Untreated Residents Research Articles

Government Spending and Voting Behavior

abstract: Does government spending on public goods affect the vote choice of citizens? On one hand, prior research has characterized voters as fiscal conservatives who may turn toward conservative parties when government spending goes up. On the other hand, increased spending may signal that the economy is doing well, which makes progressive parties a more viable option. To adjudicate between both hypotheses, this article draws on a natural experiment, which created exogenous variation in government spending. A discontinuity in the 2011 German census meant that some municipalities saw an unforeseen increase in budgets. Using a regression discontinuity design, the authors show that the increase in budgets and subsequent spending on public goods benefited left-leaning parties but had no detectable effect on incumbent support. To parse out the causal channel, the authors rely on panel evidence and demonstrate that treated residents viewed their economic situation more favorably than did untreated residents, which led the former to espouse progressive parties.

Clinical outcomes of monoclonal antibody therapy during a COVID-19 outbreak in a skilled nursing facility-Arizona, 2021.

BackgroundAdult residents of skilled nursing facilities (SNF) have experienced high morbidity and mortality from SARS‐CoV‐2 infection and are at increased risk for severe COVID‐19 disease. Use of monoclonal antibody (mAb) treatment improves clinical outcomes among high‐risk outpatients with mild‐to‐moderate COVID‐19, but information on mAb effectiveness in SNF residents with COVID‐19 is limited. We assessed outcomes in SNF residents with mild‐to‐moderate COVID‐19 associated with an outbreak in Arizona during January–February 2021 that did and did not receive a mAb.MethodsMedical records were reviewed to describe the effect of bamlanivimab therapy on COVID‐19 mortality. Secondary outcomes included referral to an acute care setting and escalation of medical therapies at the SNF (e.g., new oxygen requirements). Residents treated with bamlanivimab were compared to residents who were eligible for treatment under the FDA's Emergency Use Authorization (EUA) but were not treated. Multivariable logistic regression was used to determine association between outcomes and treatment status.ResultsSeventy‐five residents identified with COVID‐19 during this outbreak met eligibility for mAb treatment, of whom 56 received bamlanivimab. Treated and untreated groups were similar in age and comorbidities associated with increased risk of severe COVID‐19 disease. Treatment with bamlanivimab was associated with reduced 21‐day mortality (adjusted OR = 0.06; 95% CI: 0.01, 0.39) and lower odds of initiating oxygen therapy (adjusted OR = 0.07; 95% CI: 0.02, 0.34). Referrals to acute care were not significantly different between treated and untreated residents.ConclusionsmAb therapy was successfully administered to SNF residents with COVID‐19 in a large outbreak setting. Treatment with bamlanivimab reduced 21‐day mortality and reduced initiation of oxygen therapy. As the COVID‐19 pandemic evolves and newer immunotherapies gain FDA authorization, more studies of the effectiveness of mAb therapies for treating emerging SARS‐CoV‐2 variants of concern in high‐risk congregate settings are needed.

Recent status of self-measured home blood pressure in the Japanese general population: a modern database on self-measured home blood pressure (MDAS).

Despite the clinical usefulness of self-measured home blood pressure (BP), reports on the characteristics of home BP have not been sufficient and have varied due to the measurement conditions in each study. We constructed a database on self-measured home BP, which included five Japanese general populations as subdivided aggregate data that were clustered and meta-analyzed according to sex, age category, and antihypertensive drug treatment at baseline (treated and untreated). The self-measured home BPs were collected after a few minutes of rest in a sitting position: (1) the morning home BP was measured within 1 h of waking, after urination, before breakfast, and before taking antihypertensive medication (if any); and (2) the evening home BP was measured just before going to bed. The pulse rate was simultaneously measured. Eligible data from 2000 onward were obtained. The morning BP was significantly higher in treated participants than in untreated people of the same age category, and the BP difference was more marked in women. Among untreated residents, home systolic/diastolic BPs measured in the morning were higher than those measured in the evening; the differences were 5.7/5.0 mmHg in women (ranges across the cohorts, 5.3-6.8/4.7-5.4 mmHg) and 7.3/7.7 mmHg in men (ranges, 6.4-8.5/7.0-8.7 mmHg). In contrast, the home pulse rate in women and men was 2.4 (range, 1.5-3.7) and 5.6 (range, 4.6-6.6) beats per minute, respectively, higher in the evening than in the morning. We demonstrated the current status of home BP and home pulse rate in relation to sex, age, and antihypertensive treatment status in the Japanese general population. The approach by which fine-clustered aggregate statistics were collected and integrated could address practical issues raised in epidemiological research settings.

Cardiovascular Risk Associated With White-Coat Hypertension: Con Side of the Argument.

Cardiovascular Risk Associated With White-Coat Hypertension: Con Side of the Argument.

Antimuscarinic use among individuals with urinary incontinence who reside in long-term care facilities

To assess appropriateness of antimuscarinic use in long-term care facilities (LTCFs) among treated and untreated urinary incontinence (UI) residents from 2007 to 2009. We conducted a retrospective analysis using the AnalytiCare(SM) database consisting of minimum data sets (MDS) assessments and prescription records of 90,660 residents from 2007 to 2009. UI (MDS H1b ≥ 1) residents with ≥ 14-day LTCF stay were identified and categorized as treated if they had ≥ 1 antimuscarinic prescription and untreated if they had no antimuscarinics. A random sample of untreated residents was matched based on treated residents' type of MDS assessment. We defined appropriate antimuscarinic use if residents had adequate cognitive function [≤ 4 on the cognitive performance scale (0 = intact to 6 = very severe impairment)] and mobility [scoring <4 on mobility for toileting scale (MDS item G1iA 0 = independent to 4 = total dependent)]. Chi-square tests were used to detect statistical difference between cohorts. A total of 5,327 residents (2,840 treated; 2,487 untreated) were selected [mean age (standard deviation) 80 (8), 81 (8) years; female (76, 65 %), respectively]. On study-defined MDS assessment, 63 % of treated and 69 % of untreated residents had UI (P < 0.01). Approximately 84 % of treated and 74 % of untreated residents may have had cognitive function and mobility sufficient for appropriate antimuscarinic use (P < 0.01). Our study identified a high percentage of LTCF residents with UI who may have been candidates for antimuscarinics. However, due to the MDS limitation, we were unable to identify overactive bladder patients among these untreated residents with UI. It is possible that untreated control residents had UI due to other factors not amenable to treatment with antimuscarinic agents. Therefore, choice of treatment for each resident needs to be individualized and carefully monitored for efficacy and adverse effects. This retrospective analysis requires prospective confirmation. Proper patient selection for antimuscarinic treatment requires careful assessment of underlying physical status including cognitive function, mobility, and comorbidities.

Dementia Interventions Allow Aging in Place

Pamela Kumar is a freelance writer in Ellicott City, Md. More than a million elderly Americans live in assisted living facilities. These facilities differ in the services and criteria they require of residents. They also differ in size and in resident-to-staff ratios. But they share the goals of providing assistance with activities of daily living and of maximizing the quality of life for those who are able to “age in place.” The importance of such interventions was quantified in the first phase of the ongoing Maryland Assisted Living Study (MD-AL), funded by the National Institute of Mental Health and the National Institute on Aging. The initial results found unexpectedly high rates of undiagnosed and untreated dementia and psychiatric disorders in 198 residents at 22 assisted living facilities in central Maryland. Unless these disorders are addressed, assisted living residents may experience early discharges to nursing homes, according to Dr. Hochang B. Lee of Johns Hopkins Bayview Medical Center, Baltimore. A common misperception is that assisted living residents are elderly people with normal cognition and only minor functional limitations. Before the MD-AL study, there had been no direct examination of the prevalence of dementia in random sample of assisted living residents. Phase I of the study (2001–2003) assessed the prevalence, detection, and treatment of dementia in AL facilities, finding that more than two-thirds (68%) of the residents had dementia. Caregivers did not recognize or diagnose dementia in about one-fifth (22%) of the residents with dementia, although they had a mean Mini-Mental State Exam score of 18.6, suggesting that the facilities may have failed to screen for cognitive impairment or to communicate the results of the screening to the caregivers (J. Am. Geriatr. Soc. 2004;52:1618–25). About 52% of residents with dementia received complete treatment and 33% receiving partial treatment. For this study, treatment did not have to include medical/pharmacologic treatment but did include recognition of dementia, combined with a plan of care such as behavioral interventions. In the study, 30% of residents with dementia were taking an acetylcholinesterase inhibitor, said Dr. Lee. In the MD-AL study, dementia was a major predictor of time to discharge from assisted living to a nursing home. During a 3-year follow-up, the median time to discharge for residents with dementia was 521 days, compared with 707 days for those without dementia. Residents who received partial or full treatment for dementia stayed 30% longer in assisted living as did untreated residents. Screening and treating dementia may improve quality of life and may increase the likelihood of residents aging in place rather than being discharged to nursing homes, according to Dr. Lee. Dr. Peter Reed, senior director of programs with the Alzheimer's Association, Chicago, said that the sheer prevalence of dementia in assisted living as found in the study is striking and consistent with the Alzheimer's Disease Facts and Figures 2007, which indicate that more than 50% of assisted living residents have dementia. The prevalence is so high, these facilities need to offer effective assessment of physical, cognitive, and social needs of residents and provide “person-centered care,” he said. Many assisted living facilities have specialized units to help residents with dementia to age in place, but not all facilities have the resources to provide the needed care. Phase II of the MD-AL study began in July 2003 and continues through June 2008. The study continues to follow the original cohort of 198 residents as well as a 200-member cohort and is assessing the course, detection, treatment, and associated morbidity of dementia and other psychiatric disorders over time. Dr. Lee predicted the findings will reflect the importance of recognition and treatment of dementia in producing beneficial outcomes, including the ability to age in place.

A retrospective study of the association between megestrol acetate administration and mortality among nursing home residents with clinically significant weight loss

Megestrol acetate (MA) is a progestin widely used to treat weight loss and cachexia in patients suffering from AIDS or cancer. Although MA is also frequently prescribed for similarly malnourished elderly individuals, the efficacy and morbidity of MA treatment in this patient population remain unclear. The goal of this study was to examine the effects of MA therapy on weight and overall mortality in elderly nursing home residents. This was a case-control cohort study of 17,328 nursing home residents admitted to Beverly Healthcare nursing home between January 1, 2000, and December 31, 2003, who had lost either 5% of total body weight within 3 months or 10% of total body weight within 6 months. Residents within this weight loss group who received MA therapy--within 30 days of their weight loss documentation--were matched (1:2) with non-MA-treated residents with respect to age, sex, race, weight, and first notation of weight loss. Residents were further matched by propensity score for activities of daily living, cognitive functioning, number of medications taken during the 7 days before data entry, clinical condition (unstable, acute episode of a recurrent problem, end-stage disease), cancer diagnosis, and human immunodeficiency virus diagnosis. A total of 709 patients (mean [SD]age, 84.1 [9.7]years; 70.9% female) who received MA therapy were matched with 1418 non-MA-treated patients (mean [SD] age, 84.2 [9.0] years; 70.9% female). Of the 709 MA patients, 281 (39.6%) were alive and in the nursing home at last follow-up, 149 (21.0%) were alive and discharged to another facility or to home, and 279 (39.4%) died in the nursing home. For the controls, 651 (45.9%) were alive and in the nursing home, 308 (21.7%) were discharged to another facility or to home, and 459 (32.4%) died in the nursing home. The median survival of MA-treated residents (23.9 months; 95% CI, 20.2-27.5) was significantly less than untreated residents (31.2 months; 95% CI, 27.8-35.9) (P < 0.001). Median weight and median of weight differences were unchanged after 6 months of treatment with MA compared with matched controls. MA treatment of elderly nursing home residents with significant weight loss was associated with a significant increase in all-cause mortality without a significant increase in weight. Randomized, prospective studies of the use of MA in elderly nursing home residents are necessary to more fully evaluate morbidity and mortality associated with this therapy.

Does Asymptomatic Bacteriuria Predict Mortality and Does Antimicrobial Treatment Reduce Mortality in Elderly Ambulatory Women?

To determine whether asymptomatic bacteriuria in elderly ambulatory women is a marker of increased mortality and, if so, whether it is because of an association with other determinants of mortality or because asymptomatic bacteriuria is itself an independent cause, the removal of which might improve longevity. A cohort study and a controlled clinical trial of the effect of antimicrobial treatment. A geriatric center and 21 continuing care retirement communities. Women without urinary tract catheters. Urine cultures every 6 months (the same organism at 10(5) colony-forming units or more per mL on two midstream urine specimens defined asymptomatic bacteriuria), comorbidity, and mortality. In the observational study, infected residents (n = 318) were older, and sicker, and had higher mortality (18.7 per 100,000 resident-days) than uninfected residents (n = 1173; 10.1 per 100,000 resident-days). However, in a multivariate Cox analysis, infection was not related to mortality (relative risk, 1.1; P > 0.2), whereas age at entry and self-rated health (score 1 [excellent] to 4 [bad or poor]) were strong predictors. In the clinical trial, mortality in 166 treated residents (13.8 per 100,000 resident-days) was comparable to that of 192 untreated residents (15.1 per 100,000 resident-days); the relative rate was 0.92 (95% CI, 0.57 to 1.47). The cure rates among treated and untreated residents were 82.9% and 15.6%, respectively. Urinary tract infection was not an independent risk factor for mortality, and its treatment did not lower the mortality rate. Screening and treatment of asymptomatic bacteriuria in ambulatory elderly women to decrease mortality do not appear warranted.

Behavioural effects in gerbils of the 5-HT3 receptor antagonists, BRL 43694 and ICS 205-930, under circumstances of high and low light intensity

The 5-HT3 receptor antagonists, BRL 43694 and ICS 205-930, were each given for 21 days in the drinking fluid at 1.3 mg/l (120 micrograms/kg daily), to Mongolian gerbils, while the controls received tap water to drink. Effects of the treatments in reducing aversion to a brightly lit environment were assessed on behaviour during social encounters with an unfamiliar untreated resident, under bright white light and in a two-compartment black and white test box, after 12-16 days of treatment. Effects on behaviour under dim red illumination, when encountering unfamiliar untreated residents, were examined after 17-19 days. Behaviour during social encounters was recorded by ethological procedures. During encounters under bright white light, the frequency and duration of the social element "attend" were increased by BRL 43694 and ICS 205-930 and the frequency of "nose" was increased by BRL 43694. In the light-dark box, BRL 43694, though not ICS 205-930, reduced the time spent in the dark compartment. Under dim red light, BRL 43694 and ICS 205-930 increased the occurrence of the social elements, "sniff", "follow" and "sniff chin", suggesting increased sensitivity to olfactory stimuli. Increases of social investigation were associated with compensatory changes to non-social behaviour. It is suggested that 5-HT3 receptor antagonists may, on the one hand, increase sensitivity to social stimuli under dim red illumination and, on the other hand, show an apparent anxiolytic potential, associated with increase of other elements of social investigation under the more aversive test conditions of bright white light.

Salmonella Outbreak in a Nursing Home

We performed a retrospective review of an outbreak of Salmonella gastroenteritis that occurred in a community nursing home in 1987. Forty-four of 199 residents had a diarrheal illness; Salmonella heidelberg was isolated from the stool in 19 cases. Although the distribution of cases suggested a common source for the outbreak, no common source of infection could be demonstrated, despite extensive investigation. The clinical presentation of symptomatic individuals ranged from mild diarrhea to a severe gastrointestinal illness, and 26% of symptomatic, culture-positive patients required hospitalization. The median duration of pathogen excretion during convalescence in untreated residents was six weeks, but six patients who were treated with antibiotics shed S. heidelberg for a median duration of 14.5 weeks. We conclude that (1) the clinical spectrum of Salmonella gastroenteritis in nursing-home patients is variable, ranging from mild to severe illness; and (2) nursing-home Salmonella outbreaks impose a high economic burden because of expense of epidemiologic investigation, prolonged isolation measures, hospitalization for severely ill residents, and potential institutional closure.