priority.

Aged↗
PubMed1993

Reserpine reconsidered: no association with serious peptic ulcer disease.

A history of peptic ulcer disease is frequently cited as a contraindication to the use of reserpine. However, the risk of ulcer disease associated with the use of reserpine at current therapeutic doses is unknown. To address this question, the authors conducted a nested case-control study of the association between reserpine use and hospitalizations for peptic ulcer disease in elderly Tennessee Medicaid enrollees. When compared with that of nonusers of reserpine, the relative risk of hospitalization for peptic ulcer disease was 0.8 (95% CI, 0.6-1.0) among current users and 0.8 (95% CI, 0.5-1.3) among former users. The authors' data provide evidence that reserpine is not associated with ulcer disease in elderly persons and suggest that a history of ulcer disease need not be a contraindication to the use of this drug.

Aged↗
PubMed1993

Prenatal use of metronidazole and birth defects: no association.

OBJECTIVE: To determine whether the use of metronidazole by pregnant women increases the risk of birth defects in the offspring. METHODS: Two cohorts of pregnant women who delivered live-born or stillborn infants between January 1, 1983 and December 31, 1988 were identified from the Tennessee Medicaid enrollment files. The exposed cohort consisted of 1387 women who filled a prescription for metronidazole between 30 days before and 120 days after the onset of their last normal menstrual period. The unexposed cohort consisted of 1387 comparable women who did not fill a prescription for metronidazole during the same time. Medical records for 94% of the offspring of both study cohorts were then reviewed to ascertain the occurrence of birth defects. RESULTS: Pregnancy outcomes were similar for the exposed and unexposed cohort members. There was no excess of overall birth defect occurrence in the offspring of exposed women (risk ratio 1.2, 95% confidence interval 0.9-1.6), nor could an excess risk be detected for any category of birth defects. CONCLUSION: This study provides no evidence that prenatal use of metronidazole increases the risk of overall birth defect occurrence.

Abnormalities, Drug-Induced↗
PubMed1993

Medications and the older driver.

Table 4 provides a summary of the evidence that specific medications adversely affect the safety of the older driver. The preponderance of evidence suggests that benzodiazepines adversely affect the safety of the older driver, particularly for high doses and long half-life compounds. This conclusion is based upon the very consistent psychomotor function data showing pronounced dose-related impairment, the more limited epidemiologic data on crash involvement, epidemiologic data associating benzodiazepines with other types of injuries, and the fact that the reasons for most benzodiazepine use are not plausible confounders. This conclusion thus reinforces the need to prescribe benzodiazepines cautiously, including assessment of nonpharmacologic alternatives, use of the lowest possible dose for the shortest possible time, and avoidance of the very long half-life compounds. As more new nonbenzodiazepine anxiolytics and hypnotics become available, their effects on the safety of the elderly driver need to be determined. There is some evidence that cyclic antidepressants, currently the mainstay for treatment of depression in the elderly population, adversely affect driving safety; however, because of the paucity of experimental and epidemiologic data concerning the effects of depression per se on driving, further research is needed. Nevertheless, the existing data reinforce the need for careful prescribing of antidepressants, particularly avoidance of agents with high side-effect profiles (such as amitriptyline and imipramine) in the older driver. For hypoglycemics, although there is sufficient evidence of driving impairment to create a basis for concern, there are many unresolved questions. Currently, diabetic patients should be advised concerning the risk and management of hypoglycemia. For other sedating drugs, it always is prudent to advise patients concerning potential effects on driving. Unlike younger drivers, the typical older driver is a medication-taker. There now is a substantial body of evidence that commonly used medications can interfere with driving safety. Because many questions remain unanswered, there is a pressing need for further research that more fully elucidates how patient characteristics, disease, and drugs interact to affect driving safety; however, sufficient data are available to reinforce an underlying theme in geriatric medicine that is not yet fully implemented in practice: the need for caution in pharmacotherapy, with selection of a drug, dose, and regimen suitable for the unique characteristics of this population.

Aged↗
PubMed1992

Black-white differences in fracture rates.

To compare the incidence of all nonvertebral fractures between elderly blacks and whites, the authors conducted a retrospective cohort study among Tennessee Medicaid enrollees aged 65 years or more from 1987 through 1989. A previously validated computer algorithm identified 6,802 persons of black or white race with 7,645 new nonvertebral fractures. The incidence of all nonvertebral fractures in blacks was only half of that in whites. This finding persisted after the authors controlled for sex, age, and nursing home residence (relative risk = 0.4, 95% confidence interval 0.4-0.5). Rates were consistently lower among blacks within subgroups defined by these factors and for each of the 13 different fracture sites examined. The magnitude of the difference between blacks and whites in rates of all fractures combined and most site-specific fractures is similar to that previously reported for hip fractures. These consistent racial differences suggest a common underlying factor(s).

Age Factors↗
PubMed1992

Psychoactive drugs and the risk of injurious motor vehicle crashes in elderly drivers.

To determine whether commonly used psychoactive drugs increase the risk of involvement in motor vehicle crashes for drivers > or = 65 years of age, the authors conducted a retrospective cohort study. Data were obtained from computerized files from the Tennessee Medicaid program, driver's license files, and police reports of injurious crashes. Cohort members were Medicaid enrollees 65-84 years of age who had a valid driver's license during the study period 1984-1988 and who met other criteria designed to exclude persons unlikely to be drivers and to ensure availability of necessary study data. There were 16,262 persons in the study cohort with 38,701 person-years of follow-up and involvement in 495 injurious crashes. For four groups of psychoactive drugs (benzodiazepines, cyclic antidepressants, oral opioid analgesics, and antihistamines), the risk of crash involvement was calculated with Poisson regression models that controlled for demographic characteristics and use of medical care as an indicator of health status. The relative risk of injurious crash involvement for current users of any psychoactive drug was 1.5 (95% confidence interval (CI) 1.2-1.9). This increased risk was confined to benzodiazepines (relative risk = 1.5; 95% CI 1.2-1.9) and cyclic antidepressants (relative risk = 2.2; 95% CI 1.3-3.5). For these drugs, the relative risk increased with dose and was substantial for high doses: 2.4 (95% CI 1.3-4.4) for > or = 20 mg of diazepam and 5.5 (95% CI 2.6-11.6) for > or = 125 mg of amitriptyline. Analysis of data for the crash-involved drivers suggested that these findings were not due to confounding by alcohol use or driving frequency.

Accidents, Traffic↗
PubMed1992

Identification of fractures from computerized Medicare files.

Study of non-hip fractures, which are a serious public health problem for persons greater than or equal to 65 years of age, has been hindered by the absence of an economical method for case identification. We assessed the utility of computerized Medicare inpatient, emergency room, hospital outpatient department and physician claims for identifying fractures in an elderly Tennessee Medicaid population. We used these files for 1987 to identify 3086 possible fractures and reviewed medical records for a sample of 1440. Using this sample, we developed a definition of probable fractures that excluded claims unlikely to represent newly diagnosed fractures. For all fractures, this definition had a positive predictive value of 94%, which for individual fracture sites, ranged from 79% (tibia/fibula) to 98% (hip). Of fractures in the reviewed sample, 91% were identified as probable fractures; this upper bound for sensitivity varied between 75% (femoral shaft) and 100% (patella). These data suggest that computerized Medicare files can be used for rapid and economical fracture ascertainment among persons greater than or equal to 65 years of age. However, further work is needed to obtain better estimates of sensitivity.

Aged↗
PubMed1992

The Nursing Home Behavior Problem Scale.

Nursing home patients frequently have serious disturbances of behavior that can lead to use of chemical or physical restraints. To support research into better management of these problems, we developed the Nursing Home Behavior Problem Scale (NHBPS), a 29-item inventory of serious behavior problems designed to be completed by nurses and nursing assistants. NHBPS scores were obtained for two samples of nursing home residents: 431 in Tennessee and 122 in Texas. The interrater correlation was .754 in the Tennessee sample and .827 in the Texas sample. The NHBPS had a correlation of -.747 with the NOSIE scale and .911 with the CMAI. There was a pronounced association of increased NHBPS scores with mental impairment and use of sedative drugs or restraints. These data suggest the NHBPS is a useful research instrument for measuring serious behavior problems in nursing home residents.

Behavior↗
PubMed1992

Opioid analgesics and the risk of hip fracture in the elderly: codeine and propoxyphene.

We studied the risk of hip fracture in elderly persons receiving prescriptions for two commonly prescribed opioid analgesics--codeine and propoxyphene. Using automated prescription and hospitalization data, we identified 4,500 residents of Saskatchewan, Canada, aged 65 or older, who sustained a hip fracture between 1977 and 1985, and 24,041 age- and sex-matched controls. Compared to nonusers, the relative risk (95% CI) of hip fracture in current users of codeine or propoxyphene was 1.6 (1.4-1.9). There was no difference between relative risks of fracture among current users of codeine [1.6 (1.3-1.9)] and propoxyphene [1.6 (1.2-2.2)]. In new users of these opioids, the relative risk of fracture was 2.2 (1.7-2.8), compared to 1.3 (1.0-1.6) in users who received at least one additional prescription for codeine or propoxyphene in the 90-day period prior to the index date. Concurrent users of these opioids and psychotropic drugs (sedatives, antidepressants, or antipsychotics) had a risk of fracture 2.6 (2.0-3.4) times that of nonusers of either drug class. Review of a sample of medical records for 701 cases suggested this finding was not due to confounding by body mass, ambulatory status, functional status, or dementia. Given the essential role of opioids in the management of pain in geriatric practice, further study is needed to determine the psychomotor effects of opioid analgesics in older adults.

Age Factors↗
PubMed1992

Medications and the safety of the older driver: is there a basis for concern?

Medications with central nervous system (CNS) effects, including benzodiazepines, cyclic antidepressants, antihistamines, narcotic analgesics, and hypoglycemics, have been thought to have the potential to impair driving. These drugs impair performance in younger drivers and some have been linked to an increased risk of motor vehicle crashes. Even though persons 65 years of age and older frequently take these drugs and are more susceptible to CNS effects, no direct data exist regarding whether or not medications adversely affect driving safety in this population. Thus there is an urgent need for further research in this area.

Accidents, Traffic↗