摘要:

OBJECTIVE:To determine the major conditions and symptoms reported to cause difficulty in 17 physical tasks of daily life and the criterion validity of self‐report of diseases given as the causes of the difficulty in functioning, in community‐dwelling older people.DESIGN: Cross sectional analyses of data obtained in an observational cohort study.SETTING: Research clinics in four US communities: Winston‐Salem, NC, Hagerstown, MD, Pittsburgh, PA, and Sacramento, CA.PARTICIPANTS: 5201 community‐dwelling people ≥ 65 years old.RESULTS: Arthritis and other musculoskeletal diseases were given as the primary causes of difficulty in performing physical tasks by 49.0% of the participants reporting difficulty in any task, followed by heart disease (13.7%), injury (12.0%), old age (11.7%), lung disease (6.0%), and stroke (2.9%). The self‐reports of diseases that caused disability varied by task. Whereas arthritis was given as a cause of difficulty in most of the 17 different tasks, heart and lung disease were more likely to be reported as causing difficulty with activities requiring high aerobic work capacity such as walking one‐half mile or doing heavy housework. Stroke was more likely to be reported as causing difficulty with use of the upper extremities and in performing basic activities of daily living.There was a high degree of consistency (91%) between the diseases and symptoms reported to cause disabilities. The percentage of people who reported a disease as the cause of their difficulty performing a task and had independent confirmation of the diagnosis was 85% in men and 71% in women, and varied according to type of disease and the individual's cognitive status and health status.CONCLUSION: These data suggest that age‐related chronic diseases are important causes of disability in older people but that the type of disability is dependent on the underlying disease that causes the disability. Also, self‐report of the cause of disability appears to be generally accurate but is influenced by gender, health status, an

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1994.tb06206.x

出版商:Blackwell Publishing Ltd    

年代:1994

数据来源: WILEY

摘要:

OBJECTIVE:To test the impact of a geriatric evaluation and management model on the costs of acute hospital management of emergently admitted older adults.DESIGN: Randomized controlled trial. Patients were followed in the acute hospital from admission through discharge. Results based on both univariate and multiple regression analyses.SETTING: Private, nonprofit, academic medical center in a densely populated urban area.PATIENTS: Adults 70 years of age and older admitted from the Emergency Department to the medicine service (non‐ICU admission) who did not have an internist on staff at the admitting hospital. Of 141 randomized patients, 111 (78.7%) met eligibility criteria.INTERVENTION: Assignment of a geriatrician and a social worker as the primary managing team during the hospital stay.MAIN OUTCOME MEASURES: Length of stay, total cost of acute hospital care, cost of laboratory, pharmacy, and rehabilitation services.RESULTS: Patients in the intervention group had 2.1 fewer days of hospitalization, but this shorter length of stay was not statistically significant (P= 0.108). There were no differences in mortality or discharge disposition. In risk‐adjusted, multiple regression analysis the intervention group had a statistically significant lowerpredictedtotal cost per patient than the usual care group (‐$2,544,P= 0.029); assignment to the intervention group was associated with a lowerpredictedcost per patient for laboratory (including cardiology graphics) services (P= 0.007) and pharmacy costs (P= 0.047).CONCLUSIONS: When controlled for important predictors of expected resource use, care provided by a geriatric management team resulted in a significant reduction in the cost of hospitalization. A reduction in the cost of laboratory, cardiographic, and pharmacy services is consistent with the team's philosophy of defining the services needed based on goals related to functional out

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1994.tb06207.x

出版商:Blackwell Publishing Ltd    

年代:1994

数据来源: WILEY

摘要:

BACKGROUND AND PURPOSE:It has been proposed that high dietary sodium intake, resulting in a sodium‐mediated increase in renal calcium excretion, is a risk factor for osteoporosis. To evaluate the relationship between dietary sodium intake and bone mineral density (BMD), a prospective study of the Rancho Bernardo cohort was performed.METHOD: A 24‐hour diet recall was done for the period 1973 through 1975; follow‐up bone mineral density of the ultradistal radius, midradius, total hip, and spine was measured between 1988 and 1991. Covariates were ascertained by self‐report and examination at baseline. Multivariable analysis of the sodium‐BMD association was performed using gender and menopause‐specific linear regressions.RESULTS: All subjects were white. At the bone evaluation, there were 258 women (average age 73.3 years) and 169 men (average age 72.4 years). In both men and women, higher levels of sodium intake were strongly associated with higher levels of calcium intake and total calories. Body mass index increased with sodium quartile in women, while a modest negative association was seen in men. In women, after age adjustment, positive associations between dietary sodium and bone density were found at the ultradistal radius (β = 0.01,P= 0.03) and the total hip (β = 0.019,P= 0.02). BMD increased by 0.01 to 0.02 g/cm2per gram increase in sodium ingested. After adjustment for estrogen use, body mass, dietary calcium, alcohol, and total calories, these effects were no longer significant. Similar patterns were seen in pre‐ and postmenopausal women. In men, age and multivariate‐adjusted BMD increased with higher sodium intake at the ultradistal radius only (β = 0.013,P= 0.05). Stratification by gender‐specific median calcium level did not significantly effect the results.CONCLUSIONS: After control for confounders, a small, statistically significant protective effect of sodium was found at the ultradistal radius in men only. At other sites in women and men, no effect of sodium on BMD was apparent in the multivariable models. These results do not support a detrimental effect of dietary sodium on bone mineral density. Rather, the findings suggest that sodium intake, in the range measured, is not a major oste

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1994.tb06208.x

出版商:Blackwell Publishing Ltd    

年代:1994

数据来源: WILEY

摘要:

OBJECTIVES:To determine the effects of congestive heart failure on a person's ability to walk at a steady pace while ambulating at a self‐determined rate.SETTING: Beth Israel Hospital, Boston, a primary and tertiary teaching hospital, and a social activity center for elderly adults living in the community.PARTICIPANTS: Eleven elderly subjects (aged 70–93 years) with well compensated congestive heart failure (NY Heart Association class I or II), seven elderly subjects (aged 70–79 years) without congestive heart failure, and 10 healthy young adult subjects (aged 20–30 years).MEASUREMENTS: Subjects walked for 8 minutes on level ground at their own selected walking rate. Footswitches were used to measure the time between steps. Step rate (steps/minute) and step rate variability were calculated for the entire walking period, for 30 seconds during the first minute of the walk, for 30 seconds during the last minute of the walk, and for the 30‐second period when each subject's step rate variability was minimal. Group means and 5% and 95% confidence intervals were computed.MAIN RESULTS: All measures of walking variability were significantly increased in the elderly subjects with congestive heart failure, intermediate in the elderly controls, and lowest in the young subjects. There was no overlap between the three groups using the minimal 30‐second variability (elderly CHF vs elderly controls:P<0.001, elderly controls vs young:P<0.001), and no overlap between elderly subjects with and without congestive heart failure when using the overall variability. For all four measures, there was no overlap in any of the confidence intervals, and all group means were significantly different (P<0.05).CONCLUSIONS: Step rate variability is increased in elderly subjects with well compensated congestive heart failure compared with elderly subjects without congestive heart failure and healthy y

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1994.tb06209.x

出版商:Blackwell Publishing Ltd    

年代:1994

数据来源: WILEY

摘要:

OBJECTIVE:To assess colonization and infection with methicillin‐resistantStaphylococcus aureus(MRSA), high‐level gentamicin‐resistant enterococci (R‐ENT) and gentamicin and/or ceftriaxone‐resistant Gram‐negative bacilli (R‐GNB) and the factors that are associated with colonization and infection with these organisms.DESIGN: Monthly surveillance for colonization and infection over a period of 2 years. In the second year, an intervention to decrease MRSA colonization by the use of mupirocin ointment was carried out.SETTING: Long‐term care facility attached to an acute care Veterans Affairs Medical Center.PATIENTS: A total of 551 patients in the facility were followed for a period of 2 years.MEASUREMENTS: Colonization and infection rates with MRSA, R‐ENT, and R‐GNB. Analysis of risk factors associated with colonization and infection with these three groups of organisms.MAIN RESULTS: In the first year, colonization rates were highest for MRSA (22.7 ± 1% patients colonized each month) and R‐ENT (20.2 ± 1%) and lower for R‐GNB (12.6±1%). After introduction of decolonization of nares and wounds with mupirocin, the rate of MRSA colonization fell significantly to 11.5 ± 1.8%, but rates remained unchanged for R‐ENT and R‐GNB. Risk factors for MRSA colonization included the presence of wounds and decubitus ulcers. For R‐ENT, the presence of wounds, renal failure, intermittent urethral catheterization, low serum albumin, and poor functional level were significant. For R‐GNB, intermittent urethral catheterization, chronic renal disease, inflammatory bowel disease, presence of wounds, and prior pneumonia were significantly associated with colonization. Overall, of infections caused by known organisms, 49.6% were due to MRSA, R‐ENT, or R‐GNB, and 50.4% were due to susceptible organisms. Infections were more commonly due to R‐GNB (21.1% of all infections) than to R‐ENT (8.3%) or MRSA (4.6%). The most common infections were urinary tract infections (42.9% of all infections) and skin and soft tissue infections (31.9% of all infections). Risk factors for MRSA infections were diabetes mellitus and peripheral vascular disease, for R‐GNB infections were intermittent urethral catheterization and indwelling urethral catheters, and no one factor was associated with R‐ENT infection.CONCLUSIONS: In our long‐term care facility, colonization with resistant MRSA and R‐ENT was more common than R‐GNB, but infections were more often due to R‐GNB than R‐ENT and MRSA. Several host factors, which potentially could be modified in order to prevent infections, emerged as important in colonizatio

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1994.tb06210.x

出版商:Blackwell Publishing Ltd    

年代:1994

数据来源: WILEY

摘要:

OBJECTIVE:To determine changes in standard laboratory measures of dehydration among residents of a nursing home care unit (NHCU) over a 6‐month period.DESIGN: A prospective cohort analytic study.SETTING: A 130‐bed NHCU in a Department of Veterans Affairs Hospital.PATIENTS: Fifteen infirm but stable male residents (mean age 77 years; range (R) 62–93) on one ward of the NHCU.MAIN OUTCOME MEASURES: We studied prospectively for 6 months the serum osmolality (osm), serum sodium (Na), blood urea nitrogen/creatinine (BUN/Cr) ratios and weight (wt) for 15 patients of the NHCU. None of the patients was acutely ill during the study period or exhibited clinical signs of dehydration.RESULTS: Mean serum osm at baseline: 291.6 mOsm/kg (R 278 to 300); 3 months: 291.5 mOsm/kg (R 276 to 301); 6 months: 291.3 mOsm/kg (R 283–300) were all similar. Forty percent (6/15) of patients had at least one high normal/elevated reading (≥ 295 mOsm/kg) during the study. Three patients (20%) had readings of ≥ 300 mOsm/kg, but none of these patients had either concurrent increased serum Na (≥ 146 mmole/L) or BUN/Cr ratios (≥ 25). Mean serum Na at baseline: 143.0 mmole/L (R 139–148); 3 months: 142.1 mmole/L (R 138–149); 6 months: 142.9 mmole/L (R 137–150) were all similar. Sixty percent (9/15) of the patients maintained normal (nl) serum Na levels throughout the study. The relationship between the change in serum Na and serum osm levels from baseline to 6 months was not significant (r= 0.242). BUN/Cr ratios ranged from 12–34 over the study period with 3 of 15 patients (20%) demonstrating elevated ratios consistently throughout the study without clinical evidence of dehydration. Only two patients had both high nl/elevated serum osm and elevated serum Na, although both had nl BUN/Cr ratios. Neither of these patients was thought by staff to be clinically dehydrated. Analysis of variance (ANOVA) indicated none of the laboratory measures changed significantly over time (serum osm: F(2,28)<1; Na: F(2,28)<1; BUN/Cr: F(2,228)<1). There was no significant change in weight between the baseline and six month readings.CONCLUSIONS: These data suggest that in the presence of clinical stability, long‐term care residents may have a serum osm in the high normal/elevated range without overt clinical evidence of dehydration, an accompanying elevated Na, or BUN/Cr ratio. This may indicate a different central osm setting for these residents as the serum osm appeared to be stable for each resident over time. These data also suggest that measures of serum osm, Na, and BUN/Cr in the long‐term care setting may accurately predict future laboratory values in an individual patient if baseline values are drawn when the

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1994.tb06211.x

出版商:Blackwell Publishing Ltd    

年代:1994

数据来源: WILEY

摘要:

OBJECTIVE:To determine if physicians know and can apply the legal standard for determining competence; to determine if physician assessment of competence varies by physician age or specialty.DESIGN: Mail survey with specific questions about a patient scenario and general questions about the law.PARTICIPANTS: 2100 randomly selected Massachusetts internists, surgeons, and psychiatrists.MEASUREMENTS: In Part I, the survey presented a scenario adapted from a court case that involved an elderly woman's refusing lifesaving surgery. The scenario was divided into three sections: the medical history, the patient's rationale, and a psychiatrist's opinion that the patient was incompetent. Respondents were not told that an appellate court later decided the psychiatrist applied the wrong standard of competence and the patient was indeed competent. Respondents were asked whether the patient was competent, whom they would consult, and how they would respond. Part II posed a series of theoretical questions about competence. Group differences were tested by chi‐square.MAIN RESULTS: Surveys were returned by 823 (41%) of the sample. In Part I, before the psychiatrist's opinion, 58% thought the patient was competent, 92% would consult a psychiatrist to help assess competence, and only 17% would to go to court. After the psychiatrist's opinion, only 30% thought she was competent and 55% would go to court. In Part II, 89% knew the correct standard for competence; however, most incorrectly responded that conditions such as dementia and psychosis establish incompetence. Psychiatrists performed significantly better on theoretical, but frequently worse on scenario, questions.CONCLUSIONS: Physicians in general, and psychiatrists in particular, know the standard for competence but may apply it incorrectly. This suggests that the common clinical practice of relying on expert medical opinion may introduce bias and produce inaccurate results that undermine patient autonom

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1994.tb06212.x

出版商:Blackwell Publishing Ltd    

年代:1994

数据来源: WILEY

摘要:

OBJECTIVE:To examine a spectrum of elderly people to determine if hand function/dexterity measures can predict oral care ability.DESIGN: A series of dental, hand function, and dexterity measures were assessed by blinded examiners. Plaque scores were used as the criterion standard to assess plaque removal ability.PATIENTS: A convenience sample of 52, predominately male, elderly patients were recruited from the patient population of the Portland Veteran Affairs Medical Center and a community nursing home. Entry into the study required that the patient be able to give consent, be age 65 or older, have a minimum of six contiguous teeth or a minimum of 12 teeth total, be medically stable, have grossly adequate vision, and be able to hear and understand spoken instructions.OUTCOME MEASURES: The primary outcome measure was plaque score, as defined by the Turesky modification of the Quigley‐Hein index. This was related to four dexterity tests (Jebsen‐Taylor Hand Function test, Nine‐hole Peg test, Box and Block test, Toothbrushing Ability test), a grip strength measure, and a cognitive measure (Allen Cognitive Level Test).RESULTS: Oral hygiene was significantly impaired among institutionalized elderly compared with outpatient elderly (P<0.001), as was dexterity (P<0.001). All dexterity tests correlated significantly with plaque score (Spearman rho: 0.49–0.77;P<0.000). Forward stepwise regression analysis identified the Toothbrushing Ability Test (P<0.0001) and the time spent brushing (P= 0.007) as the most significant predictors of plaque score.CONCLUSIONS: Results suggest oral hygiene ability is decreased among long term care residents, that dexterity tests can help identify patients unable to perform adequate oral self‐care, and that these tests could be used to estimate brushing ability among elderly compromised

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1994.tb06213.x

出版商:Blackwell Publishing Ltd    

年代:1994

数据来源: WILEY

摘要:

OBJECTIVE:To study simultaneously the relationships among chronic diseases and physical health status as they affect health services utilization of older adults.DESIGN: Secondary analysis of a large, cross‐sectional health interview survey, the Supplement on Aging of the 1984 National Health Interview Survey, using multiple equation methods to evaluate disease‐specific impacts on physical health status, the direct impact of specific diseases on utilization of physician services and hospital care, and the indirect impact of specific diseases on utilization, mediated through physical health status.PARTICIPANTS: A total of 11,497 people aged 65 and older, representing a complex, multistage sample of the noninstitutionalized, older adult population of the United States.MEASUREMENTS: Predictor variables included specific chronic diseases (hypertension, arthritis, diabetes, cancer, and atherosclerotic heart disease), self‐rated health status, and total number of disabilities. Control variables included age, gender, race, education, social integration. Outcome variables were physician visits and hospital stays.MAIN RESULTS: Itwas shown that different diseases have different relative impacts on physical health status, probability of utilization, and amount of utilization, if any, and different chronic diseases have a different mix of direct and indirect effects on utilization.CONCLUSION: The impact of chronic disease on health services utilization in a community‐dwelling population is not a simple or direct relationship. Diseases vary according to their impact on different types of utilization, their impact on the probability of any health services use versus the amount of use, and on how much their effect on utilization is mediated through health

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1994.tb06214.x

出版商:Blackwell Publishing Ltd    

年代:1994

数据来源: WILEY

摘要:

OBJECTIVE:To assess the effectiveness of comprehensive geriatric assessment conducted in day hospitals.DESIGN: Retrospective cohort comparison study with restricted inclusionary criteria and adjustment for baseline characteristics.SETTING: A hospital‐based geriatric day hospital and geriatric clinic sites (both in the university and in the community).PATIENTS: Four hundred sixty‐eight patients referred for comprehensive geriatric assessment during a 12‐month period.INTERVENTION: Comprehensive geriatric assessment in a geriatric day hospital compared with assessment received in clinic sites without a day hospital.MAIN OUTCOME MEASURES: Services received in the first 2 weeks; hospitalization, emergency room visits, placement, death, and change in selected health status measures. Follow‐up data was obtained from medical records, a telephone survey, and death certificates.RESULTS: Except in the case of rehabilitative services, day hospital patients were more likely to receive interdisciplinary services. The population seen in the day hospital was more functionally impaired and had significantly more dementia and depression. After adjusting for subjects' baseline characteristics and limiting the analyses to subjects meeting specific inclusionary criteria, the day hospital had no significant effect on mortality, use of emergency or hospital services, placement, or change on selected measures of health status. For example, compared with the clinic patients, receiving care in the day hospital was associated with an adjusted odds ratio of 1.01 (95% confidence interval: 0.53, 1.91) of being at a higher level of care at 6 months. The results were not sensitive to the choice of inclusionary criteria.CONCLUSION: Given their cost and uncertain effectiveness, day hospitals need additional evaluation before their further diffusion

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1994.tb06215.x

出版商:Blackwell Publishing Ltd    

年代:1994

数据来源: WILEY