摘要:

Objective: To study the effect of outpatient geriatric evaluation and management on physical function, mental status, and subjective well‐being.Design: Prospective randomized controlled trial with a 1‐year study period.Setting: Large medical school‐affiliated public hospital in an urban community.Subjects: Patients at least 70 years old admitted to the medicine service were screened, randomized, and completed a 1‐year follow‐up interview.Interventions: Comprehensive geriatric evaluation and an outpatient care management program.Main Outcome Measures: Mental status (SPMSQ), ADL (Katz Index), IADL (Five‐Item OARS Scale), Life satisfaction (LSI‐Z), and self‐perception of health status (physical health section of OARS).Results: No significant differences were found for cognitive status, ADL functioning, life satisfaction, nursing home placement, or mortality. The experimental patients reported significantly higher function in IADL and more favorable self‐perception of health status compared with controls.Conclusion: Outpatient comprehensive geriatric evaluation and management appears to be a useful model for providing care to medically frail

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1993.tb06447.x

出版商:Blackwell Publishing Ltd    

年代:1993

数据来源: WILEY

摘要:

Objective: To assess change in cognitive function in elderly individuals with subjective memory loss over a follow‐up interval of more than 3 years.Design: Prospective cohort study.Setting: An outpatient research clinic in aging and dementia at a university hospital.Participants: A convenience sample of 59 healthy, elderly individuals (mean age 68.7 years) with memory complaints but no clinically apparent cognitive dysfunction.Measurements: Participants were given a full diagnostic evaluation and were administered a neuropsychological test battery at baseline and follow‐up. The cognitive assessment battery included 12 tests of recent memory, immediate memory, language function, visuospatial praxis, and psychomotor speed. Most of the tests had been established to be sensitive to cross‐sectional age differences.Results: Of 59 subjects, 54 (91.5%) were successfully followed up an average of 3.4 years later. Between baseline and follow‐up, two tests exhibited significant improvement, two tests exhibited significant decline, and the other eight were unaffected.Conclusion: Elderly individuals with subjective perceptions of cognitive decrements who fail to provide clear evidence of cognitive impairment upon clinical interview are not at high risk for progressive cognitive deterioration over the subsequent 3‐ to 4‐ye

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1993.tb06448.x

出版商:Blackwell Publishing Ltd    

年代:1993

数据来源: WILEY

摘要:

Objective: To determine the influence of differing assumptions of population growth, visit rates, prevalence of functional impairment, physician productivity, and hospitalization rates on projected need for physicians to provide medical care for older persons.Design: Sensitivity analysis of a manpower model.Main Results: The factors that appear to have the most impact on projections of physician need are related to physician productivity, especially delegation to mid‐level providers, and case‐mix. Other factors, such as the variability of census projections and per capita visit rates, are likely to have less effect on overall physician supply needs.Conclusions: Although case mix and delegation to mid‐level providers may both substantially affect the need for physician supply to care for older persons, only the latter can be directly affected by health policy decisions. Consideration should be given to increasing the supply of mid‐level providers and providing incentives for patients and physicians to receive and provide care in delivery systems that utilize mid‐level providers ex

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1993.tb06449.x

出版商:Blackwell Publishing Ltd    

年代:1993

数据来源: WILEY

摘要:

Objective: To identify characteristics present at the time of elders' (≥75 years of age) hospitalization that predicted caregivers' self‐reported physical and psychological health 1 year later.Design: A prospective observational cohort study of 104 family caregivers followed for 1 year from the time of their elders' hospitalization.Setting: Urban community hospital with academic affiliation.Subjects: Caregivers of patients enrolled in an evaluation of inpatient interdisciplinary geriatric assessment who provided care for the entire year of follow‐up and who participated in all interviews.Main Outcomes: Self‐reported physical and psychological health.Results: Caregivers' baseline self‐reported physical health (AOR = 21.8; 95% CI = 4.65–102), the impact of caregiving on their social and leisure time activities (AOR = 9.93; 95% CI = 1.71–57.8), and their relationship to their elders (AOR = 6.50; 95% CI = 1.20–35.2) were all significantly associated with self‐reported physical health at follow‐up. Caregivers' baseline self‐reported health (AOR = 3.70; 95% CI = 1.11–12.5), whether or not they had additional current caregiving responsibilities (AOR = 6.67; 95% CI = 1.89–25.0), and the interaction of perceptions of caregiving and the adequacy of family help were significant predictors of psychological health at follow‐up, adjusted for baseline psychological health.Conclusion: Information available at the time of elderly patients' admission to the hospital can help to differentiate those caregivers at risk for future physical and psychological distress from those who are li

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1993.tb06450.x

出版商:Blackwell Publishing Ltd    

年代:1993

数据来源: WILEY

摘要:

Objective: To describe relationships between age and subclinical cardiovascular disease, manifest chronic disease, and physical functioning and limitations among persons aged 65 years and older, with emphasis on the “oldest old,” those 85 years and older.Design: Observational population‐based study.Setting: Four U.S. communities: Forsyth County, North Carolina; Sacramento County, California; Washington County, Maryland; and Pittsburgh, Pennsylvania.Participants: 5,201 men and women aged 65 years and older.Measurements: Demographic data; histories of cardiovascular disease (CVD), chronic lung disease, arthritis, diabetes, and hypertension; measures of subclinical disease including arm and ankle blood pressures, internal carotid wall thickness and stenosis, ejection fraction, left ventricular mass, fractional shortening, and diastolic function, electrocardiographic left ventricular hypertrophy and cardiac injury score, forced expiratory flow and volume; functional status including self‐reported physical functioning, hearing and sight limitations and health status, and performance‐based measures of function. These variables were examined among men and women in three age groups: 65–74 years, 75–84 years, and 85+ years. Subgroups of participants with and without manifest CVD were also examined.Main Results: In women, the prevalence of CVD and other chronic conditions increased with age, and the highest rates occurred among those 85 years and older. In men, prevalence rates increased between the two younger groups, but the oldest group had lower than expected rates for coronary heart disease, cerebrovascular disease, hypertension, and chronic lung disease. In contrast, there were strong age‐related linear trends in most of the subclinical measures of blood pressure, atherosclerosis and pulmonary function and in virtually all measures of functional status in both gender groups across the age range. There was a particularly marked decline in functional status between the two older age groups. While subclinical disease was greater and functional status was poorer among those with manifest CVD, with few exceptions, age‐related trends were not significantly different between the two groups.Conclusions: Lower than expected prevalence rates of CVD among those aged 85 years and older, particularly among men, in this study of community‐dwelling elderly may represent selection bias or a real plateauing in disease prevalence with age. However, subclinical disease appears to increase and functional status to decline across the age range in both men and women regardless of the presence of CVD. The apparent increase in subclinical disease with age indicates potential for CVD prev

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1993.tb06451.x

出版商:Blackwell Publishing Ltd    

年代:1993

数据来源: WILEY

摘要:

Objective: To evaluate the skeletal health, calcium, and vitamin D homeostasis of patients upon their entry to a long‐term‐care facility. Factors that could contribute to the risk of future osteoporotic fractures were also evaluated.Design: Cross‐sectional study.Patients: Two hundred eighty‐seven consecutive admissions were invited to participate; 109 patients were recruited into the study.Measurements: A high prevalence of low to low‐normal circulating levels of 25(OH)D was found in nursing home residents upon their admission to the nursing home, with 86% of the patients having circulating 25(OH)D levels of less than 50 nmol/L and 41% having levels below 25 nmol/L. Frankly elevated parathyroid hormone levels were found in 16% of the patients. Additionally, alkaline phosphatase and osteocalcin levels were elevated in 23% and 13% of the patients, respectively. Bone mineral measurements were in the osteoporotic range for 85% of the nursing home residents. Bone density results for females with a history of any classic osteoporotic fracture were significantly lower than for those with no fracture history (68.5 arbitrary units (AU) for those with no fracture history, 58.8 AU in those with history of hip fracture;P<0.05). The bone mineral measurements were higher in women with adequate 25(OH)D compared with women with deficient or borderline 25(OH)D with and without fracture history. Levels of 25(OH)D were positively correlated with urine calcium/creatinine (r= .24;P= 0.03) and 1,25(OH)2D (r= .28;P= 0.01) and were negatively correlated with 1–84 PTH (r= ‐.24;P= 0.02).Conclusion: Hypovitaminosis D is prevalent among elderly patients entering a nursing home with secondary hyperparathyroidism and apparently increased bone turnover present in patients with circulating 25(OH)D levels below 50 nmol/L. Bone density measurements showed that a majority of the individuals entering a nursing home are osteoporotic. There is a positive association between 25(OH)D levels and bone mass and a negative association between 25(OH)D levels and a histor

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1993.tb06452.x

出版商:Blackwell Publishing Ltd    

年代:1993

数据来源: WILEY

摘要:

Objective: To describe the patterns of use of health and human services by elderly rural individuals and to determine whether cognitively impaired persons had a distinctive pattern of service utilization.Design: An epidemiological survey and cognitive screening of an age‐stratified random community sample.Setting: The mid‐Monongahela Valley, a rural community in Southwestern Pennsylvania.Participants: 1366 non‐institutionalized persons aged 65 years and older, fluent in English, and with at least a sixth grade education.Measurements: We administered a battery of cognitive screening tests (the Mini‐Mental State Examination; Immediate and Delayed Recall of a Story; Immediate and Delayed Recall of a Word List; CERAD modification of the Boston Naming Test; Verbal Fluency for initial letters P and S and for names of Fruits and Animals; Temporal Orientation; Praxis; Clock Drawing; and Trailmaking Tests A and B.) We also obtained basic demographic information and enquired about the use of health and human services in the previous year.Results: Approximately 10% of the sample was classified (by operational criteria) as cognitively impaired. In univariate analyses, cognitive impairment was found to be significantly associated with the use of certain health services: hospitalization in the previous 6 months (odds ratio, OR = 2.1; 95% CI = 1.3, 3.3), previous nursing home use (OR = 9.3; 95% CI = 3.8, 22.9), home health care (OR = 4.6; 95% CI = 2.7, 8.0), social services (OR = 6.5; 95% CI = 3.4, 12.4), mental health services (OR = 2.8; 95% CI = 1.2, 6.2), and the regular use of prescription medications (OR = 2.0; 95% CI = 1.3, 3.2). Visits to physicians were not significantly different between the impaired and unimpaired groups. In a multiple regression model, which included age and educational level, the use of home health care (OR = 3.4; 95% CI = 1.8, 6.4) and social services (OR = 2.3; 95% CI = 1.1, 4.9) remained significantly associated with cognitive impairment.Conclusions: The association of cognitive impairment with the use of these health and human services underscores the general frailty of the impaired group. These findings also point to potential target groups in the community for further evaluation and services for dementia. The findings support the need for education regarding cognitive impairment and dementia to be made available to providers of these services, particularly informal social services such as those provided by church

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1993.tb06453.x

出版商:Blackwell Publishing Ltd    

年代:1993

数据来源: WILEY

摘要:

Objective: To compare the efficacy and safety of intramuscular cefoperazone and intramuscular ceftriaxone in the treatment of nursing home‐acquired pneumonia in the nursing home setting.Design: A randomized clinical trial.Setting: Skilled nursing wards at the Veterans Home of California.Patients: 104 residents of skilled nursing wards, aged 65 years or older.Interventions: Intramuscular administration of either cefoperazone or ceftriaxone.Measurements: The variables analyzed for baseline comparability were demographics (age, sex), clinical variables (duration in nursing home; presence of sputum, fever, cough, or leukocyte count), and clinical symptoms and signs. Efficacy was assessed by days of therapy, final maximum temperature, and clinical and bacteriological response.Results: Fifty residents received cefoperazone, 1 gm every 12 hours, intramuscularly. Fifty‐four residents received ceftriaxone, 1 gm every 24 hours, intramuscularly. The total duration of treatment was scheduled for 10 days. Clinical cure was seen in 45 (90%) of the cefoperazone treatment group and 51 (94%) of the ceftriaxone treatment group, with a mean duration of therapy of 10.30 and 9.90 days, respectively. Satisfactory sputum specimens were collected in 71% of the treated residents; the most common isolate wasStreptococcus pneumoniae, followed byHaemophilus influenzaeandStaphylococcus aureus, respectively. The overall mortality was 4.5% at long‐term follow‐up. Both agents were well tolerated and no therapy was discontinued due to intramuscular pain or abnormal laboratory values.Conclusions: Intramuscular cefoperazone and intramuscular ceftriaxone are safe and effective in the treatment of nursing home‐acquired pneumonia. The clinical outcomes in both treatment groups support their use within this select population without the need for transferring the patient to an acute care hospital. Clinical studies are needed to evaluate the impact of such therapy on the control of health care expenditures within the nursing home

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1993.tb06454.x

出版商:Blackwell Publishing Ltd    

年代:1993

数据来源: WILEY

摘要:

Objective: To determine if older patients undergo fewer cardiovascular imaging procedures (CIPs) than younger patients when admitted to a tertiary care academic medical center for an acute myocardial infarction (MI), after adjusting for disease severity and comorbidities.Design: Non‐current prospective cohort study.Setting: Urban tertiary care academic medical center.Patients: Medical records of 294 patients admitted and diagnosed with an acute MI between January 1990 and April 1991 were reviewed.Measurements: The total number of different CIPs performed during hospitalization was determined. Cardiac catheterizations, echocardiograms, radionuclide ventriculograms, and thallium scans counted as CIPs. Disease severity was assessed by the Acute Physiology Score (APS) of APACHE II, admission Killip's Classification, and peak creatine phos‐phokinase (CPK) levels. Comorbidities were assessed using a modified Comorbidity Damage Index of Charlson.Results: The mean (± SD) number of different CIPs performed during hospitalization was significantly less for those ≥75 years old (1.3 ± 1.0) than for those<75 years old (1.7 ± 1.0) (P= 0.01), and CIP number negatively correlated with age (Spearmanr= −0.178;P= 0.01). Mean CIP number decreased from 2.0 ± 1.1 for those355 U/L); admission to a cardiology, medical, or family practice service; no CIP performed at an outside hospital prior to transfer; admission Killip's Classification of less than IV, and a Q‐wave MI. After adjusting for these variables in a multiple regression model, age ≥75 remained an independent predictor of decreased CIP use (P= 0.003). The modified comorbidity index score and the APS score, a general measure of severity of illness, were not significantly associated with CIP use. When procedures were examined individually, no significant age‐related differences were noted in the use of thallium scans, radionuclide ventriculograms, or echocardiograms. Older patients did, however, remain less likely to undergo cardiac catheterizations (P<0.001).Conclusion: Older patients, regardless of underlying disease severity or comorbidities, undergo fewer invasive cardiovascular evaluations than younger patients when admitted to a tertiary care academic medical ce

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1993.tb06455.x

出版商:Blackwell Publishing Ltd    

年代:1993

数据来源: WILEY

摘要:

Objective: To determine the incidence and remission rates of daytime urinary incontinence (UI) in a cohort of newly admitted nursing home (NH) residents.Design: Prospective cohort study.Setting: Eight proprietary NHs in Maryland.Subjects: Four hundred thirty new admissions age 65 or older who were participants in a larger prospective study of mental morbidity and adjustment to the NH.Measures: Nurses aides' reports of continence status, psychiatric examinations, and nursing staff assessments of mobility at 2 weeks, 2 months, and 1 year after NH admission.Results: The prevalence of daytime UI at admission was 39% in both females and males. Among the 293 members (68%) of the admission cohort remaining in the NHs 2 months after admission, the incidence of daytime UI was 27% (21% in females, 51% in males); daytime UI resolved in 23% (24% in females, 20% in males). Among the 178 members (41%) of the admission cohort remaining in the NHs 1 year after admission, the incidence of daytime UI between 2 months and 1 year after admission was 19% (16% in females, 46% in males); daytime UI resolved in 22% (23% in females, 14% in males). The continence status of about two‐thirds of residents remaining in the NH at 1 year after admission was stable over time: 22% had daytime UI, and 42% were continent at all three data collection points. The development of daytime UI was associated with male sex, the diagnosis of dementia, fecal incontinence, and the inability to ambulate or transfer independently. Resolution of daytime UI was associated with the absence of these characteristics.Conclusions: Despite limitations attributable to the method of defining UI and potential biases related to the attrition of the admission cohort over time, this is the first large prospective study to examine the incidence and remission patterns of daytime UI among NH residents. The strong association between UI and dementia was validated for the first time by direct psychiatric examinations. Sex and mobility are also closely associated with the development and remission of UI in this setting. This study provides some valuable data that can be used to assess the impacts of the recently developed Resident Assessment Protocol for UI and Agency for Health Care Policy and Research Clinical Practice Guideline

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1993.tb06456.x

出版商:Blackwell Publishing Ltd    

年代:1993

数据来源: WILEY