摘要:

Objective: To evaluate the effects of targeted outpatient geriatric evaluation and management (GEM).Design: Controlled clinical trial. Elderly persons were identified as being at high risk for hospital admission on the basis of their responses to a short, mailed, self‐administered questionnaire. The high‐risk elders who chose to participate in the GEM program were compared to those who continued to receive usual care.Setting: Outpatient GEM clinic at an urban university hospital.Subjects: Elderly Medicaid recipients whose probability of repeated hospital admission (Pra) within 4 years was calculated as 40% or greater (Pra≥ 0.40).Main Outcome Measures: Mortality, use of institutional services, satisfaction.Results: Of the 1210 persons who were sent questionnaires, 624 responded (response rate = 51.6%), of whom 154 (24.7%) were deemed to be a high risk for hospitalization. Of these, 43 received GEM (experimental subjects); 111 received usual care (controls). At baseline, the experimental and control groups' demographic and health‐related characteristics did not differ significantly. The average experimental subject was 76.5 years old, had 9.6 significant medical problems, and took 6.7 significant long‐term prescription medications. During the program's first 17 months of follow‐up, the experimental subjects had lower annual rates of mortality (2.9% vs 19.2%,P= 0.03) and emergency room use (0.6 vs 1.0 visits,P= 0.01) than did the controls. The experimental subjects also tended to use nursing homes, but not hospitals, at a lower rate than the controls. All of the experimental subjects rated the program as either excellent (81.0%) or good (19.0%); 100% said they would recommend it to others. Their established primary physicians rated the GEM services as appropriate and helpful.Conclusion: Targeted outpatient GEM was associated with reduced mortality, reduced use of emergency rooms, and a trend toward reduced use of nu

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1994.tb04965.x

出版商:Blackwell Publishing Ltd    

年代:1994

数据来源: WILEY

摘要:

Objective: The primary objective was to confirm the results of a prior study that demonstrated a strong independent correlation between the severity of protein‐energy undernutrition and the risk of subsequent morbidity in a population of elderly rehabilitation patients. A second objective was to determine whether inadequate in‐hospital nutrient intake is a co‐contributor to the risk of subsequent morbidity.Design: Cohort study.Setting: Geriatric Rehabilitation Unit (GRU) of a Veterans Administration hospital.Patients: Three hundred fifty randomly selected admissions to the GRU, of whom 99% were male, and 75% were white. The average age of the study patients was 76 years.Measurements: At admission, each patient completed a comprehensive medical, functional, neuro‐psychological, socioeconomic, and nutritional assessment. While remaining in the hospital, each subject was monitored on a daily basis for the development of complications. Complete calorie counts were obtained at least every other day, and the average pre‐complication daily nutrient intake was expressed as a percent of predicted requirements as determined using the Harris‐Benedict equation.Results: Of the 96 variables evaluated, the strongest predictor of subsequent complications was the Katz Index of ADL score, followed by serum albumin, usual weight percent, number of prescription medications, presence of renal disease, individual income, the presence of decubiti, dysphagia, and mid‐arm muscle circumference. When all nine of these variables were included in the logistic regression analysis, the final model had a sensitivity of 70%, a specificity of 71%, and an overall predictive accuracy of 71%. When tested using the data from the previous study, the model differentiated the patients who developed a complication from those who had not at a sensitivity of 76.7, a specificity of 76.1, and an overall predictive accuracy of 76.3. There was no difference in the pre‐complication average daily nutrient intake between the complication and the no‐complication groups (79%vs75% of predicted requirements,P>0.2).Conclusions: Protein‐energy undernutrition appears to be a strong independent risk factor for in‐hospital morbidity. However, in‐hospital nutrient intake may not be a signific

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1994.tb04966.x

出版商:Blackwell Publishing Ltd    

年代:1994

数据来源: WILEY

摘要:

Objective: To determine if pre‐complication nutrient intake can be predicted based on an admission assessment.Design: Survey (cross‐sectional study).Setting: Geriatric Rehabilitation Unit (GRU) of a Veterans Administration hospital.Patients: Three‐hundred‐twelve randomly selected admissions to the GRU.Measurements: At admission, each patient completed a comprehensive medical, neuropsychological, functional, and nutritional assessment. While remaining hospitalized, each subject was monitored on a daily basis for the development of complications. Complete calorie counts were obtained at least every other day, and the average pre‐complication daily volitional nutrient intake was expressed as a percent of predicted requirements as determined using the Harris‐Benedict equation.Results: Based on a stepwise linear regression analysis, the strongest predictor of pre‐complication volitional intake was the first day calorie count, followed by waist circumference, the percent of weight lost in the 6 months prior to admission, supra‐iliac skinfold thickness, and admission Katz ADL score. The modelR2= 0.66.Conclusions: It is possible to predict pre‐complication nutrient intake with a fair degree of accuracy based on an admission assessment, which includes a 1

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1994.tb04967.x

出版商:Blackwell Publishing Ltd    

年代:1994

数据来源: WILEY

摘要:

Objective: To determine the factors associated with impaired function in older women.Design: Cross‐sectional analysis of baseline data collected for a multicenter, prospective study of risk factors for osteoporotic fractures.Setting: Four clinical centers in Portland, Oregon, Minneapolis, Minnesota, Baltimore, Maryland, and the Monongahela Valley, Pennsylvania.Participants: A total of 9,704 ambulatory, non‐black women, aged 65 years and older, recruited from population‐based listings.Measurements: Independent variables, including demographic and historical information (medical conditions, health habits, and medications) and physiologic measures (anthropometry, blood pressure, mental status, vision, and neuromuscular performance) were obtained from a baseline questionnaire, interview, and examination. Measurement of function was assessed by self‐reported ability to perform six physical and instrumental activities of daily living (ADL) and impaired function (dependent variable) was defined as difficulty performing three or more physical and instrumental ADLs.Results: In order of decreasing strength of association, hip fracture, osteoarthritis, parkinsonism, slower walking speed, lower hip abduction force, back pain, greater Quetelet index, osteoporosis, former alcohol use, stroke, never drinking alcohol, lower mental status, use of anxiolytics and/or sleeping medications, inability to hold the tandem position, postural dizziness, cataracts, greater waist to hip ratio, lower physical activity in the past year, greater lifetime cigarette consumption, and lower grip strength were independently associated with impaired function in multivariate analyses. Age, low educational level, diabetes, current heavy alcohol use, postural hypotension, depth perception, and contrast sensitivity were not independent predictors. A combination of neuromuscular performance measures, including decreased muscle strength and impaired balance and gait, appeared to account for the effect of age on disability.Conclusion: A combination of many factors, including medical conditions, health habits such as obesity, smoking, alcohol abstinence, and physical inactivity, and direct measures of neuromuscular performance are associated with impaired function in olde

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1994.tb04968.x

出版商:Blackwell Publishing Ltd    

年代:1994

数据来源: WILEY

摘要:

Objective: The GDS (Geriatric Depression Scale) has demonstrated validity among ambulatory elderly but is less useful in nursing home (NH) populations, probably because of high rates of cognitive impairment. We, therefore, sought the lowest level of Mini‐Mental Status Exam (MMSE) score for which the GDS would remain valid.Design: Validation Study.Setting: Nursing Homes in New York City.Participants: A total of 66 of 168 newly admitted residents to the NH were able to complete psychiatric assessment, undergo an MMSE, and complete the GDS. The psychiatrists and testers (all non‐MDs) were blinded to each others' results. Using a cutoff of 10 or greater on the GDS to indicate depression, the GDS's validity (when compared with the psychiatric diagnoses) was sought at ever decreasing levels of cognitive function as measured by the MMSE.Results: The results of all participants (n= 66) revealed a sensitivity of 63% and a specificity of 83%. When only those with an MMSE score ≥15 (the best cutoff score) were included, 44 (64%) participants were selected, with a sensitivity and specificity of 84% and 91%, respectively.Conclusions: The two‐step procedure of first selecting those with MMSE scores ≥15 and then giving the GDS significantly increases the utility of the GDS in detecting depression in NH residents and should improve the diagnostic process for this widely underdetecte

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1994.tb04969.x

出版商:Blackwell Publishing Ltd    

年代:1994

数据来源: WILEY

摘要:

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 (≥65) could stand independently (≥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'sr= 0.72;P<0.001), and the clinical measures of balance (functional reach, mobility maneuvers, timed chair stands and walk) were modestly intercorrelated (rfrom 0.35 to 0.65; allPvalues ≤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 ≥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 standar

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1994.tb04970.x

出版商:Blackwell Publishing Ltd    

年代:1994

数据来源: WILEY

摘要:

Objective: To determine the difference in the recognition and intervention/referral rates for urinary incontinence (UI) by out‐patient Geriatric Assessment Units (GAUs) and private physicians in community‐based practices (CMDs).Design: A multi‐site, randomized, controlled study where block randomization was utilized to assign subjects 65 years of age and older to either a GAU or a CMD for assessment.Setting: One academic and three hospital‐based GAUs and CMDs in private practice in a large metropolitan area.Participants: Three hundred sixty‐four community‐dwelling frail men (14%) and women (86%) with a mean age of 75 years.Measurements: The independent variable was the type of out patient care, either CMD or GAU, to which the subjects were randomized. The dependent variables were recognition of UI by the health care providers and intervention or referral for the problem of UI once it was identified. Instruments included a structured in‐home interview performed before randomization designed to uncover health problems such as urinary incontinence, as well as a medical record review form used post‐assessment to ascertain recognition rates and intervention for UI by CMDS and GAUs. Both of the instruments were developed and piloted by the investigators in a preliminary study.Main Results: Of the 364 subjects, 151 (41.5%) reported UI during the in‐home interviews. Recognition rates for UI were significantly better for GAUs (48 of 81, 59.3%) than CMDs (11 of 70, 15.7%) (P<0.001). This was true for mild (<3 times/week) 44.2% vs 2.1% (P3 times/week) 86.2% vs 43.5% (P= 0.00111) for GAUs and CMDs, respectively. There were no significant differences in the rate of referral/intervention for recognized cases of UI by GAUs or CMDs. GAUs referred/treated five (21.7%) cases of mild UI and 10 (40%) cases of severe UI while CMDs referred/treated three (30%) cases of severe UI but did not offer intervention for the one recognized case of mild UI. GAUs were more likely to refer to Continence Programs (12, 25%) compared with CMDs who were more likely to refer (3, 100%) to a urologist. A majority of the subjects with UI did not receive treatment or referral for their problem (8, 72.7% CMDs and 33, 68.6% of GAUs).Conclusions: GAUs out performed CMDs in the identification of subjects with both mild and severe UI. However, the intervention/referral rates were low for both GAUs and CMDs. The outcome of this study points to the need for increased emphasis on UI in curriculum preparing physicians and other health providers as well as the need for continuing education for those al

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1994.tb04971.x

出版商:Blackwell Publishing Ltd    

年代:1994

数据来源: WILEY

摘要:

Objectives: When large disturbances of upright stance occur, balance must usually be restored by taking a step. We undertook this study to examine the biomechanics of stepping responses to sudden backward pulls at the waist. Primarily, response differences between young and old healthy adults were sought.Design: A controlled laboratory study.Subjects: Two groups of healthy and physically‐fit adult females, 12 of mean age 22 (Young) and 12 of mean age 73 years (Old).Measurements: Response kinematics were measured. From them, the stepping strategies of the subjects were derived, including the timing, length, and height of the first step taken and the rotations of major body segments and at major body joints that occurred.Results: In response to sufficiently large backward pull forces, all subjects responded by taking one or more steps backwards. No significant age group difference appeared in the smallest disturbance for which subjects sometimes used a step response. A significant age group difference appeared in the smallest disturbance at which subjects began consistently to use step responses, and that disturbance was larger for the Old than for the Young. Distinct age group differences were found in stepping strategy. At large disturbance levels, the Young mostly responded by taking a single step, whereas the Old mostly responded by taking multiple steps. The steps taken by the Old, compared with those of the Young, were significantly shorter, had significantly smaller heights, and were taken significantly earlier in the responses. Body segment and joint rotations were generally modest, and few significant age group differences were found in these kinematics.Conclusions: In restoration of perturbed balance by step‐taking, the responses of the healthy, physically‐fit young and old adults studied here were similar in many respects, but they differed in some important features. Joint range of motion (ROM) limitations are unlikely to explain age group differences in stepping responses to postural disturbances among healthy subjects because the ROM actually used in any of the responses observed were substantially smaller than the ROM avai

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1994.tb04972.x

出版商:Blackwell Publishing Ltd    

年代:1994

数据来源: WILEY

摘要:

Objective: To determine whether there is an age‐related difference in the therapeutic response to antithyroid drugs in hyperthyroid Graves' disease.Design: Retrospective analysis of treatment duration and recurrence rate.Patients: Two hundred and twenty‐two patients who have triiodothyronine‐suppressible thyroids within 4 years of methimazole treatment.Measurements: Serum thyroid hormone levels, serum thyrotropin receptor antibody titer, and thyroidal radioiodine uptake.Main results: A longer period of methimazole treatment was needed to normalize serum thyroid hormone levels and to restore normal thyroidal triiodothyronine suppressibility in young than in aged patients. There was an average 10‐month lag between normalization of thyrotropin receptor antibody titer and restoration of thyroidal triiodothyronine suppressibility in both young and aged patients. Recurrence after discontinuation of methimazole was more frequent in young than in aged patients.Conclusions: Aged patients with hyperthyroid Graves' disease show a more favorable response to antithyroid drugs than young count

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1994.tb04973.x

出版商:Blackwell Publishing Ltd    

年代:1994

数据来源: WILEY

摘要:

Objective: To learn whether patients with early Alzheimer's disease tend to under‐report or over‐report symptoms and to compare their comorbidity with non‐demented patients.Design: Case Control Study in a population‐based dementia registry.Setting and Patients: Three groups of subjects (mean age 76) were enrolled from an HMO base population: 154 cases had clinically diagnosed probable Alzheimer's disease, 92 subjects were found to be not demented although they had complaints of cognitive impairment, and another 129 cognitively intact controls were enrolled after frequency‐matching for age and sex.Measurements and Results: Medical records were examined for the 2 years prior to enrollment. Symptoms suggestive of cognitive impairment were evident 7.8 months prior to enrollment (median 6 months) in 95% of cases, in 77% of the not demented subjects, and in 6% of controls. After corrections for multiple comparisons, only symptoms of cognitive impairment were more frequent in cases, whereas several common symptomsnotsuggestive of cognitive impairment (eg, gastrointestinal discomfort, joint pain, vision problems) occurred more often in controls and the not demented group, even though comorbidity was similar among all three groups (Charlson Index mean scores: case = 0.7, not demented = 0.7, control = 0.5).Conclusions: Persons with Alzheimer's disease do complain of symptoms clearly related to cognitive impairment early in the course of illness, but may under‐report common symptoms not suggestive of cognitive impairment, even though their comorbidity is similar to patients witho

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1994.tb04974.x

出版商:Blackwell Publishing Ltd    

年代:1994

数据来源: WILEY