Decisions to treat or not to treat pneumonia in demented psychogeriatric nursing home patients: development of a guideline. (1/68)

Non-treatment decisions concerning demented patients are complex: in addition to issues concerning the health of patients, ethical and legal issues are involved. This paper describes a method for the development of a guideline that clarifies the steps to be taken in the decision making process whether to forgo curative treatment of pneumonia in psychogeriatric nursing home patients. The method of development consisted of seven steps. Step 1 was a literature study from which ethical, juridical and medical factors concerning the patient's health and prognosis were identified. In step 2, a questionnaire was sent to 26 nursing home physicians to determine the relative importance of these factors in clinical practice. In a meeting of nine experienced physicians (step 3), the factors identified in step 2 were confirmed by most of these professionals. To prevent the final guideline being too directive, a concept guideline that included ethical and legal aspects was designed in the form of a "checklist of considerations" (step 4). Experts in the fields of nursing home medicine, ethics and law reviewed and commented on the concept guideline (step 5). The accordingly adapted "checklist of considerations" was tested in a pilot study (step 6), after which all experts endorsed the checklist (step 7). The resulting "checklist of considerations" structures the decision making process according to three primary domains: medical aspects, patient's autonomy, and patient's best interest (see annex at end of paper).  (+info)

Assessing needs from patient, carer and professional perspectives: the Camberwell Assessment of need for Elderly people in primary care. (2/68)

BACKGROUND: despite evidence that needs assessment of older people can improve survival and function when linked to effective long-term management, there is no structured needs assessment tool in widespread use. The Camberwell Assessment of Need for the Elderly is a new tool not previously evaluated in primary care. It includes the views of patients, carers and health professionals, enabling a direct comparison of their perspectives. AIM: to conduct a feasibility study of Camberwell Assessment of Need for the Elderly in primary care and to compare the needs identified by patients, carers and health professionals. METHODS: we selected a random sample of 1:20 of all people aged 75 and over from four general practices in inner-city and suburban north-west London. We interviewed the patients, their informal carers and lead health professionals using the Camberwell Assessment of Need for the Elderly schedule. RESULTS: 55 (65.5%) of 84 patients, 15 (88.2%) of 17 carers and all of 55 health professionals completed interviews. The patients' three most frequently identified unmet needs were with 'eyesight/hearing', 'psychological distress' and 'incontinence'. The carers' three most frequently identified unmet needs were with 'mobility', 'eyesight/hearing' and 'accommodation' and the health professionals' were with 'daytime activities', 'accommodation' and 'mobility'. Kappa tests comparing patient and health professional assessments showed poor or fair agreement with 18 of the 24 variables and moderate or good agreement with six. None showed very good agreement. CONCLUSION: the Camberwell Assessment of Need for the Elderly schedule is feasible to use in primary care and can identify perceived needs not previously known about by health professionals. A shorter version of Camberwell Assessment of Need for the Elderly focusing on areas of poor agreement and high levels of need might be useful in the assessment of needs in older people in primary care.  (+info)

Dyspnoea and quality of life in older people at home. (3/68)

OBJECTIVES: To determine the prevalence of dyspnoea in older people at home, measure its impact on function and quality of life, and identify associated cardio-respiratory diseases. DESIGN: Cross-sectional population-based study. METHODS: We sent a modified Medical Research Council (MRC) dyspnoea questionnaire to identify breathlessness in 1404 randomly selected subjects from general practitioner lists of 5002 subjects aged 70 years and over living at home. We visited a further random sample of 500 of these subjects at home and at a study centre. SETTING: Community-based study in South Wales. MAIN OUTCOME MEASURES: Prevalence of dyspnoea (MRC grades 3-5) and its effect on psychological and functional status, and quality of life as measured by Hospital Anxiety and Depression, Nottingham Extended Activities of Daily Living and SF-36 questionnaires. RESULTS: The prevalence of dyspnoea as defined was 32.3% (95% confidence intervals: 30.3, 34.3). Breathless subjects had poorer functional status than non-breathless subjects. They also had poorer physical and mental health and were more likely to be anxious and depressed. The prevalence of left ventricular systolic dysfunction, reversible airways disease and obesity were all higher in those with dyspnoea. CONCLUSIONS: Dyspnoea is common in older people. Given its profound adverse effect on people's lives, dyspnoea is an important public health issue.  (+info)

Interpersonal psychotherapy for late-life depression: past, present, and future. (4/68)

Interpersonal psychotherapy (IPT) has demonstrated efficacy in protecting against a recurrence of major depression in elderly subjects when used alone on a monthly basis and when combined with antidepressant medication. The authors summarize their experience using IPT over the past 10 years and discuss a variety of treatment correlates. In addition, preliminary results using IPT combined with paroxetine in depressed elders reveals no difference in remission rates between cognitively intact and cognitively impaired depressed elders.  (+info)

Risk communication and older people-understanding of probability and risk information by medical inpatients aged 75 years and older. (5/68)

OBJECTIVE: To determine older people's understanding of probability and risk information, and the impact of pictorial representation of risk. DESIGN: A researcher-administered questionnaire. SUBJECTS: 50 inpatients aged > or =75 years on elderly medicine wards at Huddersfield Royal Infirmary, Huddersfield, UK. RESULTS: Older people understand percentage probability better than fractional probability, and a wide range of incorrect responses indicated significant over- and underestimation of probabilities. Visual data about percentages were well received and understood, and were perceived as a good idea by participants. CONCLUSIONS: We have demonstrated a wide variation in understanding of risk and probability information by older people, with over- and underestimations of probability, along with confusion between fractional and percentage probability. Pictorial representation of probability was well understood. It could be developed as a simple, yet powerful communication tool to be used in daily clinical practice to help older people understand information on risks and benefits when making decisions about treatment choices.  (+info)

Factors associated with health status of older Americans. (6/68)

BACKGROUND: health status is increasingly used as a measure of healthcare effectiveness. How diseases and symptoms are associated with health status is not completely understood. OBJECTIVES: to find diseases, symptoms and demographic factors associated with physical and mental health status in older Americans. METHODS: we analysed data from a survey of over 100 000 Medicare beneficiaries aged 65 and older. We used the short-form 36 physical and mental summary scores as measures of health status. Other data collected included demographic details, symptoms and diagnoses. RESULTS: age as a single variable explained 4% of variation in physical health status. Adding other demographic information and increased disease burden explained variation to 8% and 27% respectively. Together, shortness of breath, back pain, difficulty getting in and out of chairs, arthritis of hip or knee, a recent change in health and age explained 54% of variation. All available variables explained 59%. The role of age as an independent factor decreased markedly after disease and symptoms were considered. Similar factors were associated with lower mental health status, but age was not. CONCLUSION: these data suggest that heart and lung disease and back pain are the most important factors affecting the average physical health status of older people. Sex, marital status and race have very little independent effect. Efforts to improve average physical health status scores might best be targeted at these conditions rather than demographic characteristics. Mental health status does not decline with age, and similar factors affect it but to a lesser degree.  (+info)

Community surveys of late-life depression: who are the non-responders? (7/68)

BACKGROUND: community surveys of depression among older people may be particularly prone to non-response. Information on non-responders is difficult to obtain and often limited to demographics. Therefore, the full extent of response bias is not always known. OBJECTIVE: to determine factors associated with non-response at each stage of a two-stage survey of late-life depression. SETTING: one large general practice (registered population >30000) serving the market town of Melton Mowbray, Leicestershire, UK. SUBJECTS: community residents (n=2633) aged 65-74 years registered with the practice. METHODS: a two-stage community survey of patients aged 65-74 years. The first stage was an interviewer-administered general health survey including a measure of depressive symptoms. We asked those who screened positive for possible depression to undergo a semi-structured psychiatric interview. We compared use of services and medication by non-responders and responders to both stages using primary-care records. We compared Townsend deprivation scores using data obtained from the 1991 census. RESULTS: responders to stage 1 were more likely to use both primary [odds ratio (OR) 1.65, 95% confidence interval (CI) 1.38-1.96] and secondary (OR 1.59, 95% CI 1.25-2.02) services and tended to live in more affluent areas (P=0.002). At stage 2, the only difference observed was a lower level of use of tranquillisers or hypnotics among responders (OR 0.27, 95% CI 0.11-0.67). CONCLUSIONS: older people with low levels of contact with health services may be under-represented in community surveys of depression. Investigators should look outside traditional health settings to promote the uptake of response in these studies.  (+info)

Burden of delayed admission to psychogeriatric nursing homes on patients and their informal caregivers. (8/68)

OBJECTIVE: To assess the deleterious effects of waiting for admission to a nursing home on the state of health of patients and their informal caregivers, and on the burden of caring. DESIGN AND PARTICIPANTS: Prospective longitudinal study consisting of interviews with informal caregivers during the period on the waiting list and after admission of the patient to a nursing home. Analysis of patients' files on diagnosis, date of registration on the waiting list, and date of admission to nursing home. SETTING: Ninety three patients registered on waiting lists for admission to a psychogeriatric nursing home in two regions of Amsterdam. RESULTS: Seventy eight of the 93 patients were admitted to a nursing home. The burden on the caregivers declined after admission of the patient but depressive symptoms did not. After 6 months a subgroup of 19 caregivers whose relatives were still waiting to be admitted were interviewed. The health of these patients remained stable during this waiting period and only problems in activities of daily living increased. The burden on these 19 informal caregivers and their state of health remained stable during the waiting period. CONCLUSIONS: A decline in the state of health and a rise in the burden on caregivers during the waiting period did not occur. However, a decrease in the burden and an improvement in mental health could have started earlier if patients had been admitted earlier.  (+info)

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