摘要:

In the standard medical model of diagnosis, there is a 1:1 correspondence between clinical symptoms and signs and a pathological disease process. However, it is believed that this model does not accurately define many illness presentations in elderly patients. The frequency with which the medical model is diagnostically accurate, and the other models that might more effectively diagnose geriatric illness, are unknown. This study was designed to ascertain the frequency with which the medical model of diagnosis pertains in a clinical population of older adults and to develop and validate alternative models for diagnosis of illness presentation in this population. Using a retrospective chart review (n =86) and a prospective validation in a second sample (n =56) of geriatric assessment clinic patients, it was found that the medical model of illness fit less than half of the patients. To describe the illness presentations of the remaining patients, four new diagnostic models of illness presentation were identified which incorporate comorbidity, functional, and psychosocial factors. Use of these new models along with the medical model of illness diagnosis may assist in more accurate and complete diagnosis in elderly patients and enhance teaching of effective diagnosis in geriatric medicine.

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1991.tb01612.x

年代:1991

数据来源: WILEY

摘要:

Cross‐sectional studies have revealed a high prevalence of comorbid psychological problems among geriatric medical patients, a low rate of detection by primary care professionals, and greater psychosocial dysfunction and poorer physical health associated with comorbidity. Less is known about the course and impact of psychiatric comorbidity. Psychiatric status, physical health status, psychosocial functioning, and health care utilization for a sample of geriatric patients (n = 102) were assessed on admission to a medical hospital and again one year later. Results revealed a very stable and high prevalence of comorbid psychological problems, especially depression, a low rate of treatment by mental health professionals, greater physical impairment consistently associated with psychiatric comorbidity, but few health care utilization differences. A closer look at depression revealed that it typically began in late life and did not readily resolv

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1991.tb01613.x

年代:1991

数据来源: WILEY

摘要:

Nursing home residents are frequently transferred to hospital emergency departments. Delayed transfer may lead to poor outcomes. However, inappropriate transfer of the frail elderly may cause social and financial problems. We prospectively evaluated 221 consecutive ambulance transfers from community nursing homes to a VA emergency department. The objectives of the study were to describe the process and outcomes of transferred patients and to determine if alternative interventions were feasible. The results indicate that the problems of nearly half the study group could have been treated at the nursing home by a visiting physician with minimal medical equipment. Those admitted to the hospital (52%) were seriously ill, had prolonged lengths of stay (23.6 days), and had a high mortality rate (11%). Complex issues of physician reimbursement, proprietary nursing home budgeting, and day‐to‐day expediency appear to be involved in decisions to transport patients by ambulance to VA emergency departme

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1991.tb01614.x

年代:1991

数据来源: WILEY

摘要:

A population of sunlight‐deprived elderly was studied to determine the daily intake of vitamin D and whether dietary intake was sufficient to maintain a normal vitamin D status. Twenty‐two subjects over 65 years old with serum creatinine<180 μmol/L and confined indoors for more than 6 months were chosen from the community and a nursing home in Southeast Baltimore. Three‐day food records were obtained along with serum levels of 25‐hydroxyvitamin D (25‐OHD), 1,25‐dihydroxyvitamin D (1,25‐(OH)2D), and intact parathyroid hormone (PTH). The mean daily vitamin D intake was over twofold greater than the adult Recommended Daily Allowance (RDA) of 200 IU. The mean 25‐OHD level was 40 nmol/L (normal 25–138 nmol/L) with seven patients less than 25 nmol/L. Of those participants with 25‐OHD values less than 25 nmol/L, the mean vitamin D intake was 467 IU (range 36–1096 IU). We conclude that the current RDA seems inadequate for many older individuals who do not get sun exposure. This particular population of elderly is at risk to develop vitamin D deficiency and the as

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1991.tb01615.x

年代:1991

数据来源: WILEY

摘要:

This study evaluated a modified, timed version of the “Get‐Up and Go” Test (Mathias et al, 1986) in 60 patients referred to a Geriatric Day Hospital (mean age 79.5 years). The patient is observed and timed while he rises from an arm chair, walks 3 meters, turns, walks back, and sits down again. The results indicate that the time score is (1) reliable (inter‐rater and intra‐rater); (2) correlates well with log‐transformed scores on the Berg Balance Scale (r = −0.81), gait speed (r = −0.61) and Barthel Index of ADL (r = −0.78); and (3) appears to predict the patient's ability to go outside alone safely. These data suggest that the timed “Up&Go” test is a reliable and valid test for quantifying functional mobility that may also be useful in following clinical change over time. The test is quick, requires no special equipment or training, and is easily included as part of the routin

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1991.tb01616.x

年代:1991

数据来源: WILEY

摘要:

Previous studies have suggested that education and race may affect performance on standardized mental status tests. In order to more clearly define these relationships, a prospective longitudinal study was devised to answer two questions: (1) whether race or level of education affects scores on the Mini‐Mental State (MMS) exam in non‐demented people and (2) what numerical cutpoints maximize the sensitivity and specificity of utilizing the MMS to help diagnose dementia in blacks of varying educational attainment.A total of 100 white and 258 black individuals, recruited from two city hospital primary care geriatric clinics, were evaluated and subsequently followed longitudinally over a2 1/2year period in order to assess accurately the presence or absence of dementia. In the non‐demented, total MMS scores and performance on each item of the MMS were analyzed, revealing that people with an 8th grade or less education consistently had significantly (P<.01) worse results than the better educated (9th grade or better) on borough, attention items, recall of table and dog, copying, sentence writing, phrase repeating, and total score. Furthermore, a total of 25% of the lower education group had an MMS score in the 18–23 range, traditionally thought to suggest dementia. There were no consistently significant differences between blacks and whites of equal education. In the better educated groups, using a score of 23 or less to define dementia maximizes the sensitivity and specificity of using the MMS in this diagnosis at 93% and 100%, respectively. In the lower education group, using 17 or less to define dementia maximizes sensitivity and specificity at 81% and 100%, respectively. It is concluded that MMS results are affected by education but not by race, that only certain MMS items are educationally related and perhaps could be modified, and that on the unmodified MMS a score of 17 or less should be used as the outpoint for suggesting the presence of dementia in the poorly e

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1991.tb01617.x

年代:1991

数据来源: WILEY

摘要:

High prevalence rates of psychiatric disorders and disruptive behaviors in nursing home residents create the need for structured programs of psychiatric consultation and teaching in the long‐term care setting. Over 40 months, 473 residents were evaluated by a psychiatric consultation‐liaison clinical nurse specialist; 100 of these cases were reviewed in detail. Apparent depression was the most common reason for referral, and depressive and adjustment disorders were the most common diagnostic conclusions of the consultation team. Behavioral complications of dementia were also frequently diagnosed. Treatment recommendations usually included the development of a behavioral management plan, but the institution of psychotropic medications, usually antidepressants, was indicated in about one‐fifth of the 100 cases. Treatment interventions were effective in the majority of cases. About one‐half of the problems prompting referral were within the expertise of the nurse specialist and did not require the direct involvement of the geropsychiatrist. This nurse‐centered consultation model proved effective, well accepted, and easy to

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1991.tb01618.x

年代:1991

数据来源: WILEY

摘要:

In a double‐blind, randomized trial the effects of caffeinated and decaffeinated drinks on postprandial hemodynamic and neurohumoral changes were studied in seven fit, elderly subjects after a standard 2.4MJ meal. There was a significant difference in supine postprandial systolic blood pressure between the placebo and caffeine phases (P<0.01); at 60 minutes, supine systolic blood pressure had fallen 14 mmHg [95% confidence interval (CI) −7 to −11 mmHg, p<0.01) after placebo, but was unchanged after caffeine (+9 mmHg, CI 0 to 18 mmHg, NS]. Similar differences between placebo and caffeine were seen in erect systolic and diastolic blood pressure (P<0.01), although orthostatic tolerance was maintained throughout each study period. Postprandial plasma noradrenaline levels were higher (P<0.02) and the increase greater (P<0.02) after caffeine than after placebo. Caffeine administered at the end of a standard test meal prevents the postprandial fall in blood pressure in fit, elderly subjects. The clinical relevance of this finding has yet to be determined, but it may offer a simple remedy for patients with symptomatic postprandial hypote

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1991.tb01619.x

年代:1991

数据来源: WILEY

摘要:

A statistical quality‐control process was used to assess how well incontinence management procedures were being implemented by indigenous nursing staff in four nursing homes. Eighty‐one incontinent patients were treated with the prompted‐voiding toileting procedure. Thirty‐six of these patients proved responsive to the toileting procedures, and nursing home staff was instructed to maintain the toileting program for these responsive patients. The first part of the quality‐control model involved setting job standards specifying how dry the patients should be if toileted on a 2‐hour schedule. Second, a job‐monitoring control chart was used to continuously assess how well the job standards were being met. The remaining forty‐five patients, who were unresponsive to the toileting protocol, were managed with a 2‐hour changing schedule. Job standards specifying how wet (volume) the patient would be if changed on a two‐hour basis were set. Control‐chart monitoring of these patients' urine output assessed how well the changing procedures were being implemented. Incontinence care in nursing homes is difficult to supervise because of problems in measuring how consistently nursing aides change or toilet patients. This paper describes a management system for effect

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1991.tb01620.x

年代:1991

数据来源: WILEY

摘要:

Because there are both treatable and untreatable causes of dementia, the physician's ability to conduct (or refer a patient for) a differential diagnosis could have a profound effect on health outcomes for patients and on health care costs. This study was undertaken to assess physician practices with regard to the diagnosis of dementing disorders. Data from 53 physicians (a response rate of 48%) in several specialties were obtained from a self‐administered mail questionnaire. Results indicate that the majority of physicians provided history taking, physical examination, and neurological examination. Physicians were more likely to refer patients for psychiatric and neuropsychological examinations than to provide these services themselves. The results also point to deficiencies in two key areas: the use of formal, published diagnostic criteria, and the use of mental status and cognitive function tests. Over 75% of physicians surveyed did not use either DSM‐III or NINCDS‐ADRDA diagnostic criteria, and 42% of physicians did not provide any mental status tests themselves. The need for continuing education to close knowledge gaps is empha

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1991.tb01621.x

年代:1991

数据来源: WILEY