摘要:

ObjectiveTo evaluate the effect of an Inpatient Geriatric Consultation Team on patient outcome.DesignRandomized controlled clinical trial.SettingA non‐academic‐affiliated 503‐bed community hospital.PatientsAll inpatients over the age of 70 years. Sixty‐two patients received multidimensional geriatric assessment and 58 patients received no intervention.InterventionTeam assessment, leading to formal recommendations to the attending physician.MeasurementsData were collected on hospital length of stay, referrals to community service, discharge destination, hospital readmissions in 6 months, number of post‐discharge physician visits, and change in functional status. Mortality at 6 months and at 1 year was determined for each patient.Main ResultsAt 6 months, 12/58 patients (21%) had died in the control group versus 3/62 (6%) patients in the experimental group (P= 0.01). During hospitalization, the length‐of‐stay was 10.1 days for the control group versus 9.0 days for the experimental group (P= 0.20). The control group had significantly more readmissions (0.6 per patient vs 0.3 per patient,P= 0.02). A higher number of experimental patients, 22% (13/59), showed improvement in ADL scores compared with 7% (4/46) of control patients,P= 0.07. At one year for all randomized patients, 7/68 (10%) of experimental patients and 13/64 (20%) of control patients had died.ConclusionsShort‐term mortality can be reduced in community inpatient acute hospital settings by comprehensive geriatric consultation teams. Important differences in mortality remain at 1 year of followup. Trends towards improved functional status and fewer hospital readmissions favor the int

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1993.tb02040.x

年代:1993

数据来源: WILEY

摘要:

ObjectiveTo assess the occurrence, type, and burden of adverse clinical events (ACE) among residents of chronic facilities. An ACE is any acute or subacute change in health status suggesting acute or subacute illness.DesignSurvey with face‐to‐face functional assessment and 3‐month retrospective chart review.Study PopulationOne hundred six continuing‐care residents with a minimum length of stay of 4 months at an Italian chronic care facility.MeasurementsFunctional assessment and chart review‐based classification of ACE burden on care management according to a clinical‐functional Severity Rating Scale.Main ResultsFunctional dependence, dementia and concurrent clinical problems were common. Two hundred seventy‐three ACEs were detected. Eighty‐nine percent of residents experienced at least one ACE. Only 21% of ACEs could be managed by simple medical intervention and monitoring within 1 day; in 23% there was need for more complex care management; 7% of the latter ACEs resulted in residual (new) functional impairment. Cardiovascular and gastrointestinal systems were most commonly involved in ACEs. Neurological ACEs were the most frequent category leading to new functional impairment (22%). ACE occurrence/burden was higher in male residents (P<0.01) and strongly associated with the number of concurrent medical problems (P<0.001). Neither cognitive nor functional dependence levels were related to ACE occurrence.ConclusionsThis description of the burden on care management resulting from acute and subacute changes in clinical and functional status of chronic patients emphasizes the continuing and unpredictable nature of medical attention required in a nursing home or chronic care facility. ACEs occur far more frequently among the elderly than is generally recognized. Thus a high level of medical and nursing skill is necessary in chronic

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1993.tb02041.x

年代:1993

数据来源: WILEY

摘要:

ObjectiveTo examine public opinion regarding certain elements of consent: disclosure, advance directives, substitute decisions, emergency treatment, and advocacy.DesignCross‐sectional random‐digit‐dialing telephonic survey.SettingGeneral public.ParticipantsOne thousand randomly‐selected adults living in Ontario.InterventionsNone.Main Outcome MeasuresSelf‐reported attitudes and behaviors.ResultsOf 5,708 telephone numbers drawn, 641 were non‐valid or non‐residential, 1,283 were not in service, 1,068 had no answer, a busy line, or an unavailable respondent, 147 subjects had a language barrier, 1,497 subjects refused, 72 interviews were incomplete, and 1,000 interviews were completed. With regard to disclosure, 33% of respondents said that a doctor should withhold information from a patient if asked to do so by the patient's family. With regard to advance directives, 36% of respondents had had advance discussions with their families, and 12% had completed a living will. With regard to substitute decisions, 77% of respondents said that they would want their wishes followed if they were unable to make medical decisions for themselves; 58% wanted their spouse or partner to make such decisions for them. With regard to emergency treatment, 48% of respondents stated that a doctor should give a life‐saving blood transfusion to an unconscious adult carrying a card stating that blood transfusion was against his or her religious beliefs. With regard to advocacy, 78% of respondents supported mandatory advocacy services for serious health decisions such as whether to have heart surgery; 33% supported advocacy services for less serious decisions such as whether to have a dental filling.ConclusionsThese data highlight the need to reconsider legislative provisions regarding and/or target public education programs toward specific consent‐related issues including disclosure, advance directives, substitute decisions, emergency treatm

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1993.tb02042.x

年代:1993

数据来源: WILEY

摘要:

ObjectiveTo determine the prevalence of underweight and hypoalbuminemia in Veterans Affairs nursing home residents and the frequency with which physicians, nurses, and dieticians documented their awareness of the presence of underweight and hypoalbuminemia.DesignRetrospective survey of medical records.SettingTwenty‐six Department of Veterans Affairs nursing homes located in the Department's Central Region.Patients2811 residents.Main Outcome Measures(1) Prevalence of underweight (defined as body weight less than 80% of standard) and hypoalbuminemia (defined as serum albumin less than 3.5 g/dl); (2) frequency with which physicians, nurses, and dieticians documented the prevalence of underweight and hypoalbuminemia in the records.ResultsThree hundred thirty‐two (11.8%) of the patients were underweight and 772 (27.5%) were hypoalbuminemic. The prevalence of the two conditions varied widely across nursing homes. The prevalence of low serum albumin ranged from 5% to 58% in the 26 institutions, and the prevalence of body weight less than 80% of standard ranged from 2% to 20%. In the Region as a whole, the dietician's notes in the medical charts mentioned underweight in an average of 95% of affected cases but mentioned the suboptimal albumin level in only 82% of the hypoalbuminemic individuals. In the nurses's notes, these figures were only 80% and 45%, respectively, and in the physician's notes, only 62% and 46%, respectively. The frequency of documented awareness of underweight and hypoalbuminemia by nurses and physicians varied tremendously across the 26 facilities (as few as 7% of the undernourished cases in one nursing home, 100% of the affected individuals in another).ConclusionsThis study showed a high prevalence of calorie and protein undernutrition in the nursing home residents of VA nursing homes, wide variation in the prevalence across nursing homes, and frequent lack of documentation of these nutritional deficiencies by physicians and nur

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1993.tb02043.x

年代:1993

数据来源: WILEY

摘要:

ObjectiveTo compare presenting manifestations of meningioma in elderly patients with those in younger patients.DesignRetrospective survey.SettingTertiary care center.PatientsAll hospitalized adult patients with the primary diagnosis of meningioma over a 5‐year period (n= 116). Nine patients with recurrence of a previously resected meningioma were excluded. Fifty‐two percent (56/107) of patients were ≥65 years of age.MeasurementsPresenting symptoms were classified as asymptomatic, focal, non‐specific, or both focal and non‐specific. Presenting neurologic signs on physical examination were classified as focal, non‐focal, or normal. Duration of symptoms was classified as ≤1 week, 1 week to 1 month, 1 to 6 months, and>6 months.ResultsOlder patients presented more commonly with confusion (32% vs 4%) and dystaxia (28% vs 10%) than younger patients and presented less commonly with headache (23% vs 49%) and visual changes (21% vs 43%). While 2% of patients were asymptomatic at presentation, the remainder had symptoms categorized as focal (38%), non‐specific (26%), or both (34%). There was no significant difference between older and younger age groups in the proportions of patients having focal symptoms. Duration of symptoms for all patients was categorized as ≤1 week (15%), 1 week to 1 month (16%), 1 to 6 months (23%), and>6 months (44%). In general, older patients were diagnosed earlier than younger patients. The presence of focal neurologic signs was not significantly different between older and younger patients.ConclusionsPresenting manifestations of meningioma differ between older and younger adult patients, but focality of symptoms and signs is similar. In this case series, the duration of symptoms prior to diagnosis was shorter in older than in

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1993.tb02044.x

年代:1993

数据来源: WILEY

摘要:

ObjectiveTo evaluate what nursing home medical directors actually do, what they and other nursing home personnel believe would be desirable to do, and what problems and deficiencies are perceived.DesignMail survey with follow‐up telephone interview when necessary.SettingForty‐five nursing facilities in upstate New York.ParticipantsThe medical directors, administrators, and directors of nursing of the 45 facilities.MeasurementsInventory of what medical directors reported as to their actual activities and time spent, and of what they, the administrators, and the directors of nursing felt should be their responsibilities and activities under ideal circumstances.ResultsFor part‐time medical directors, self‐reported time spent on medical directorship activities averaged 12 hours per month; of all directors, 45% spent 8 hours or less per month. Proportion of time spent on various specific activities varied widely. There was general agreement that substantially more time should be spent, in particular, on evaluating and addressing problems of adequacy and quality of care, communicating with attending physicians about problems, and assisting with inservice training programs.ConclusionsTo fill the role adequately, more time should be spent by many part‐time medical directors, which will require greater financial commitment by facilities and reimbursement systems. Efforts need to made to better coordinate the expectations of medical directors and facil

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1993.tb02045.x

年代:1993

数据来源: WILEY

摘要:

ObjectiveTo compare the self‐reported role of nursing home medical directors in 1989 (prior to the implementation of the nursing home reform amendments of OBRA 87 in 1990) with the role outlined in the Joint Commission on Accreditation of Healthcare Organizations Long Term Care Standards Manual.DesignSurvey.MeasurementsUsing a telephone interview survey, physicians were questioned about their role as nursing home medical director. Responses were compared with the definition of the medical director's role in the Long Term Care Standards Manual. Information about time spent per month and reimbursement received for medical direction was also obtained.ParticipantsPhysicians serving as nursing home medical directors in 1989 in Houston/Harris County, Texas.ResultsOf 50 nursing home medical director positions in Houston/Harris County in 1989, interviews were completed for 36 (72%). The majority of the medical directors met the criteria for having a signed agreement with the facility, assuring continuous medical coverage, developing emergency procedures, and participating in quality assurance activities. Twenty‐eight percent of the medical directors received no monetary compensation for their work. Of those who were paid, the mean monthly earnings for nursing home medical direction were $345.ConclusionAlthough all nursing facilities are now required by regulation to have medical directors, a wide variation in medical directors' level of involvement and commitment was documen

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1993.tb02046.x

年代:1993

数据来源: WILEY

摘要:

ObjectiveTo explore the relationship between an elderly subject's cognitive status and the reliability of multidimensional assessment data.DesignSurvey, with cognitive status as the independent variable and interrater reliability as dependent variable.SettingMedicare/Medicaid‐certified nursing homes.Participants147 residents age 65 or older.MeasurementsDual assessments of elderly nursing home residents were performed by nurse assessors using the Health Care Financing Administration's new Minimum Data Set for Nursing Home Resident Assessment and Care Screening (MDS). Assessments were classified on the basis of residents' cognitive status, and levels of disagreement between assessors were analyzed.Main ResultsOverall assessment reliability, agreement concerning a resident's activities of daily living status, and the reliability of estimates of his or her communication skills and sensory abilities were significantly affected by a resident's cognitive status. The presence of cognitive impairment made these measurements less reliable—especially those related to communication skills, vision, and hearing.ConclusionsAssessments of residents suffering from cognitive impairment were significantly less reliable than assessments of cognitively intact residents. However, these differences in reliability were not uniform across all assessment domains. When treating the cognitively impaired elderly, clinicians must exercise caution in their reliance on standardized measurements that may be less reliable for this populat

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1993.tb02047.x

年代:1993

数据来源: WILEY

摘要:

ObjectiveTo investigate the relationship of selenium and oxygen‐deactivating enzymes with age in the elderly.SampleThe study sample consisted of volunteers recruited from the PAQUID study. This study is conducted in a representative sample of non‐institutionalized individuals aged ≥65 years living in Southwestern France; its main objective is to study longitudinally the incidence and risk factors of dementia.MethodsPlasma and erythrocyte selenium and activities of oxygen metabolizing enzymes in erythrocytes (GSH‐Px, CuZn‐SOD, and GSSG‐RD) were measured in 239 volunteers (108 males and 131 females; mean age 73.7 years).ResultsPlasma selenium (PSe) decreased significantly with age; a similar but non‐significant trend was found for erythrocyte selenium (ESe). None of the enzyme activities showed a clear relationship with age. Women had significantly higher GSH‐Px activities than men. For PSe levels lower than 77 ng/mL, there was a strong correlation between PSe and GSH‐Px; above this value, the correlation decreased, suggesting that the selenium requirement for GSH‐Px production had been satisfied. In this sample, CuZn‐SOD was correlated negatively with GSH‐Px (r= −0.18;P≤ 0.01) and positively with GSSG‐RD (r= +0.20; P ≤ 0.01).ConclusionsIn individuals aged ≥65 years, we found that blood selenium levels were negatively correlated with age. Our analysis of the relationship between selenium and GSH‐Px activity suggests that low selenium values are associ

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1993.tb02048.x

年代:1993

数据来源: WILEY

摘要:

ObjectiveTo examine the effects of testosterone administration to older hypogonadal males (bioavailable testosterone less than 70 ng/dL).DesignAlternate‐case controlled trial.SettingSt. Louis University.PatientsEight males (mean age 77.6 ± 2.3 years) who received testosterone and six males (mean age 76 ± 2.3 years) who served as controls. Selected from alumni of the SHEP trial and attendees at the St. Louis University Impotence Clinic.InterventionsTestosterone enanthate (200 mg/mL) was administered intramuscularly to the treatment group every 2 weeks for 3 months.MeasurementsSerum testosterone, bioavailable testerone and estradiol, weight, % body fat, right hand muscle strength, balance, cholesterol, HDL‐cholesterol, hematocrit, BUN, creatinine, albumin, calcium, PTH, 25(OH) vitamin D, 1,25 (OH)2vitamin D, osteocalcin, prostate‐specific antigen, and fructosamine.ResultsMales who received testosterone had a significant increase in testosterone and bioavailable testosterone concentration, hematocrit, right hand muscle strength and osteocalcin concentration. They had a decrease in cholesterol (without a change in HDL‐cholesterol) levels and decreased BUN/Creatinine ratios.ConclusionThese preliminary findings support the need for long term studies of testosterone therapy in older hypogona

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1993.tb02049.x

年代:1993

数据来源: WILEY