A randomized trial of comprehensive geriatric assessment and home intervention in the care of hospitalized patients.
(25/1708)
OBJECTIVE: to prove the effectiveness of geriatric evaluation and management for elderly, hospitalized patients, combined with post-discharge home intervention by an interdisciplinary team. DESIGN: randomized controlled trial with outcome and costs assessed for 12 months after the date of admission. SETTING: university-affiliated geriatric hospital and the homes of elderly patients. SUBJECTS: 545 patients with acute illnesses admitted from home to the geriatric hospital. INTERVENTIONS: patients were randomly assigned to receive either comprehensive geriatric assessment and post-discharge home intervention (intervention), comprehensive geriatric assessment alone (assessment) or usual care. MAIN OUTCOME MEASURES: survival, functional status, rehospitalization, nursing home placement and direct costs over 12 months. RESULTS: the intervention group showed a significant reduction in length of hospital stay (33.49 days vs 40.7 days in the assessment group and 42.7 days in the control group; P < 0.05) and rate of immediate nursing home placement (4.4% vs 7.3% and 8.1%; P < 0.05). There was no difference in survival, acute care hospital readmissions or new admissions to nursing homes but the intervention group had significantly shorter hospital readmissions (22.2 days vs 34.2 days and 35.7 days; P < 0.05) and nursing home placements (114.7 days vs 161.6 days and 170.0 days; P < 0.05). Direct costs were lower in the intervention group [about DM 7000 (US $4000) per person per year]. Functional capacities were significantly better in the intervention group. CONCLUSIONS: comprehensive geriatric assessment in combination with post-discharge home intervention does not improve survival, but does improve functional status and can reduce the length of the initial hospital stay and of subsequent readmissions. It can reduce the rate of immediate nursing home admissions and delay permanent nursing home placement. It may also substantially reduce direct costs of hospitalized patients. (+info)
Limitations of the SF-36 in a sample of nursing home residents.
(26/1708)
OBJECTIVE: to assess test characteristics of the Medical Outcomes Study SF-36 (Short-Form 36) with residents of nursing homes. RESEARCH DESIGN: nursing home residents with 17 or more points on the Mini-Mental State Examination (MMSE) and > or = 3 months residence (128 of 552 screened) were selected randomly. Interviewers administered the SF-36 (repeated after 1 week), Geriatric Depression Scale and MMSE. We recorded activities of daily living and medication data from medical records. Data analysis included test-retest intraclass correlations, item completion, score distributions and SF-36 correlations with measures of physical and mental functioning. RESULTS: 97 nursing home residents (75.8%) consented. Test-retest intraclass correlation coefficients were good to excellent (range = 0.55 to 0.82). Convergent validity between SF-36 physical health scales and the activities of daily living index was modest (r range = -0.37 to -0.43). About 25% of residents scored zero (lowest score) on at least one SF-36 physical function measure. SF-36 mental health scales correlated strongly with the Geriatric Depression Scale (r range = -0.63 to -0.71) and modestly with bodily pain (r = -0.35). No SF-36 scales correlated strongly with the MMSE. CONCLUSION: only one in five nursing home residents met minimal participation criteria, suggesting limited utility of the SF-36 in nursing homes. Reliability and validity characteristics were fairly good. Skewed scores were noted for some SF-36 scales. The utility of the SF-36 may be limited to assessments of subjects with higher cognitive and physical functioning than typical nursing home residents. The SF-36 might benefit from modification for this setting, or by tests of proxy ratings. (+info)
Do nursing home residents make greater demands on GPs? A prospective comparative study.
(27/1708)
BACKGROUND: The number of people residing in nursing homes has increased. General practitioners (GPs) receive an increased capitation fee for elderly patients in recognition of their higher consultation rate. However, there is no distinction between elderly patients residing in nursing homes and those in the community. AIM: To determine whether nursing home residents receive greater general practice input than people residing in the community. METHOD: Prospective comparative study of all 345 residents of eight nursing homes in Glasgow and a 2:1 age, sex, and GP matched comparison group residing in the community. A comparison of contacts with primary care over three months in terms of frequency, nature, length, and outcome was carried out. RESULTS: Nursing home residents received more total contacts with primary care staff (P < 0.0001) and more face-to-face consultations with GPs (P < 0.0001). They were more likely to be seen as an emergency (P < 0.01) but were no more likely to be referred to hospital, and were less likely to be followed-up by their GP (P < 0.0001). Although individual consultations with nursing home residents were shorter than those with the community group (P < 0.0001), the overall time spent consulting with them was longer (P < 0.001). This equated to an additional 28 minutes of time per patient per annum. Some of this time would have been offset by less time spent travelling, since 61% of nursing home consultations were done during the same visit as other consultations, compared with only 3% of community consultations (P < 0.0001). CONCLUSION: Our study suggests that nursing home residents do require a greater input from general practice than people of the same age and sex who are residing in the community. While consideration may be given to greater financial reimbursement of GPs who provide medical care to nursing home residents, consideration should also be given to restructuring the medical cover for nursing home residents. This would result in a greater scope for proactive and preventive interventions and for consulting with several patients during one visit. (+info)
Use of physical restraints and psychotropic medications in Alzheimer special care units in nursing homes.
(28/1708)
OBJECTIVES: This study analyzed the use of mechanical restraints and psychotropic medication in Alzheimer special care units (SCUs) in nursing homes. METHODS: We analyzed 1993 data for more than 71,000 nursing home residents in 4 states, including more than 1,100 residents in 48 SCUs. The dependent variable in multinomial logistic regression was use of physical restraints or psychotropic medication. Models contained covariates representing facility and resident characteristics, and multivariate matching strategies were used to protect against selection bias. RESULTS: Residents in SCUs did not differ from similar residents in traditional units in their likelihood of being physically restrained. Residents in SCUs were more likely to receive psychotropic medication. CONCLUSIONS: With regard to the measures used in this research, the findings indicate that residents in the SCUs in the 4 study states did not receive quality of care superior to that provided to similar residents in traditional units. In fact, the results related to drug use raise the question of whether some may have received poorer care. (+info)
Visual acuity measurements in a national sample of British elderly people.
(29/1708)
BACKGROUND: Despite the fact that visual function has an important role in the quality of life in later years, very few studies have measured visual acuity in population based nationwide samples of British elderly people. Such measurements were carried out in the context of the national diet and nutrition survey of people aged 65 years or over (NDNS). METHODS: NDNS participants, who were living in 80 different randomly selected postcode areas of mainland Britain, were visited at their home by a nurse who measured visual acuity at 3 metres, using the Glasgow acuity card (GAC) method. In addition, a brief questionnaire related to ocular health was administered. RESULTS: Visual acuity was measured in 1362 NDNS participants who were not classified as mentally impaired. Visual impairment (using the WHO low vision criteria) was measured in 195 (14.3%) subjects. Prevalence of visual impairment increased significantly with age (65-74 years 3.1%; 75-84 years 11.6%; 85+ years 35.5%, p<0.001 for trend). Impaired vision was more common in subjects living in a nursing home (odds ratio adjusted for age 2.59 (95% CI 2.23 to 2. 96)) and in women (odds ratio adjusted for age 1.55 (95% CI 1.21 to 1.89)). 132 (9.7%) subjects had previously undergone cataract surgery and another 157 (11.5%) had been told that they currently had cataract. Vision improved 0.2 log units or more (at least one Snellen line) with the aid of a pinhole occluder in 289 subjects (21. 2%). CONCLUSION: Results of this nationwide, community based study confirm that problems with poor distance visual acuity exist in a substantial part of the elderly community, particularly in women and people living in nursing homes. (+info)
Protein-energy oral supplementation in malnourished nursing-home residents. A controlled trial.
(30/1708)
OBJECTIVES: To validate a nutritional intervention programme for elderly people living in nursing homes. DESIGN: In a prospective, randomized, controlled study of 88 residents, we determined nutritional status at day 0 and day 60 using a record of dietary intake, anthropometry, hand-grip strength and mini-nutritional assessment. Dietary intake, grip strength and body weight were also recorded at day 30. We divided subjects into four groups according to their mini-nutritional assessment score. Those with a score 24 received no oral supplementation. Those at risk of malnutrition (with a score of 17-23.5) were randomized to oral supplementation. Those with a score <17 received oral supplementation. We recorded the amount of oral supplements consumed daily. RESULTS: Compliance with oral supplementation was good, and daily intake averaged about 400 kcal. The total energy intake on day 60 was significantly higher in both of the groups that received supplements. Following supplementation, most subjects at risk of malnutrition improved their mini-nutritional assessment score and increased their weight (by 1.4 +/- 0.5 kg). Neither the mini-nutritional assessment score nor weight improved in subjects at risk of malnutrition who did not receive supplements. Supplementation in the malnourished group resulted in a mean mini-nutritional assessment score increase (from 13.9 +/- 2.6 to 17.1 +/- 3.9) and a mean weight gain of 1.5 +/- 0.4 kg. CONCLUSION: Oral nutritional supplements are well accepted and result in increased daily protein and energy intake, body weight and nutritional status in most malnourished patients and in those at risk of malnutrition. (+info)
The Dutch pressure sore assessment score or the Norton scale for identifying at-risk nursing home patients?
(31/1708)
OBJECTIVE: To investigate the usefulness of a Dutch pressure sore risk assessment scale--the Centraal Begeleidingsorgaan voor de Intercollegiale Toetsing (CBO; National Organization for Quality Assurance in Hospitals) score--in the detection of patients at risk of developing pressure sores after admission to a nursing home. As the Norton score is the standard method of risk assessment, we also investigated which score (Norton or CBO) has the stronger relationship to the development of pressure sores. DESIGN: Longitudinal cohort design. PATIENTS: 220 nursing home patients, 80 men, 140 women, mean age 79 years (standard deviation 3). MEASURES: Admission assessments for the presence of pressure sores, CBO and Norton scores, preventive measures and demographic characteristics. We made observations every week for 4 weeks. MAIN OUTCOME MEASURE: Presence or absence of pressure sores. MAIN RESULTS: 54 patients (25%) developed a pressure sore. A significant, nonlinear relationship was found between the CBO score on admission and the development of pressure ulcers for the first 2 weeks after admission. Multiple logistic regression analysis showed that only mobility (odds ratio = 3.6, P = 0.0001) and mental state (odds ratio = 2.0, P = 0.03) showed a significant relationship with the development of pressure ulcers. The CBO score was no better in risk assessment than the Norton score. CONCLUSIONS: The CBO score can be used for assessment of the risk of developing pressure ulcers in the first 2 weeks after admission to a nursing home, but is no better than the Norton score. Since the Norton score is easier to use, it is slightly preferable for use in this setting. However, neither score is a good indicator of patients at risk. Physicians should not depend solely on risk scores when prescribing preventive measures. (+info)
Appropriate use of psychotropic drugs in nursing homes.
(32/1708)
The Omnibus Budget Reconciliation Act (OBRA) of 1987 limited the use of psychotropic medications in residents of long-term care facilities. Updates of OBRA guidelines have liberalized some dosing restrictions, but documentation of necessity and periodic trials of medication withdrawal are still emphasized. Antidepressant drugs are typically underutilized in nursing homes. Tricyclic antidepressants have many side effects and thus are not preferred medications in elderly patients. Anxiety and insomnia are common problems in the institutionalized elderly. If behavioral measures are not successful, antidepressant medications with shorter half-lives may avoid drug accumulation, which can lead to excessive sedation, cognitive impairment and an increased risk for falls. In the elderly, antipsychotic medications can cause serious side effects, such as extrapyramidal symptoms and tardive dyskinesia. Newer antipsychotic drugs are less often associated with these side effects, but they should be used only for specific diagnoses and when behavioral and environmental measures are unsuccessful. (+info)