How Safe is Your Neighborhood? Perceived Neighborhood Safety and Functional Decline in Older Adults
Sun VK, Irena Cenzer S, et al. The Journal of General Internal Medicine 2012; 27(May): 541-547
BACKGROUND: Neighborhood characteristics are associated with health and the perception of safety is particularly important to exercise and health among older adults. Little is known about the relationship between perception of neighborhood safety and functional decline in older adults.
OBJECTIVE: To determine the relationship between perceived neighborhood safety and functional decline in older adults.
DESIGN/SETTING: Longitudinal, community-based.
PARTICIPANTS: 18,043 persons, 50 years or older, who participated in the 1998 and 2008 Health and Retirement Study.
MAIN MEASURES: The primary outcome was 10-year functional decline (new difficulty or dependence in any Activity of Daily Living, new mobility difficulty, and/or death). The primary predictor was perceived neighborhood safety categorized into three groups: “very safe”, “moderately safe”, and “unsafe.” We evaluated the association between perceived neighborhood safety and 10-year functional decline using a modified Poisson regression to generate unadjusted and adjusted relative risks (ARR).
KEY RESULTS: At baseline 11,742 (68.0%) participants perceived their neighborhood to be very safe, 4,477 (23.3%) moderately safe, and 1,824 (8.7%) unsafe. Over 10 years, 10,338 (53.9%) participants experienced functional decline, including 6,266 (50.2%) who had perceived their neighborhood to be very safe, 2,839 (61.2%) moderately safe, and 1,233 (63.6%) unsafe, P<0.001. For the 11,496 (63.3%) of participants who were functionally independent at baseline, perceived neighborhood safety was associated with 10-year functional decline (moderately safe ARR 1.15 (95%) CI 1.09!! 1.20; unsafe ARR 1.21 95% CI: 1.03–1.31 compared to very safe group). The relationship between perceived neighborhood safety and 10-year functional decline was not statistically significant for participants who had baseline functional impairment.
CONCLUSION: Asking older adults about their perceived neighborhood safety may provide important information about their risk of future functional decline. These findings also suggest that future studies might focus on assessing whether interventions that promote physical activity while addressing safety concerns help reduce functional decline in older adults.
KEVIN'S COMMENTS: Neighborhood safety is an important factor to consider in the overall functional evaluation of an older adult. Fear of harm in one’s neighborhood may limit opportunities for physical fitness and social engagement. Lack of exercise may lead to functional decline and dependence, and social isolation is a risk factor for depression, dementia, and mortality. Personal safety and security assume major importance for older adults and often influence the choice of whether they decide to remain in their own homes or consider alternative living arrangements (e.g., senior living communities).
Predictors of Avoidable Hospitalizations Among Assisted Living Residents
Becker M, Boaz T, et al. The Journal of the American Medical Directors Association 2012; 13(May): 355-359University of South Florida, College of Behavioral and Community Sciences, Louis de la Parte Florida Mental Health Institute, Department of Aging and Mental Health Disparities, Tampa, FL
OBJECTIVES: Hospitalizations for long term care residents, including those from assisted living facilities (ALFs), are very costly, often traumatic, and increase risk for iatrogenic disorders for those involved. Currently, hospital expenditures account for approximately one-third of total national health care spending. Hospitalizations for ambulatory care–sensitive (ACS) conditions are considered potentially avoidable, as these are physical health conditions that can often be treated safely at a lower level of care or occur as a result of lack of timely, adequate treatment at a lower level of care. The goal was to examine risk factors for hospitalization for an ACS condition of Medicaid-enrolled younger and older ALF residents during 2003–2008.
DESIGN: This is a retrospective cohort study that used 5 years of Medicaid enrollment and fee-for-service claims data.
PARTICIPANTS: The study sample included 16,208 Medicaid-enrolled ALF residents in Florida, 7991 (49%) of whom were 65 years of age or older.
RESULTS: In total, study participants had 22,114 hospitalizations, 3759 (17%) of which were for an ACS condition. Sixteen percent of all ALF residents (n = 2587), about 12% of the younger residents and 20% of the older residents, had at least one ACS hospitalization. ACS hospitalizations constitute 13% of all hospitalizations for the younger residents and 22% of all hospitalizations for the older residents. Using Cox proportional hazard regression, we found that for both age groups, increased age, being Hispanic or of other race/ethnicity, and having comorbid physical health conditions were associated with a higher risk of ACS hospitalization. For older residents, having a dementia diagnosis and being African American reduced the risk of ACS hospitalization, whereas for younger residents having a major psychotic disorder reduced the risk of ACS hospitalization.
CONCLUSION: The results highlight the need for increased education, communication, and future research on these predictive factors. The increased frequency of hospitalization for ACS conditions among ALF residents with minority status and older age may well indicate that their more complex health care needs are not being adequately addressed. The role of serious mental illness and dementia in risk for ACS hospitalization also deserves further attention.
KEVIN'S COMMENTS: Assisted living communities are more and more resembling nursing facilities as residents with multiple medical conditions age in place. The average assisted living resident requires help with two or more activities of daily living, such as bathing, dressing, or toileting, and uses eight to ten medications per day. Recent research suggests that more than 50% of assisted living residents have some degree of cognitive impairment and more than 90% need help with taking medications properly. Hospitalizations of assisted living and nursing home residents are frequent and may be associated with numerous complications that can cause morbidity and excess health care costs. Common complications may include discomfort for the hospitalized resident, anxiety among family members, and hospital-acquired complications (such as delirium, de-conditioning, decline in functional status, falls, pressure ulcers, incontinence, hospital-related infections, polypharmacy and adverse drug effects). Research also suggests that a substantial proportion of these hospitalizations are avoidable with timely onsite recognition of change in condition and earlier intervention, especially for ambulatory-sensitive conditions. The good news is that tools and resources (see below) have been developed that can assist nursing home and assisted living providers in reducing hospitalizations and readmissions through early recognition of an acute change in condition and better communication among health care providers, especially as a resident transitions from one health care setting to another.
Caregiver’s Communication Guide: Protocols for Change of Condition
INTERACT II (Interventions to Reduce Acute Care Transfers)
National Transitions of Care Coalition
Dental X-Rays and Risk of Meningioma
Claus EB, MD, Calvocoressi L, et al. Cancer, published online April 10, 2012
BACKGROUND: Ionizing radiation is a consistently identified and potentially modifiable risk factor for meningioma, which is the most frequently reported primary brain tumor in the United States. The objective of this study was to examine the association between dental x-rays—the most common artificial source of ionizing radiation—and the risk of intracranial meningioma.
METHODS: This population-based case-control study included 1433 patients who had intracranial meningioma diagnosed at ages 20 to 79 years and were residents of the states of Connecticut, Massachusetts, North Carolina, the San Francisco Bay Area, and 8 counties in Houston, Texas between May 1, 2006 and April 28, 2011 (cases). A control group of 1350 individuals was frequency matched on age, sex, and geography (controls). The main outcome measure for the study was the association between a diagnosis of intracranial meningioma and self-reported bitewing, full-mouth, and panorex dental x-rays.
RESULTS: Over a lifetime, cases were more than twice as likely as controls (odds ratio [OR], 2.0; 95% confidence interval [CI], 1.4-2.9) to report having ever had a bitewing examination. Regardless of the age at which the films were obtained, individuals who reported receiving bitewing films on a yearly basis or with greater frequency had an elevated risk for ages <10 years (OR, 1.4; 95% CI, 1.0-1.8), ages 10 to 19 years (OR, 1.6; 95% CI, 1.2-2.0), ages 20 to 49 years (OR, 1.9%; 95% CI, 1.4-2.6), and ages 40 years (OR, 1.5; 95% CI, 1.1-2.0). An increased risk of meningioma also was associated with panorex films taken at a young age or on a yearly basis or with greater frequency, and individuals who reported receiving such films at ages <10 years had a 4.9 times increased risk (95% CI, 1.8-13.2) of meningioma. No association was appreciated for tumor location above or below the tentorium.
CONCLUSIONS: Exposure to some dental x-rays performed in the past, when radiation exposure was greater than in the current era, appears to be associated with an increased risk of intracranial meningioma. As with all sources of artificial ionizing radiation, considered use of this modifiable risk factor may be of benefit to patients.
KEVIN'S COMMENTS: Dental x-rays are commonly done in the United States, often to search for occult or asymptomatic disease. This report highlights the heightened risk of meningioma in those exposed to ionizing radiation, the most important modifiable risk factor for meningioma. Meningiomas are benign brain tumors that may cause symptoms related to expansion and compression of adjacent brain structures. They are the most common primary brain tumors accounting for one-third of all primary brain tumors. The American Dental Association has stated that there is little evidence to support the routine use of dental x-rays to search for occult disease or obtain dental x-rays in asymptomatic persons at regular intervals.