The POLST program is widely used in Oregon nursing facilities. A majority of individuals with DNR orders requested some other form of life-extending treatment, and advanced age was associated with orders to limit treatments.

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POLST completion in ElderPlace exceeds reported advance directive rates. Care matched POLST instructions for CPR, antibiotics, IV fluids, and feeding tubes more consistently than previously reported for advance directive instructions. Medical intervention level was consistent with POLST instructions for less than half the participants, however. We conclude that the POLST is effective for limiting the use of some life-sustaining interventions, but that the factors that lead physicians to deviate from patients' stated preferences merit further investigation.

The mean age of the CI subjects was 83, and 83% were women. The mean Mini-Mental State Exam score was 15.7. One-third of the CI subjects were unable to complete any of the three pain assessment tools. Of the 104 subjects completing at least one tool, 13 (12.5%) reported no pain and 91 (87.5%) reported some pain. Sixteen (10%) of the subjects were depressed as measured with the GDS or Cornell instrument. In 70 of the 104 subjects (67%) able to complete any tool, the caregiver and CI subject agreed as to the level of pain experienced by the CI subject. The number of tools completed by the CI subjects decreased with increased cognitive impairment. The Pain Intensity Scale was the tool most likely to be completed by both CI subjects and caregivers. The means of test scores were not significantly different for the paired groups of CI subject and caregiver, and the nonparametric correlation of each tool was significant: "faces" (Spearman's rho (p) = .417); "line" (p = .420); and PIS (p = .452). The Hospice Approach Discomfort Scale did not correlate well with other tools. The Pain Intensity Scale seems to be more useful than other pain assessment tools in assessing pain in cognitively impaired patients and can be used by nonprofessional caregivers in a community-based care setting.

Aside from existing drug therapies, certain lifestyle and nutritional factors are known to reduce the risk of osteoporosis. Among the nutritional factors, dried plum or prunes (Prunus domestica L.) is the most effective fruit in both preventing and reversing bone loss. The objective of the present study was to examine the extent to which dried plum reverses bone loss in osteopenic postmenopausal women. We recruited 236 women, 1 -10 years postmenopausal, not on hormone replacement therapy or any other prescribed medication known to influence bone metabolism. Qualified participants (n 160) were randomly assigned to one of the two treatment groups: dried plum (100 g/d) or dried apple (comparative control). Participants received 500 mg Ca plus 400 IU (10 mg) vitamin D daily. Bone mineral density (BMD) of lumbar spine, forearm, hip and whole body was assessed at baseline and at the end of the study using dual-energy X-ray absorptiometry. Blood samples were collected at baseline, 3, 6 and 12 months to assess bone biomarkers. Physical activity recall and 1-week FFQ were obtained at baseline, 3, 6 and 12 months to examine physical activity and dietary confounders as potential covariates. Dried plum significantly increased BMD of ulna and spine in comparison with dried apple. In comparison with corresponding baseline values, only dried plum significantly decreased serum levels of bone turnover markers including bone-specific alkaline phosphatase and tartrate-resistant acid phosphatase-5b. The findings of the present study confirmed the ability of dried plum in improving BMD in postmenopausal women in part due to suppressing the rate of bone turnover. Key words: Osteoporosis: Dried plums: Clinical trialsOsteoporosis is a major public health problem in postmenopausal women. In the USA alone, eight million women have osteoporosis that results in more than one million fractures per year in women who are 45 years and older (1) . The cost of treating osteoporosis and its fractures has been estimated to be over $19 billion/year. Although there are a number of agents available for the treatment and/or prevention of osteoporosis, some patients have contraindications to using them or prefer alternative therapies including dietary supplements and functional foods (2) . Studies have consistently shown that a higher fruit and vegetable intake has positive effects on bone mineral density (BMD) (3 -7) . Muhlbauer et al. (8) examined the effects of a number of fruits and vegetables on bone resorption by assessing the urinary excretion of 3 H released from bone, and showed that dried plum (8) among fruits and onion among vegetables were the most effective functional foods with bone-modulating effects. To our knowledge, Muhlbauer et al. (8) were the first group who showed that prunes (dried plums) have the ability to prevent osteoporosis by inhibiting bone resorption. To follow up on Muhlbauer's findings, our laboratory conducted several animal studies and a 3-month clinical trial. The results of these studies showed that dried...

Overall, short-term hospital utilization among PACE participants is low in contrast with that for other older and disabled populations. Participant predictors of hospitalization in PACE are generally consistent with other studies in older clinical and community populations. Both utilization and risk vary considerably across PACE sites, independent of participant-level risk factors, hence suggesting that further investigation is required to study PACE's management of acute illness and hospitalization decisions. Critical to maintaining PACE's success is an understanding of the independent impact of the organization and the environment of health care on this management.

This paper aims to define the role of the primary care physician (PCP) in the management of Alzheimer's disease (AD) and to propose a model for a work plan. The proposals in this position paper stem from a collaborative work of experts involved in the care of AD patients. It combines evidence from a literature review and expert's opinions who met in Paris, France, on July 2009 during the International Association of Geriatrics and Gerontology (IAGG) World Congress. The PCP's intervention appears essential at many levels: detection of the onset of dementia, diagnostic management, treatment and follow-up. The key role of the PCP in the management of AD, as care providers and care planners, is consolidated by the family caregiver's confidence in their skills. In primary care practice the first step is to identify dementia. The group proposes a "case finding" strategy, in target situations in which dementia should be detected to allow, secondarily, a diagnosis of AD, in certain cases. We propose that the PCP identifies 'typical' cases. In typical cases, among older subjects, the diagnosis of "probable AD" can be done by the PCP and then confirm by the specialist. While under-diagnosis of AD exists, so does under-disclosure. Disclosure to patient and family should be done by both specialist and PCP. Then, the PCP has a central role in management of the disease with the general objectives to detect, prevent and treat, when possible, the complications of the disease (falls, malnutrition, behavioural and psychological symptoms of dementia). The PCP needs to give basic information to the caregiver on respite care and home support services in order to prevent crisis situations such as unplanned institutionalisation and "emergency" hospital admission. Finally, therapeutic research must be integrated in the daily practice of PCP. It is a matter of patients' right to benefit from access to innovation and clinical research whatever his age or diseases, while of course fully respecting the rules and protective measures that are in force.

Our understanding of the causes of disability in the older population has improved significantly over the last decade. There has also been noteworthy progress in our knowledge about the effects of selected rehabilitation interventions, especially exercise-related interventions. However, the cost-effectiveness of many rehabilitative interventions remains unclear, particularly for differing patient groups across the continuum of care. More research will be needed to evaluate the effects of managed care on rehabilitation outcomes in older persons.