ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1994.tb06975.x

出版商:Blackwell Publishing Ltd    

年代:1994

数据来源: WILEY

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1994.tb06976.x

出版商:Blackwell Publishing Ltd    

年代:1994

数据来源: WILEY

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1994.tb06977.x

出版商:Blackwell Publishing Ltd    

年代:1994

数据来源: WILEY

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1994.tb06978.x

出版商:Blackwell Publishing Ltd    

年代:1994

数据来源: WILEY

摘要:

OBJECTIVE: To assess variability in the use of coronary artery bypass grafting (CABG) and percutaneous transluminal angioplasty (PTCA) in the Systolic Hypertension in the Elderly Program (SHEP) cohort with incident coronary heart disease (CHD) by age, sex, and race.DESIGN: Retrospective analysis of a multicenter prospective cohort study.PATIENTS: Among 4736 subjects initially enrolled in SHEP, there were 432 incident cases of CHD, excluding those patients who experienced rapid or sudden cardiac death.SETTING: Community‐based ambulatory population in academic centers.MAIN OUTCOME MEASURE: Incident cases of CHD who underwent CABG or PTCA.RESULTS: Of those participants ≤ 60 and75 years (P = 0.14). 15.4% of those lt75 underwent CABG surgery, compared with 7.8% of those 75 and older (P = 0.018). When both of these endpoints, CABG and PTCA, were combined, 22.4% of those lt75 underwent a procedure, while only 11.7% of the older cohort did (P = 0.005).Twenty‐six percent of men underwent either CABG or PTCA, while only 9.1% of women did (P<0.001). Of those<75 years of age, 31.1% of men and 12.3% of women underwent CABG or PTCA (P<0.001). In the 75 and older age category, 19.5% of men underwent these interventions, compared with 5.9% of women (P = 0.005).Active treatment group was significantly associated with decreased use of procedures in participants<75 year old with CHD. Race, activity limitations, number of comorbid conditions, education level, marital status, employment status, and social support were not significantly associated with CABG or PTCA use. When the variables studied were ntered into a logistic regression model, increased age and female sex remained independently associated with decreased CABG and PTCA use.CONCLUSION: In the SHEP trial older patients and women, regardless of comorbid conditions, socioeconomic status, and social support, underwent less intensive cardiovascular interventions than did younger patients and men when they develope

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1994.tb06979.x

出版商:Blackwell Publishing Ltd    

年代:1994

数据来源: WILEY

摘要:

OBJECTIVE: To describe the prevalence and content of long‐term care facility policies regarding the use of life‐sustaining treatments (cardiopulmonary resuscitation (CPR), artificial hydration and nutrition, dialysis, antibiotics for life‐threatening infections, transfer to acute care hospital) and advance directives in Canada.DESIGN: Cross‐sectional mailed survey.SETTING: Canadian long‐term care facilities with 25 beds or more listed in the 1991–92 Directory of Long Term Care Centres in Canada. Institutions listed as, “general hospitals,” “psychiatric hospitals,” “children's treatment centres,” “group homes,” or as purely residential facilities were excluded.PARTICIPANTS: Chief Executive Officers or their designates.MAIN OUTCOME MEASURES: Respondents' self‐reports regarding the existence of life‐sustaining treatment or advance directive policies and content analysis of the policies themselves.RESULTS: Of 1472 long‐term care facilities, 1021 (69%) responded. Of these, 344 (34%) institutions had 397 policies regarding the use of life‐sustaining treatments or advance directives. Three hundred twenty facilities (31%) had 349 do‐not‐resuscitate (DNR) policies (40% on CPR alone and 60% on CPR plus other life‐sustaining treatments). Seventeen institutions (2%) each had one policy addressing life‐sustaining treatments other than CPR, and 31 institutions (3%) each had one policy addressing advance directives. Of the 397 policies, 171 (43%) required routine discussion with all patients, 156 (39%) mentioned futility, 331 (83%) indicated that the competent patient had the right to make a decision about life‐sustaining treatment, 265 (67%) indicated that the family of the incompetent patient had this right, 27 policies (7%) mentioned conflict resolution, 378 (95%) had an explicit requirement for recording the decision, 10 (3%) required explicit communication of the decision to the competent patient, 10 (3%) required such communication to the family of the incompetent patient, 260 (66%) required updating of the decision, and 213 (54%) mentioned rescinding or changing the decision.CONCLUSIONS: Only one‐third of Canadian long‐term care facilities have do‐not‐resuscitate policies, and even fewer have policies on advance directives or life‐sustaining treatments other than CPR. The policies themselves could be improved by encouraging routine advance discussions, scrutinizing the use of the futility standard, stipulating procedures for conflict resolution, and explicitly requiring communication of the decision to competent patient

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1994.tb06980.x

出版商:Blackwell Publishing Ltd    

年代:1994

数据来源: WILEY

摘要:

OBJECTIVE: To compare three approaches for improving compliance with influenza and pneumococcal vaccination of elderly patients.DESIGN: Randomized controlled trial using three parallel group practices at a public urban teaching hospital.SETTING: Public teaching hospital.SUBJECTS: All patients 65 years of age and older (n = 1202) seen by resident physicians (n = 66) attending three ambulatory medical practices from October 1, 1989 to March 31, 1990.INTERVENTIONS: All three provider groups received intensive education in immunization standards. The control group received no further intervention. Staff in the second group offered education to patients at their visits. In the third group, the prevention team, a flowsheet was used, patient education offered, and staff had their tasks redefined to facilitate compliance; for vaccinations, eg, nurses could vaccinate independent of MD initiative.MEASUREMENTS AND MAIN RESULTS: Medical records were reviewed for the 1202 patients seen, including 756 patients seen during both the 1988‐89 and 1989‐90 influenza seasons, to determine documented offering and receipt of vaccinations. During the intervention period (1989‐90), influenza vaccinations were offered significantly more frequently to prevention team patients (68.3%) than to patients in either the patient education (50.4%) or control (47.6%) groups (P = 0.006), even after adjusting for the patients' prior vaccination status, age, gender, race, and high‐risk co‐morbidity and for physicians' level of training. Likewise, pneumococcal vaccinations were offered more frequently to previously unvaccinated prevention team patients (28.3%) than to patient education (6.5%) or control (5.4%) group patients (P = 0.001), even after adjusting for the factors using multivariate analysis. Compliance rates did not differ between patient education and control subjects for either vaccine. Pre‐intervention physician surveys documented higher perceived than actual compliance for both vaccines, with 89.0% and 52.8% of physicians believing that they complied with influenza and pneumococcal vaccination guidelines, respectively.CONCLUSIONS: The results of this trial provide strong support for organizational changes that involve non‐physician personnel to enhance vaccination rates among

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1994.tb06981.x

出版商:Blackwell Publishing Ltd    

年代:1994

数据来源: WILEY

摘要:

OBJECTIVE: To determine the effects of carbamazepine versus placebo on ratings of behavior in agitated nursing home patients with dementia.DESIGN: Nonrandomized, placebo‐controlled, crossover trial conducted in 25 patients in two nursing homes.INTERVENTION: Carbamazepine and placebo were administered during two 5‐week periods separated by a 2‐week washout. The carbamazepine dose was determined for each patient by a nonblinded physician who did not participate in ratings (modal dose 300 mg/day).MEASUREMENTS: The primary outcome measures were Brief Psychiatric Rating Scale scores and Clinical Global Impression of Change, rated by blind observers. Secondary measures of behavior, adversity, cognition, and functional status were also included.MAIN RESULTS: Median total Brief Psychiatric Rating Scale score decreased 7 points on carbamazepine versus 3 on placebo (P = 0.03). Sixteen subjects were rated as improved globally on carbamazepine versus four on placebo (P = 0.001). Secondary measures of behavior showed similar changes at significant or suggestive (P<0.10) levels. One subject developed carbamazepine‐induced tics, and one died with a pneumonia. There was minimal other adversity.CONCLUSION: This preliminary study suggests that carbamazepine in low doses can reduce agitated behaviors in some patients, with limited adversity resulting. Further research is required to confirm and extend this finding before it can be considered routine clinical p

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1994.tb06982.x

出版商:Blackwell Publishing Ltd    

年代:1994

数据来源: WILEY

摘要:

OBJECTIVE: To define a sensitive and specific index, based on nutritional indicators, predicting mortality in nursing home patients.DESIGN: A prospective cohort study.SETTING: A nursing home.MEASUREMENTS: Anthropometric and laboratory nutritional indicators were assessed in 104 nursing home elderly residents (20 males, 84 females). Patients were aged 60 years and older and had relatively good somatic health and nutritional status. Mortality data were collected over an 18‐month follow‐up period. Discriminant analysis was used to compute an adimensional measure (index) that could predict mortality with the highest sensitivity and specificity.RESULTS: Mortality was 0.20/year. A nonlinear, “U‐shaped” relationship of cholesterol levels with mortality was found. A prognostic index based on cholesterol, lymphocyte count, mid‐arm circumference, hemoglobin, age, and gender was obtained. Higher values of this index were associated with progressively higher risks at 12 months and 18 months. Sensitivity and specificity calculated on 18‐month mortality were 80% and 78.4%, respectively.CONCLUSIONS: This index, based on simple measures, can be a useful tool in the evaluation of health status of the elderly living in

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1994.tb06983.x

出版商:Blackwell Publishing Ltd    

年代:1994

数据来源: WILEY

摘要:

OBJECTIVE: We report the development and validation of an MDS‐based cognitive index, the MDS Cognition Scale (MDS‐COGS), by evaluating it against two popular dementia rating scales, the Global Deterioration Scale (GDS) and the Mini‐Mental State Examination (MMSE).DESIGN: A Cross‐sectional study.PARTICIPANTS: Two hundred nursing home residents.MEASUREMENTS: Each study participant was assessed on the GDS and the MMSE by trained medical students. At the same time, but independent of the medical students, a geriatric nurse completed the Minimum Data Set (MDS) instrument on each participant.MAIN RESULTS: The Cognitive Performance Scale (CPS), a categorical measure of cognition that uses MDS items, was compared with the GDS in 133 subjects, using a split‐sample technique. The GDS was found to be more appropriate as a 4‐stage than a 7‐stage scale, with GDS stages 1–4 acting as a single stage. The CPS showed very poor percent agreement with GDS stages 5 and 7 (50% or less) and, therefore, was revised by adding other MDS predictors. The new instrument, designated MDS‐COGS, is a 0–10 point scale generated from eight MDS cognitive items. The MDS‐COGS was then validated against the 4‐stage GDS and MMSE in the remaining 67 nursing home residents. Chance‐corrected agreement (kappa) between the MDS‐COGS and GDS in the 67 subjects was 0.80 (95% CI = 0.70, 0.88), and percent agreement with GDS stages 5 and 7 was 60% and 85%, respectively. The MDS‐COGS was also demonstrated to be a valid measure of cognitive impairment as defined by the MMSE, with sensitivity, specificity, chance‐corrected agreement (kappa), and area under the ROC curve, all above 0.80.CONCLUSIONS: The MDS Cognition Scale, the MDS‐COGS, provides a valid measure of the presence and severity of cognitive impairment in nursing home residents usin

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1994.tb06984.x

出版商:Blackwell Publishing Ltd    

年代:1994

数据来源: WILEY