摘要:

OBJECTIVES:To evaluate the feasibility of an intervention involving post‐discharge geriatric home assessment and follow‐up and to describe the spectrum of significant clinical problems identified during the home assessment.DESIGN:Prospective observational study nested within a randomized controlled trial.SETTING:Inpatient service of a large academic medical center in Southern California.PATIENTS:There were 152 adults aged 65 or greater who had one or more specific risk factors for functional decline or increased mortality, who were awaiting discharge from the hospital, and who were assigned to the intervention arm of a randomized controlled trial of post‐discharge comprehensive geriatric home assessment.MAIN RESULTS:During the home assessment, the gerontologic nurse practitioner (GNP) identified new or worsening problems in 150 patients (99%); 61 problems (eg, serum sodium 125 mg/dL; severe orthostatic hypotension) were considered by a reviewing physician to require urgent medical attention. Older age, non‐white race, and new incontinence were associated independently with a greater number of findings (P<0.05). Based on the findings, an interdisciplinary team made an average of 3.4 recommendations per patient; only two of 111 requests for written approval of recommendations were rejected.CONCLUSIONS:Post‐discharge visitation by a GNP to patients at high risk is capable of detecting a high yield of important and potentially reversible clinical problems. This multidisciplinary approach is acceptable to physicians. Research is needed to identify additional links between short hospital stays, impairment or instability at discharge, and adverse

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1994.tb06502.x

出版商:Blackwell Publishing Ltd    

年代:1994

数据来源: WILEY

摘要:

OBJECTIVE:To examine the relationship of possible modifiable risk factors, including obesity, physical activity level, alcohol consumption, blood pressure, and thiazide diuretic use with the development of non‐insulin‐dependent diabetes mellitus (NIDDM) requiring treatment among a large cohort of community‐dwelling elderly.SETTING:The East Boston Senior Health Project, one of four components of the National Institute on Aging‐sponsored Established Populations for the Epidemiologic Study of the Elderly (EPESE).PARTICIPANTS:Residents of East Boston who were 65 years of age or older.MEASUREMENTS:We performed a prospective cohort study with follow‐up over two consecutive 3‐year time periods beginning in 1982–1983. The main outcome measure was the occurrence of NIDDM, defined as new treatment with a hypoglycemic agent. A total of 2737 study participants contributed 4682 3‐year intervals for analysis.MAIN RESULTS:NIDDM requiring hypoglycemic therapy occurred in 185 participants over the duration of the study. High body mass index (>26 kg/m22) (adjusted odds ratio 2.4, 95% confidence interval 1.3–4.4) and low physical activity level (adjusted odds ratio 1.5, 95% confidence interval 1.0–2.1) were significant predictors of NIDDM in a multiple logistic regression model adjusting for age, sex, blood pressure, and self‐report of “high blood sugar”; moderate alcohol consumption (0.5‐

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1994.tb06503.x

出版商:Blackwell Publishing Ltd    

年代:1994

数据来源: WILEY

摘要:

OBJECTIVE:To assess the quality of medication prescribing in ambulatory elderly patients on multiple medications using the Medication Appropriateness Index (MAI).DESIGN:Cross‐sectional study.SETTING:General Medical Clinic of the Durham VA Medical Center.PATIENTS:208 elderly outpatients on five or more regularly scheduled medications.MEASUREMENTS:Medication prescribing appropriateness was measured with the MAI, a reliable method that employs 10 implicit criteria. A weighted MAI score (range 0–18 per drug) served as a summary measure of appropriateness.RESULTS:There were 1644 medications evaluated; 26% received no inappropriate ratings, 37% had one, 19% had two, and 18% had three or more. Of 16,440 ratings, 2295 (14%) were evaluated as inappropriate. The percentage of inappropriate ratings varied across prescribing dimensions: drug‐drug interactions, 0%; drug‐disease interactions, 1.4%; medication effectiveness, 4.7%; therapeutic duplication, 5.7%; indication, 11.5%; duration of treatment, 16.5%; dosage, 17.3%; practical directions, 20.3%; cost, 29.7%; and correct directions, 32.4%. The mean MAI score for all medications was 2.2 ± 2.1 (range 0–10) and varied by therapeutic class. MAI scores were significantly lower for medications with a high potential for adverse effects compared with those with a low potential (MAI score of 1.8 vs 2.9, P<0.001). Regression analysis revealed that no patient characteristics were associated with a higher likelihood of inappropriate prescribing.CONCLUSIONS:Medication prescribing for elderly outpatients taking multiple medications was substantially appropriate. Prescribing dimensions with the most room for improvement were more exact directions, less expensive drugs, and practical directions. Drugs at high risk for adverse effects were prescribed more appropriately than those a

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1994.tb06504.x

出版商:Blackwell Publishing Ltd    

年代:1994

数据来源: WILEY

摘要:

OBJECTIVE:To review the incidence of neurological complications occurring after carotid sinus massage performed for diagnostic purposes.DESIGN:Case review and comparison with previously published work.SETTING:Syncope Clinic, Royal Victoria Infirmary, Newcastle‐upon‐Tyne, and Chelsea and Westminster Hospital, London.PARTICIPANTS:Patients undergoing investigation of dizziness, syncope, or unexplained falls.METHODS:Carotid sinus massage performed for 5 seconds in both supine and erect postures, both before and after atropine. Contraindications to carotid sinus massage were the presence of carotid bruits, recent myocardial or cerebral ischemia, or previous ventricular tachyarrhythmias.RESULTS:Two cases of neurological complications were reported from a total of 500 patients (2000 massage episodes) investigated in one center, giving an incidence of 0.1%. Combining this data with another center performing investigations in a similar fashion, seven neurological complications arose from a total of 5000 massage episodes, an incidence of 0.14%. Reported complications were pyramidal signs in five cases and visual field defects in two. Pyramidal weakness persisted in one case with a pre‐existing stroke on the same side, and a visual field loss was permanent in one.CONCLUSIONS:Neurological complications following carotid sinus massage for diagnosis of the carotid sinus syndrome are uncommon and usually transient. Contraindications to carotid sinus massage should be respected and the standardized technique

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1994.tb06505.x

出版商:Blackwell Publishing Ltd    

年代:1994

数据来源: WILEY

摘要:

OBJECTIVE:To identify predictors of nonresponse in a community survey of cognitive status in the elderly.DESIGN:Cross‐sectional community survey with two stages of recruitment: an initial, less‐intensive method, followed by a more aggressive approach that included face‐to‐face contact. Characteristics of initial nonresponders and responders were compared.SETTING:A close‐knit rural community with higher than usual proportions of elderly, especially the very old. Subjects were interviewed in their homes. Collateral informants were subsequently interviewed by telephone.PARTICIPANTS:Utah heads of household aged 75 and older who resided in a noninstitutionalized setting.MEASUREMENTS:Mini‐Mental State Examination (MMSE), Dementia Questionnaire, and an autobiographical risk factor and family history questionnaire provided measures for all independent variables. The dependent variable was status as initial responders or initial nonresponders.RESULTS:An initial participation rate of 63% was achieved, but a final rate of 93% was achieved when initial nonresponders were contacted later face‐to‐face. MMSE score was significantly related to responder status when analyzed alone (p = ‐.19, P = 0.02) and remained a significant predictor after adjusting for education and whether born in Cache County (P = ‐.16, P = 0.041) or current drinking, diabetes, or “other” health problems (P = ‐.18, P = 0.028). After controlling for the informant report of subject's problems with activities of daily living, MMSE score fell just below statistical significance (P = ‐.16, P = 0.079).CONCLUSIONS:Nonresponders in community surveys of the elderly appear to be disproportionately cognitively impaired. The increase in participation rates achieved after more persistent recruitment suggests that many initial nonresponders can still be recruited if

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1994.tb06506.x

出版商:Blackwell Publishing Ltd    

年代:1994

数据来源: WILEY

摘要:

OBJECTIVES:We determined elderly persons' knowledge about the epidemiology and treatment of urinary incontinence (UI) as part of a preintervention survey for the Educational Demonstration of Urinary Continence Assessment and Treatment for the Elderly (EDUCATE).DESIGN:An intact‐group pretest—posttest design was employed to measure the effects of multimethod educational interventions on the knowledge, attitudes, and practices of physicians and older people concerning UI.PARTICIPANTS:A random sample of community‐dwelling people aged 65 years and older from two counties in Massachusetts was selected (n= 1,140).MEASUREMENT:A 14‐item urinary incontinence quiz was developed from information presented in the AHCPR UI Guideline Panel's recommendations. Participant answers to the quiz were part of a 20‐minute telephone interview.RESULTS:For nine of the fact items, the elderly respondents were more likely to give the correct answer than the incorrect answer. However, for only four of those nine did the percentage of correct responses exceed 50% (there were substantial proportions of “don't know” responses). For several fact items, those who were younger, female, or had more formal education were more likely to provide correct responses.CONCLUSIONS:There are substantial gaps in the knowledge of older persons about urinary incontinence, especially among men, those age 85 and older, and those with lower levels of education. These knowledge gaps may contribute to misinterpretation of symptoms and underreporting of symptoms to health care professionals. This pattern of findings indicates a greater need for community education on urinary

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1994.tb06507.x

出版商:Blackwell Publishing Ltd    

年代:1994

数据来源: WILEY

摘要:

OBJECTIVE:To determine the efficacy of intracavernosal injection of prostaglandin E1(alprostadil) in elderly men with erectile failure.DESIGN:Prospective study.SETTING:Outpatients at a university‐affiliated VA Medical Center.PARTICIPANTS:Ten subjects aged 65 years and older with duration of erectile failure of 6 months or longer.INTERVENTIONS:Subjects received intracavernosal injections of prostaglandin E1in the office and self‐administered intracavernosal prostaglandin E1at home.MEASUREMENTS:Penile rigidity was measured by palpation and by the Rigiscan rigidity monitor.RESULTS:Intracavernosal injection of prostaglandin E1produced erections adequate for intercourse in 9 of the 10 subjects. Attempts at intercourse were rated satisfactory by two‐thirds of the subjects and their spouses.CONCLUSIONS:Intracavernosal injection of prostaglandin E1is safe and effective for erectile failure in elderl

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1994.tb06508.x

出版商:Blackwell Publishing Ltd    

年代:1994

数据来源: WILEY

摘要:

OBJECTIVE:Traditional mental status and psychometric assessments bottom out in the late stages of Alzheimer disease (AD). A method adapted from cognitive testing in infants, the Ordinal Scales of Psychological Development was modified (M‐OSPD) and applied to a severely demented population. The concurrent validity of this method was tested in comparison with Functional Assessment Staging (FAST). Internal consistency as a measure for reliability was also determined.DESIGN:Cross sectional study.SETTING:Subjects were generally evaluated in their residence, usually a nursing home or a private home.PATIENTS:Severely cognitively impaired subjects who fulfilled criteria for probable AD were studied.MEASUREMENTS:Evaluation consisted of clinical global, mental status, functional, and cognitive assessments including the Global Deterioration Scale (GDS) and the Mini‐Mental State Examination (MMSE).RESULTS:Seventy patients were evaluated. Traditional mental status assessments (eg, the MMSE) manifested virtually uniform bottom scores in all GDS stage 7 subjects (n = 46), and GDS stage 6 subjects had MMSE scores within one standard deviation unit of zero. In contrast, the M‐OSPD scale continued to show results in the last stages of the disease. The Spearman correlation coefficient between the M‐OSPD total score and the 11 FAST substages represented in this sample was −0.77 (P<0.001).CONCLUSIONS:The results indicate that patients who are functionally more impaired also show continuing increments in cognitive loss. These cognitive and functional assessments for measuring the magnitude of deterioration in AD can be applied to the estimated half‐million nursing home residents presently labeled “untestable” with the goal of optimization of care and resi

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1994.tb06509.x

出版商:Blackwell Publishing Ltd    

年代:1994

数据来源: WILEY

摘要:

OBJECTIVE:To evaluate the clinical use and adverse effects of enalapril and lisinopril in elderly hypertensive subjects.DESIGN:A multi‐center, retrospective, drug use evaluation survey.SETTING:Ambulatory care clinics at 14 VA and 14 academic medical centers.PATIENTS:422 elderly (>60 years of age) patients with hypertension and no clinical evidence of congestive heart failure.INTERVENTION:At least 3 consecutive months of anti‐hypertensive therapy with either enalapril or lisinopril.MEASUREMENTS:Blood pressure, serum creatinine, serum potassium, concomitant disease states, concurrent medications, and documentation of any adverse event that might be related to ACE inhibitor therapy.RESULTS:There were no significant differences in systolic and diastolic blood pressures, serum creatinine, or serum potassium between enalapril‐ and lisinopril‐treated patients at baseline and after 3 months of therapy. Both treatments resulted in a significant reduction in diastolic blood pressure. There was no significant difference in the incidence of adverse effects between the two treatments. Significantly more patients were dosed on a twice daily regimen of enalapril than lisinopril.CONCLUSION:The data from this retrospective study confirm the safe and effective use of enalapril and lisinopril, two long‐acting ACE inhibitors, in elderly hypertensive

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1994.tb06510.x

出版商:Blackwell Publishing Ltd    

年代:1994

数据来源: WILEY

摘要:

OBJECTIVE:To identify predictors of 6‐month mortality known before emergent admission to intensive care (IC) and to describe obstacles to the use of patient preferences in emergency triage decisions.DESIGN:Historical cohortSETTING:A 600‐bed university hospitalPATIENTS:263 consecutive patients triaged in the emergency room to receive intensive careMEASUREMENTS AND MAIN RESULTS:Medical records were abstracted for age, performance status, and chronic disease severity as predictors of 6‐month survival. Acute Physiology Score (APS) in the emergency room was used as a measure of acute illness severity. Deaths during the 6 months following IC admission were determined from record review and death certificate data. Obstacles to communication of patient treatment preferences at the time of triage were described.Six‐month mortality was 19 percent, and increased with increasing APS, age ≤ 80 (43%), poor performance status (56%), and severe chronic disease (33%) (P ≤ 0.01). In multivariate analysis, APS, age ≤ 80 and performance status were independent predictors of 6‐month mortality. Only APS predicted mortality in hospital.The most common obstacles to use of patient preferences in triage decisions were absence of documented advance directives (95%) and the brief duration of acute illness (72%). Mental status changes were very common in the emergency room for nonsurvivors (61%), but chronic cognitive impairment was rare (3%).CONCLUSIONS:Patients with poor performance status or very advanced age have increased mortality within 6 months of emergent triage to IC. Mental status changes, absence of advance directives, and time constraints are common barriers to communication of patient preferences at the time of triage. Primary care physicians need to elicit and record patients' preferences before the time of emergent dec

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1994.tb06511.x

出版商:Blackwell Publishing Ltd    

年代:1994

数据来源: WILEY