摘要:

Objective To test the hypothesis that many nursing home residents with an apparently blunted fever response (maximum temperature<101°F) may actually have a significant change in temperature (ΔT ≥ 2.4°F) which is not recognized because of a low baseline temperature.Design: Retrospective chart review for cases of infection that met specific criteria and for chart‐recorded baseline and infection temperatures. Chart‐recorded baseline temperatures were prospectively compared with re‐measurement of morning temperatures.Setting: Nursing Home Care Unit of the VAMC West Los Angeles.Patients: Random review of 40 residents' charts resulted in the detection of 69 infections among 26 residents over a 20‐month period. Fifty randomly selected residents prospectively underwent comparison of chart‐determined and actual re‐measurement of baseline temperatures.Results: In 50 randomly selected residents, the mean oral baseline temperature of 97.4 ± 0.2 (°F ± SEM) closely approximated the mean nurse‐recorded measures in the charts (97.6 ± 0.1). Chart review detected 69 infections among 26 residents, with 53 episodes having a temperature recorded during the infection. The mean maximum temperature (Tmax) during an infection was 101.3 ± 0.3 (°F ± SEM) but 47% (25/53) of the episodes had a “blunted” fever response (Tmax<101°F). Of the 25 “blunted” fevers (Tmax2.4°F) and/or lowering the threshold for recognition of fevers (to 99° or 100°F) in nursing home residents with a change in function sh

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1991.tb04450.x

出版商:Blackwell Publishing Ltd    

年代:1991

数据来源: WILEY

摘要:

Objective: to assess the effect of dizziness on the probability that an older person will die or become functionally disabled within 2 years. Dizziness is a common symptom for which the prognosis is uncertain. This report compares the prognoses for dizzy and not‐dizzy older people in order to assist clinicians who diagnose and treat these patients.Design: a prospective study of a representative sample of elderly (70+) non‐institutionalized Americans. Elderly subjects (n = 3,798) in the Longitudinal Study of Aging (LSOA) were asked questions about the presence of dizziness, medical conditions, and functional disability in 1984. The cohort was reinterviewed about functional disability in 1986.Outcome Measure: transition from functional ability to disability after 2 years.Results: Bivariate analyses showed that dizziness predicts functional decline but not mortality. Multivariate models revealed that age, race, sensory impairment, vascular disease, and other morbidity are independent predictors of becoming disabled. Controlling for these potential confounders, dizziness does not predict an increased probability of becoming disabled.Conclusion: Elderly people who are dizzy should be evaluated for the presence of these related conditi

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1991.tb04451.x

出版商:Blackwell Publishing Ltd    

年代:1991

数据来源: WILEY

摘要:

Objective: We examined predictors of hospital and 6‐month mortality in older Medical Intensive Care Unit (MICU) patients with particular attention to age and functional status. Age is generally thought to be strongly associated with intensive care outcomes, but this relationship may be confounded by age‐related changes. These age‐related changes may be approximated by changes in functional status (FS).Design: We conducted a retrospective chart review and collected severity of illness data using the Acute Physiology Score (APS), pre‐hospitalization FS dichotomized as limited or not limited, and hospital mortality. County death records were reviewed for 6‐month mortalitySetting: Three community hospital MICUs.Patients: Four‐hundred MICU patients aged 50 and older admitted during the study period.Results: Limited FS was found in 42% of the 227 patients who had FS data in the chart. Mortality was significantly associated with APS, age, FS, immunocompromise state, comorbidity, and nursing home residence. In logistic regression analyses, while controlling for important variables, APS (P<0.001) and age ≥75 with limited FS (P<0.05) were associated with hospital mortality. Six‐month mortality predictors were APS (P<0.001), hospital (P<0.05), immunocompromised state (P<0.05) and age ≥75 with limited FS (P<0.05).Conclusions: We found that among patients without functional limitations, the oldest group was no more likely to die than the youngest group. Age and functional status had a significant interaction: patients older than 75 years with functional limitations were almost six times more likely to die in hospital compared to the reference group of patients between 50–64 years old without functional limitations. We conclude that functional status is an important predictor of outcome in

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1991.tb04452.x

出版商:Blackwell Publishing Ltd    

年代:1991

数据来源: WILEY

摘要:

Objective. To examine the relationship between selected resident and facility characteristics and the frequency and quality of tranquilizer prescribing and use in skilled nursing facilities.Design. Retrospective review of medication profiles and pharmacy billing records using standardized protocol.Settings. Seven skilled nursing facilities.Participants. All residents aged 65 years or older were eligible. Consent was given by 760 residents or guardians. Six refused permission.Outcome Measures. Drug use measures included the presence or absence of a tranquilizer order, any tranquilizer use during previous 30 days, and any deviation from selected drug use criteria.Results. Of 760 residents, 38% had an order for an antipsychotic or antianxiety agent, and 28% actually received a tranquilizer. Comparing tranquilizer practices with specific drug‐use criteria showed that nearly 19% of all elderly residents were exposed to some type of excess use such as long duration, polymedicine, or therapeutic duplication. Residents in facilities with less adequate staffing and other resources were significantly more likely to have a tranquilizer order, to have a tranquilizer administered, and to have any deviation from drug‐use criteria. The data also show higher rates of deviation from criteria among residents with a diagnosed mental disorder, younger residents, and Medicaid recipients.Conclusion. More attention must be paid to environmental factors that may undermine current efforts to improve psychotropic drug prescribing and use in skilled nursing facilit

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1991.tb04453.x

出版商:Blackwell Publishing Ltd    

年代:1991

数据来源: WILEY

摘要:

We studied whether Mini‐Mental State Examination (MMSE) norms for detecting dementia in elderly outpatients vary according to educational attainment. Subjects were 109 elderly outpatients with Alzheimer's dementia and 100 non‐demented outpatient controls. Receiver operating characteristics (ROC) of the MMSE were examined among three strata of educational attainment: middle school, high school, and college/graduate school. MMSE ROC curve areas were .95–.96 in the three educational strata. Assuming a dementia prevalence of 10%–30%, the most accurate lower limits of normal for MMSE scores and their attendent sensitivities and specificities were 21 for middle school (.82/.94), 23 for high school (.79/.97), and 24 for college/graduate school (83/1.00) attainment. These norms accurately classified over 90% of subjects in all three educational strata. We conclude that education‐specific norms optimize performance of the MMSE as a screening test for Alzheimer's dementia in elderly ou

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1991.tb04454.x

出版商:Blackwell Publishing Ltd    

年代:1991

数据来源: WILEY

摘要:

Objective: To study the epidemiology of depressive disorder in younger and older medical inpatients.Design, Patients,&Setting: Depressive disorders were examined using the Diagnostic Interview Schedule in 116 young and 332 elderly medically ill men hospitalized in a VA medical center.Results: Major depressive disorder was diagnosed in 22.4% of men under 40 and 13.3% of those age 70 or over; minor depression was found in 18.1% of young and 29.2% of older men. Besides age, other risk factors for major depression were impaired social support, severe medical illness or functional disability in older men, and history of psychiatric problems primarily in younger men; specific medical diagnosis was not a risk factor. Major depression was associated with more severe symptomatology in younger patients; in both age groups, however, symptoms were of prolonged duration and frequently included suicidal thoughts.Conclusions: Depressive disorder in hospitalized male veterans is common, varies with age, severity of medical illness, degree of social support, and history of psychiatric problems and is associated with considerable psychological morbidity.

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1991.tb04455.x

出版商:Blackwell Publishing Ltd    

年代:1991

数据来源: WILEY

摘要:

Objective: To determine if detectable serum tumor necrosis factor alpha (TNF) levels are associated with higher mortality in nursing home residents.Subjects and methods: The basal serum concentrations of TNF and interleukin‐1 alpha (IL‐1) were measured in 129 elderly nursing home patients (mean age of 89 years), and survival in the cohort was monitored over a 13‐month period.Results: At 4 months follow‐up, seven out of 33 patients with detectable serum TNF levels had died (21.2%), and only three out of 96 patients with undetectable serum TNF levels had died (3.1%) (P<0.001). The difference in mortality remained significant up to 13 months of follow‐up (P<0.05). Those with detectable serum TNF levels and those with undetectable levels were comparable in age, body mass index, hematocrit, lymphocyte counts, and serum level of albumin, prealbumin, and retinol‐binding protein. When patients with detectable serum IL‐1 levels were compared to those with undetectable levels, there were no significant differences in mortality over a 13‐month period.Conclusion: Detectable serum TNF levels in elderly nursing home patients may be a predictor of

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1991.tb04456.x

出版商:Blackwell Publishing Ltd    

年代:1991

数据来源: WILEY

摘要:

To address the paucity of patient‐level data regarding the effectiveness of Medicare's prospective payment system (PPS), we conducted a population‐based study of inpatient hospitalizations among individually identified elderly residents of Olmsted County, Minnesota, 1970–1987.A 4.3% increase in total days of care/1000 population from 2,652/1,000 in 1970 to 2,766/1,000 in 1980 was followed by a 9.8% decline from 1980 to 1987 (2,495/1,000). The decline was due primarily to a 13.4% decrease in mean length stay (9.7 days in 1980 to 8.4 days in 1987). The number of hospitalizations/1,000 Olmsted County elderly in 1980 was already below 1987 U.S. figures and did not exhibit the decline evidenced nationally between 1980 and 1987. A 4.6% decline in the proportion of county residents age 65–74 years who were hospitalized (174/1,000 in 1980 to 166/1,000 in 1987) was offset by an 8.3% increase for persons age ≥ 75 (252/1,000 to 273/1,000) and by a 5.7% increase in the number of hospitalizations per individual hospitalized for persons age 65–74 years (1.34 to 1.42).Using a time‐dependent Cox model, which adjusted for differences in patient characteristics between years, there was a significantly higher risk of readmission within 14 days in 1987 vs 1980 (hazard ratio (HR) = 1.33, 95% confidence interval (CI) = 1.05–1.70). The difference between years was no longer evident at 30 or 60 days (HR = 0.84, 95% CI = 0.63–1.11 between 15 and 30 days; HR = 1.12, 95% CI = 0.84–1.49 between 31 and 60 days).This study suggests that initial effects of PPS on utilization may be temporary and that more research is needed to appreciate the impact of cost‐containme

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1991.tb04457.x

出版商:Blackwell Publishing Ltd    

年代:1991

数据来源: WILEY

摘要:

The management of pressure sores in elderly patients raises a number of ethical dilemmas for health care professionals. Aggressive treatment of advanced pressure sores is often inconsistent with the overall goals of therapy. Private and public funding for effective prevention and early treatment are restricted and constrained. Little information is available that proves treatment efficacy. Health care professionals and their institutions are often stigmatized by the occurrence of a pressure sore even though accountabilities may lie in the natural history of the disease. We use case analysis to identify ethical dilemmas in pressure sore prevention and management and suggest a framework for ethical decisionmaking so that health care professionals and public policy analysts can make informed judgments about patients and standards of quality care.

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1991.tb04458.x

出版商:Blackwell Publishing Ltd    

年代:1991

数据来源: WILEY

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1991.tb04459.x

出版商:Blackwell Publishing Ltd    

年代:1991

数据来源: WILEY