摘要:

ObjectiveTo describe the pedestrian traffic flow at a busy urban intersection and determine the percentage of older pedestrians at risk for injury as a result of reduced walking speeds.DesignObservational study.SettingThe intersection of Third Street and Fairfax Avenue in Los Angeles, California.ParticipantsAll pedestrians who started to cross the intersection during the legally acceptable parts of the traffic cycle during three days of observation (n= 1229) and a subsequent sample of 100 consecutive younger and 100 consecutive older crossers.MeasurementsThe ability of all subjects to cross the intersection in the allotted time was measured. A questionnaire was administered to pedestrians who were unable to cross the intersection in time. In addition, we measured the actual gait speed of a subsequent consecutive sample of 100 younger and 100 older pedestrians.ResultsOf the 592 older pedestrians observed, 27% were unable to reach the opposite curb before the light changed to allow cross traffic to enter the intersection, and one‐fourth of this group were stranded by at least a full traffic lane away from safety. All younger pedestrians were able to cross in the allotted time. Older pedestrians took significantly longer than younger pedestrians to cross the street (P<0.0001). The mean walking velocity ±1 SD for older and younger pedestrians was 0.86 ± 0.17 and 1.27 ± 0.17 m per second, respectively. Fifty‐three percent of those older pedestrians unable to cross in time were willing to be surveyed. Mean age was 77 years, 74% considered the intersection to be “dangerous,” and 63% stated they cross the street at least once daily. City traffic reports revealed that over the preceding 5 years about one older pedestrian per year had been hit in this intersection, and 165 such injuries had occurred city‐wide per year.ConclusionThe timing of this pedestrian signal does not allow adequate time for many older pedestrians to cross and puts them at potential risk. Providing more crossing time may reduce pedestrian injuries and allow for an increased feeling of independence and confidence by ol

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1994.tb01745.x

年代:1994

数据来源: WILEY

摘要:

ObjectiveTo compare the efficacy of an influenza hemagglutinin‐diphtheria toxoid conjugate vaccine with the commercially available influenza hemagglutinin‐subunit vaccine in preventing influenza in older adults living in a nursing home.DesignA prospective, randomized, double‐blind vaccine trial with 5 months of follow‐up after vaccination.SettingFourteen Wisconsin nursing homes.ParticipantsNursing home residents at least 65 years old who were able to give informed consent and were free of malignancy and not receiving immunosuppressive therapy.InterventionsParticipants received, by intramuscular injection, 0.5 mL of a trivalent influenza vaccine containing 15 μg each of A/Leningrad/360/86 (H3N2), A/Taiwan/1/86 (H1N1), and B/Ann Arbor/1/86 (HA) or 0.5 mL of an influenza vaccine containing the same antigens conjugated to diphtheria toxoid (HA‐D).MeasurementsBlood was obtained pre‐ and 1 month post‐vaccination to assess for any vaccine‐induced antibody titer change. Clinical surveillance for respiratory illness was performed twice weekly for 5 months. A record was kept of all signs and symptoms of new respiratory illness, and a viral culture and acute and convalescent sera were obtained.Results204 participants received HA and 204 received HAD. Both groups had similar baseline antibody levels to all influenza antigens. HA‐D recipients seroconverted more frequently based on serum neutralizing activity (P<0.05), had a greater increase in geometric mean titer (GMT), and sustained the increase in antibody titer longer than HA recipients. Vaccine hemagglutinin recall was greater in a subset of HA‐D recipients as measured by lymphocyte proliferative assays (P<0.05). During an outbreak of influenza A (H3N2 A/Shanghai/11/87‐like and A/Victoria/7/87‐like), fewer HA‐D (29/195) than HA (43/204) recipients had laboratory‐confirmed infection (P= 0.053), and, of these, fewer HA‐D‐treated subjects had lower respiratory tract involvement (5/29 HA‐D and 17/43 HA) (P= 0.022).ConclusionsHA‐D was more immunogenic in institutionalized elderly recipients and produced greater protection from influenza infection. Superior protection may be due to HAD's ability to stimulate and recruit antigen‐presenting cells, thus enabling the recipient to achieve a

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1994.tb01746.x

年代:1994

数据来源: WILEY

摘要:

ObjectiveTo determine if an educational intervention aimed at house staff will increase knowledge about and recognition of delirium.DesignBefore/after study, with blinding of participants to the intent of the study.SettingUniversity hospital in Halifax, Nova Scotia.PatientsOne hundred eighty‐seven control patients, seen as consecutive admissions of elderly patients (65+ years) to the General Medicine services of the Victoria General Hospital prior to the educational intervention, and 247 patients seen thereafter.InterventionEducational intervention at grand rounds, housestaff rounds, sign‐in rounds, and bedside teaching.MeasurementsRecognition of delirium in the admitting history or progress notes, Confusion Assessment Method (CAM) as recorded by nurses, diagnosis of delirium by independent study physicians using DSM‐IIIR criteria and the Trzepacz Delirium Symptom Rating Scale.ResultsPrior to the intervention, delirium or acute confusion was diagnosed in 3% of patients; after the intervention, delirium or acute confusion was diagnosed in 9% of patients (P<0.01). Other abnormalities in mental state were noted in 8.5% of admissions prior to the intervention, and 15.6% of admissions after the intervention. After the intervention there was a significant difference in the proportion of patients in whom a mental status questionnaire had been carried out and in whom there was formal comment on various aspects of the mental state. The nursing CAM had a sensitivity of 0.68 and a specificity of 0.97.ConclusionsA simple educational intervention aimed at house staff appears to be effective in changing house staff behavior. Improved recognition of delirium may lead to better patient out

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1994.tb01747.x

年代:1994

数据来源: WILEY

摘要:

ObjectivesTo examine the association between radiographic lumbosacral (LS) osteoarthritis (OA) and lumbar flexibility in elders without back pain or known spinal pathology and to develop a reliable grading system for osteoarthritis of the lumbosacral spine.DesignCross‐sectional study.SettingDurham VA and Duke University Medical Center Department of Radiology.Participants35 volunteers aged 64–90 (nursing home residents and community dwellers). Exclusion criteria were known spinal pathology, back pain, inability to stand independently for 1 minute, and>150% of ideal body weight.InterventionsAll subjects underwent LS spine radiographs and flexibility measures (forward flexion, extension, lateral flexion, and axial rotation).Main Outcome MeasuresReliability of ordinal OA X‐ray grading system, tested using intraclass correlations (ICCs); stability of flexibility measures, using ICCs; and association of disc or facet summary scores (sum of all levels, T12 thru SI) with flexibility measures, using Pearson correlations.ResultsICCs for interest flexibility measures ranged from 0.72 to 0.94. ICCs for interobserver X‐ray scores were 0.85 for facet disease and 0.93 for disc disease. The correlation of facet disease with forward lumbar flexion was 0.29. The correlation of disc disease with flexibility showed modest correlation for forward (r= 0.34), right lateral (r= 0.36), and left lateral (r= 0.35) flexion. None of the correlations was influenced by age.ConclusionsWe have developed a reliable radiographic scoring instrument for assessing radiographic OA of the LS spine. It appears that painless LS disc OA is one factor that influences spinal

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1994.tb01748.x

年代:1994

数据来源: WILEY

摘要:

ObjectiveTo determine whether mortality is independently associated with urinary incontinence.Design6‐year prospective study that started in 1983/84.SettingA Midwestern County.ParticipantsProbability sample of 1956 community‐residing persons 60 years of age and older in 1983/84.MeasurementsThe independent variables of urinary incontinence, its types and severity, were measured by survey self‐report, which was validated with clinical exams. The control variables of age, education, and health status were also self‐reported. The dependent variable of death was established during follow‐up interviews from reports of previously designated contact persons.ResultsNeither incontinence status nor its severity level or types were found to be positively associated with 6‐year mortality in logistic regression analyses that adjusted for age, education, and health status.ConclusionWhereas urinary incontinence can be an embarrassing and socially debilitating condition, it does not itself predict or contribute t

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1994.tb01749.x

年代:1994

数据来源: WILEY

摘要:

ObjectivesTo determine the incidence of falls within the first month after hospitalization and risk factors associated with falling during this period.DesignCohort study with 1‐month follow‐up after hospital discharge.Setting370‐bed community hospital.PatientsConsecutive sample of 214 patients, aged 70 years and over, hospitalized for medical illness more than 48 hours and discharged to the community. Exclusion criteria: terminal illness, neurologic diagnosis, discharge to skilled nursing facility.MeasurementsInformation was obtained at hospital admission, discharge, and 1 month after discharge. Initial assessment included demographic data, vision, mood, pre‐admission function, and use of assistive device. Discharge assessment included length of hospital stay, use of assistive device, need for professional help after discharge, medications, cognition, and functional status. Patients were assessed 1 month after discharge for history of confusion and falls. Main outcome measure was falls in the first month after discharge.Main ResultsTwenty‐nine patients (13.6%) fell during the month after discharge. Major risk factors for falls included, at discharge, decline in mobility (P= 0.005), use of assistive device (P= 0.002), and cognitive impairment (P= 0.05), and after hospital discharge, self‐report of confusion (P= 0.002). Patients who were functionally dependent and needed professional help after discharge had the highest rate of falls (20.2%). In contrast, only 8.4% of independent patients not requiring professional help fell (P= 0.01).ConclusionsThere is a high incidence of falls after hospital discharge, particularly among patients who are functionally dependent. Further study is needed to determine to what extent acute illness and hospitalization may influence

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1994.tb01750.x

年代:1994

数据来源: WILEY

摘要:

ObjectiveTo examine changes in the aggressiveness of care of the nursing home population and to determine the factors that predict whether care is limited.DesignRetrospective chart review.SettingAll nursing homes in Hennepin County, Minnesota that care for Medicaid patients.PatientsA random sample of 1605 residents of Hennepin County, MN nursing homes from 1984 and 1988 who were also Medicaid beneficiaries. The sample was stratified by year and by whether the resident died in that year. The residents were sampled disproportionately to allow approximately 400 individuals in each stratum. A total of 1405 charts (87%) was reviewed; the remainder had either been lost or destroyed.Main Outcome MeasureOrders limiting care (do not resuscitate, supportive care only, etc.), care that was less aggressive than care usually given to a person of that age (eg, not using antibiotics for a clear infection or not sending a resident to the hospital for an illness for which someone would “usually” be sent to the hospital), determined implicitly through chart review.ResultsThe demographic characteristics of the nursing home population did not change between 1984 and 1988, but the population had significantly greater severity of illness in 1988. The percentage of residents with 'sdo not resuscitate's orders (DNR) increased from 12% to 37% (P<0.0001), and the use of other orders to limit care (do not hospitalize, supportive care only, etc.) increased from 12% to 17% (P<0.05). The use of CPR did not change between the two years but the percentage of residents who were found to receive less aggressive care through implicit chart review increased from 31% to 40% (P<0.01). The year the resident was in the nursing home, the severity of illness, functional status, and dementia were significant predictors of DNR status. Factors that predict receipt of less aggressive care were similar except that age was also a significant predictor.ConclusionsThe nursing home population received less aggressive care in 1988 than in 1984. Further, there was a discrepancy between what was ordered and what was delivered in the nursing home in that residents with DNR orders had care limited beyond the withholding of

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1994.tb01751.x

年代:1994

数据来源: WILEY

摘要:

ObjectiveTo study the effects of antipsychotic withdrawal in elderly nursing home residents.DesignLongitudinal prospective study. Setting: 12 community nursing homes that participated in a randomized controlled trial of an educational program designed to reduce antipsychotic use.Subjects271 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).MeasurementsChange 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).ResultsThe 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.ConclusionIn this sample, nursing home residents whose antipsychotics were discontinued had significantly improved affect and no discernable advers

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1994.tb01752.x

年代:1994

数据来源: WILEY

摘要:

ObjectiveTo examine the association of distant vision and physical function in the population of older adults.DesignCross‐sectional and cohort study.Participants5143 older residents of three communities (Established Populations for the Epidemiologic Studies of the Elderly) who were interviewed in 1988–89, including residents of two communities who were re‐interviewed 15 months later (n= 3133, 97% of those eligible).MeasuresVisual acuity screening, self‐reported activities of daily living and mobility, and objective physical performance measures of balance, walking, and rising from a chair.ResultsLimitations in mobility, activities of daily living, and physical performance were associated with worse visual function. In prospective analyses controlling for potential confounders, participants with severe visual impairment had 3‐fold higher odds of incident mobility and activity of daily living limitations than those with acuity of 20/40 or better (P<0.001). In prospective analyses investigating the relationship of vision with improvement in function, those with poor vision were about half as likely to improve as those with better acuity, but this relationship was only statistically significant for improvement in mobility limitations.ConclusionsDistant visual function appears to play an important role in physical function, particularly for mobility. An intervention to improve vision in at‐risk elders might preserve function and prevent disability; this warrants further in

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1994.tb01753.x

年代:1994

数据来源: WILEY

摘要:

ObjectiveTo compare sociodemographic characteristics, physical function, and cognition of Mexican American and non‐Hispanic white nursing home residents.Design and SettingCross‐sectional survey of residents in eight proprietary nursing homes and one Veterans Affairs nursing home in San Antonio, Texas.SubjectsResidents with lengths of stay greater than or equal to 90 days.MeasurementsSociodemographic characteristics, residence prior to admission, and dependency in activities of daily living (ADL) were abstracted from the medical record. The Folstein Mini‐Mental State Examination (MMSE) was administered in the resident's self‐selected language to a subset of residents.Main ResultsThere were 1160 participants, 261 Mexican American (23%) and 899 non‐Hispanic white residents (77%). Mexican Americans were younger (77.1 vs 80.7 years), more often men (44% vs 30%), less educated (6.2 vs 10.8 years), and more often dependent on Medicaid funding (66% vs 40%) than non‐Hispanic whites. Mexican Americans were less independent in feeding (34% vs 49%), transfers (18% vs 30%), toileting (19% vs 29%), and dressing (12% vs 19%). Mean MMSE scores were different in Mexican Americans and non‐Hispanic whites (8.93 vs 11.85), and this difference remained significant after adjustment for age and education (P= 0.04). ADL function was strongly associated with MMSE (P= 0.0001) and less strongly associated with ethnicity (P= 0.056) in multiple regression analysis.ConclusionsThis study provides the strongest evidence to date that Mexican American nursing home residents are more cognitively and functionally impaired than non‐Hispanic white residents. Further studies should explore whether medical conditions, selection and referral patterns or cultural factors explain functional differences between Mexican American and non‐Hispanic white nursi

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1994.tb01754.x

年代:1994

数据来源: WILEY