Screening the elderly in the community: controlled trial of dependency surveillance using a questionnaire administered by volunteers.

OBJECTIVE--To test the benefits of regular surveillance of the elderly at home using an activities of daily living questionnaire administered by volunteers. DESIGN--Randomised controlled study. PATIENTS--539 Subjects aged 75 and over from two general practices. INTERVENTION--All subjects were visited at the beginning and end of the study by volunteers, who completed a scored activity of daily living questionnaire. The study group were revisited at regular intervals. Individuals with an increase in score greater than 5 were referred to their general practitioners. All interactions with social services and health authorities were recorded for both groups. MAIN OUTCOME MEASURES--Mortality, activity of daily living score, total number of days in institutions, geriatric and psychogeriatric service contacts, primary health care team contacts, use of community support services. RESULTS--The study group were admitted to hospital more often than the controls (335 occasions v 252), but the control group spent 33% more days in institutions, mainly in long term admissions to residential accommodation. The number of falls reported in the control group doubled (from 17 before the first interview to 36 before the last) and in the study group remained unchanged (12 before both interviews). The study group received community support services sooner than the control group. There was no difference between the groups in mortality or activity of daily living score. CONCLUSION--Regular visiting of old people at home by non-professional volunteers using a simple activity of daily living questionnaire is a practical way of identifying problems and initiating action for this group.     

Are elderly people living alone an at risk group?

OBJECTIVE--To test the hypothesis that elderly people living alone are an at risk group with a high level of morbidity that makes high demands on health and social services. DESIGN--Secondary analysis of data from a community survey of 239 people aged 75 and over, identified from general practitioners'' age-sex registers. SETTING--Nine practices in the London boroughs of Brent and Islington. MAIN OUTCOME MEASURES--Scores on the mini-mental state examination; stated satisfaction with life; assessment of mobility; numbers of diagnoses of major physical problems; numbers of prescribed drugs taken; urinary incontinence; alcohol consumption; contacts with general practitioners and hospital outpatient and inpatient services; contact with community health and social services. RESULTS--There were significantly more women among those living alone (93/120 (78%) v 63/119 (53%); p < 0.0005) and the median age of elderly people living alone was higher (81 v 80; p < 0.04). Those living alone and those living with others showed no significant differences in measures of cognitive impairment, numbers of major physical diagnoses, impaired mobility, or use of general practitioner or hospital services. Stated satisfaction with life was somewhat higher in those living alone. Elderly people living alone were significantly more likely to have contact with chiropody, home help, and meals on wheels services and less likely to have someone they could contact in an emergency or at night. Living alone increased the likelihood of contact with one or more community health professionals (district nurses, health visitors, or chiropodists) considered as a group and also increased the likelihood of contact with social services as a whole. There was a tendency for more of those living alone than those living with others to have home visits from their general practitioners, but there were no significant differences in contact with hospital services between the two groups. CONCLUSIONS--Elderly people living alone do not have an excess of morbidity compared with those living with others and do not seem to be an at risk group requiring specifically targeted assessments. More help is needed to provide elderly people living alone with a point of contact in case of emergency.     

Reduction in hospital readmission stay of elderly patients by a community based hospital discharge scheme: a randomised controlled trial.

STUDY OBJECTIVE--To compare a community support scheme using care attendants with standard aftercare for their effects on independence and morale of elderly patients discharged from hospital and on their use of health and social services. DESIGN--Randomised controlled study of cohort of patients over 75 discharged to their own homes. SETTING--District general hospital and community. PATIENTS--Total of 903 patients (mean age 82, 25% over 85). INTERVENTIONS--Total of 464 patients received support from care attendants on first day at home and for up to 12 hours a week for two weeks. Support comprised practical care, help with rehabilitation, and organising social help. The remaining 439 patients received standard aftercare. END POINT--Difference between two groups of 7% in hospital readmission rates or one point on activities of daily living scale (power 80%, significance level 5%). MEASUREMENTS AND MAIN RESULTS--Three months after the initial discharge 763 patients were interviewed (84%). There were no significant differences between the two groups in physical independence (activities of daily living scale), in measures of morale (Philadelphia scale), or in death rates. Hospital readmission rates within 18 months of discharge, however, were significantly higher in the control group and they spent more days in hospital (mean; control group 30.6 days, support group 17.1 days; p = 0.014). Of the patients living alone who were followed up for 18 months 21 (15%) receiving standard aftercare were readmitted more than twice compared with 6 (5%) supported by care attendants (p less than 0.01). CONCLUSIONS--If the findings are confirmed, and the policy extended to all patients over the age of 75 living alone, an average health district might expect either to save about 23 hospital beds at a net annual saving of about pounds 220,000 in the short term or to increase available beds by this number.     

Blocked beds.

In a cross-sectional survey of 325 surgical and orthopaedic beds 43 (16%) of the 265 occupied beds were filled by patients who had no medical need to be in an acute ward. They had been in hospital for a median time of 40 weeks up to the survey date. Of the 43 patients, 11 were awaiting transfer to a geriatric ward; 13 to community residential care; and seven to their homes. There was no plan for discharge or transfer for the remaining 12 (28%). Those "at risk" of becoming long-stay patients for social reasons on these wards were women, over 75, living alone or with one relative, who had been admitted to hospital in emergency with a fractured femur, head injury, or other trauma. Action necessary to reduce the number of social long-stay patients includes (a) changing attitudes to the solving of social case problems; (b) revising procedures of assessment and planning of future care; (c) improving teamwork and record keeping within the hospital and the community services; (d) providing a better balance of acute, medium and long-stay hospital beds; and (e) putting more resources into rehabilitation.     

The elderly mentally ill--whose responsibility?

The elderly mentally ill make considerable demands on health and social services. To evaluate the need for these services a one-day census of all people aged 65 and over was carried out in an area containing 220 000 people (40 000 over 65). Data were obtained on the nursing needs and psychiatric state of the 2162 elderly people in hospital or local authority residential homes for the elderly, or living at home receiving care from the community nursing service. One-third were classified as having psychiatric problems, more than half of them being outside hospital. Residential homes and community nurses play a significant part in caring for the elderly mentally ill, and an integrated but flexible manpower policy is important.     

Residential care for elderly people: a decade of change.

OBJECTIVE--To determine the changes between 1979 and 1990 in demography and dependency levels in elderly people in residential care. DESIGN--Censuses of those aged 65 years and over in any type of residential care at midnight on 11 December 1979 and 27 November 1990. SETTING--Leicestershire District Health Authority (population 865,133, 1991 census), coterminous with county and social services boundaries. MAIN OUTCOME MEASURES--Age, sex, length of stay, and dependency levels (measured by activities of daily living). RESULTS--In 1990 (1979), 6079 (4678) elderly people were enumerated in 241 (133) establishments, a 30% increase in the numbers of elderly people in residential care and an 82% increase in the number of establishments between 1979 and 1990. Dependency levels rose between 1979 and 1990 in all but the geriatric sector, the greatest increases being found in private residential homes where the largest percentage increase in the number of residents had occurred. CONCLUSIONS--Dependency levels in residential care have risen substantially, particularly in the private sector, even beyond levels expected from the greater numbers of elderly people. With the impending move to community care, dependency levels are likely to rise further, and more appropriate staff training and medical input to homes will become necessary.     

Who pays for community care? The same old question.

Trends in mental health service funding over the past 40 years show that the programme of hospital closures has not resulted in a significant release of resources to fund community based services. Far from being excessive, the current provision of residential services (both NHS and non-NHS) for mentally ill people is now below levels recommended as sufficient by the government, the Royal College of Psychiatrists, and the National Schizophrenia Fellowship. What clinical research evidence there is suggests that more rather than fewer residential places are required. This situation is likely to be compounded by the recent transfer of responsibility for funding private and voluntary residential care from the Department of Social Security to local authority social services departments.     

Randomised trial of impact of model of integrated care and case management for older people living in the community

Objective: To evaluate the impact of a programme of integrated social and medical care among frail elderly people living in the community. Design: Randomised study with 1 year follow up. Setting: Town in northern Italy (Rovereto). Subjects: 200 older people already receiving conventional community care services. Intervention: Random allocation to an intervention group receiving integrated social and medical care and case management or to a control group receiving conventional care. Main outcome measures: Admission to an institution, use and costs of health services, variations in functional status. Results: Survival analysis showed that admission to hospital or nursing home in the intervention group occurred later and was less common than in controls (hazard ratio 0.69; 95% confidence interval 0.53 to 0.91). Health services were used to the same extent, but control subjects received more frequent home visits by general practitioners. In the intervention group the estimated financial savings were in the order of £1125 ($1800) per year of follow up. The intervention group had improved physical function (activities of daily living score improved by 5.1% v 13.0% loss in controls; P<0.001). Decline of cognitive status (measured by the short portable mental status questionnaire) was also reduced (3.8% v 9.4%; P<0.05). Conclusion: Integrated social and medical care with case management programmes may provide a cost effective approach to reduce admission to institutions and functional decline in older people living in the community.

Key messages

• Responsibility for management of care of elderly people living in the community is poorly defined
• Integration of medical and social services together with care management programmes would improve such care in the community
• In a comparison of this option with a traditional and fragmented model of community care the integrated care approach reduced admission to institutions and functional decline in frail elderly people living in the community and also reduced costs

     

Health and social status of elderly Asians: a community survey.

A sample based on general practices was the starting point for a community survey of Asians aged 65 years and over to describe: family structure and social contact; aspects of lifestyle; language and communication; capacity for self care; and knowledge about and use of services. A total of 726 (95% of those approached) old people were interviewed in their own languages. Almost all had been born in India, mainly in Gujarat or the Punjab, but most had come to Britain via east Africa. Over half of the over 75s were not fully independent in basic activities of daily living, and a fifth were occasionally or often incontinent of urine, though these levels of incapacity were little different from those found in the indigenous elderly. Few elderly Asians were aware of social services, such as meals on wheels, home helps, social workers, and particularly chiropody. Language also excluded them: 37% of men and only 2% of women could speak English. Moreover, two thirds of elderly Asian women were illiterate in all languages. Health education initiatives directed at these people must understand these cultural and language barriers and perhaps use alternative methods, such as Asian radio programmes and home videos, in providing information on health and welfare services.     

Community care for the elderly 1976-84.

The aging of the elderly population is of crucial importance as people who are over 80 make far greater use of health and social services than any other age group. Government guidelines on the provision of services, which are generally related to the whole population aged 65 and over, fail to take account of this change in the age structure of the elderly population and are no longer appropriate. Recent trends in the provision of domiciliary services, day care, specialist housing for the elderly, and residential care have been related to changes in the number of potential consumers. Ironically, despite the government''s stated commitment to "community care," the chief growth area has been private institutional care. The number of day care places and sheltered housing units has also increased in real terms, but the provision of domiciliary services, such as home help and health visitor visits to the elderly, has either fallen behind or barely matched the increase in the number of very old people. If community care is to be made a reality and if the present inadequate levels of service are to be maintained, let alone improved, then additional resources, greater cooperation among agencies, and a more imaginative approach to the development and delivery of services are urgently needed.     

Factors associated with home visiting in an inner London general practice.

We decided to examine the services provided by doctors in an inner London practice for domiciliary care. It was expected that the study would highlight the most relevant questions and variables related to access and uptake of this service; it would thus contribute to the design of an accurate procedure for auditing the pattern of delivery of home care to be conducted in the practice in the future. During the study period, 1976-81, there were 90 500 doctor-patient contacts. For patients up to the age of 10 years the proportion of home visits was 9.2%, falling to 2.2% in the age group 20 to 29; then there is a quasi plateau till the age of 60. After 60 the proportion of home visits doubles in each of the following 10 year age groups, reaching 54% in the over 80s. The proportion of home visits (standardised by age) rises from social class II (8.0%) to social class V (10.0%), but is higher in social class I (11.7%). The proportion of home visits according to distance from the practice rises from 8.2% near the health centre to 9.6% at a distance of 0.25 to 0.50 mile, and drops to 8.8% beyond 0.75 mile. The distance effect is not consistent when the social class dimension is added: social classes I and II have higher proportions of home visits in certain age and distance groups. Single people have the lowest proportion of home visits (6.8%); there are large differences between men and women among widowed (14.1% and 8.6% respectively) and divorced or separated (7.0% and 10.7% respectively) patients. There are important variations in the proportions of home visits made by the doctors in the practice, the trainees carrying out proportionally many more home visits. Data collected in the practice can be used to define specific issues for future audit exercises. Furthermore, sociodemographic characteristics of patients have been shown to be associated with use and access to medical services.     

Oral health care for frail elderly people: actual state and opinions of dentists towards a well-organised community approach

Objective: This study was undertaken to provide an analysis of the actual oral heath care for frail elderly people living in different settings and to explore opinions of dentists towards new concepts in developing a community approach. Method: Data were collected from a sample of 101 dentists (15%) in the county of Antwerp using a self‐administered 30‐item questionnaire including questions about age, gender, education, organisational aspects of dental surgery, questions concerning dentists’ own contribution to oral healthcare services for frail elderly people and statements concerning opinions and attitude toward the organisation of oral health care for frail elderly people. At the same time, qualitative data were collected from focus group sessions with all participating dentists. Non‐parametric analysis was used to explore possible relationships between opinion and possible explanatory variables. Results: Half of the dentists offered dental services to residential or nursing homes (mean number of treatments a year: 5.4) and at home (mean number of treatments a year: 2.4). Prosthetic treatments such as relieving denture pressure points, repairing, rebasing and making new dentures were carried out in 77.4% and 76.7% of the cases in residential or nursing homes and at home respectively. Extractions were carried out in 16% and 18.6% of the cases in both living situations respectively. The main reasons for dentists refusing domiciliary oral health care were the absence of dental equipment (63%), lack of time (19%), with 11% convincing the patients to be treated in their dental surgery. Analysis showed different opinions of dentists depending on age, gender and university of education; however, statistically significant differences were only found by age. Conclusion: The older the dentist, the greater the tendency to refuse domiciliary oral healthcare services. The younger dentists were reluctant to cooperate in the provision of oral health care in a structured community approach.     

Care of the terminally ill at home.

Care of the terminally ill at home demands the attention of the medical and paramedical community. Patients who choose to remain at home while death approaches must be given full physical, emotional and psychological support by the attending physician and home care services personnel. In 1974 the Vancouver early hospital discharge home care service provided such care to 47 patients. Generally both patient and family were happy with the program. A few families were unable to cope for more than a few days but most continued the care almost to the end, a large number (14) keeping the patient at home until death occurred. Added benefits are the lower costs and the freeing of hospital beds.     

Outcome of planned home births in an inner city practice.

OBJECTIVE--To assess the outcome of pregnancy for women booking for home births in an inner London practice between 1977 and 1989. DESIGN--Retrospective review of practice obstetric records. SETTING--A general practice in London. SUBJECTS--285 women registered with the practice or referred by neighbouring general practitioners or local community midwives. MAIN OUTCOME MEASURES--Place of birth and number of cases transferred to specialist care before, during, and after labour. RESULTS--Of 285 women who booked for home births, eight left the practice area before the onset of labour, giving a study population of 277 women. Six had spontaneous abortions, 26 were transferred to specialist care during pregnancy, another 26 were transferred during labour, and four were transferred in the postpartum period. 215 women (77.6%, 95% confidence interval 72.7 to 82.5) had normal births at home without needing specialist help. Transfer to specialist care during pregnancy was not significantly related to parity, but nulliparous women were significantly more likely to require transfer during labour (p = 0.00002). Postnatal complications requiring specialist attention were uncommon among mothers delivered at home (four cases) and rare among their babies (three cases). CONCLUSIONS--Birth at home is practical and safe for a self selected population of multiparous women, but nulliparous women are more likely to require transfer to hospital during labour because of delay in labour. Close cooperation between the general practitioner and both community midwives and hospital obstetricians is important in minimising the risks of trial of labour at home.     

Community care and social services.

The aim of community care is to enable people with various types of disability to live in their own homes, rather than in institutions. This involves the provision of support and services at home by various agencies. After a critical report in 1986 identified problems with coordination and flexibility of community care services, the white paper Caring for People (1989) stated the government''s aim to provide a "needs led," responsive range of services, promoting maximum independence of those wishing to live at home rather than enter institutional care. New arrangements were introduced in 1993, involving a formal assessment procedure and the production of a personalized care plan for each individual, incorporating services provided by private and voluntary agencies as well as by social services departments. This article describes the components of community care services supplied by local social services authorities, including housing adaptations, equipment, telephones and alarms, home care, meals, and respite care.     

Toward an Understanding of Health Services Use in Women with Binge Eating Disorder

Objectives : This study examined health services use in community samples of 102 white and 60 black women with binge eating disorder (BED), 164 white and 85 black healthy comparison women, and 86 white and 21 black women with a noneating Axis I psychiatric disorder. Research Methods and Procedures : Participants were matched on age, ethnicity, and education and were asked about their use of emergency room visits, outpatient physician visits for medical care, outpatient psychotherapy visits, and days spent in the hospital over the previous 12 months. Total health services use was computed. Results : There were no between‐group differences in outpatient physician visits or inpatient hospital days. Relative to healthy comparison women, women with BED and women with other Axis I disorders had increased total health services use, psychotherapy visits, and emergency department visits. Relative to women with noneating Axis I disorders, women with BED had less use of psychotherapy visits. Although obese white women were more likely to report emergency department visits than obese black women were, nonobese white women were less likely to report emergency department visits than nonobese black women were. Discussion : That health services use by women with BED compared more with that of women with other Axis I disorders than with that of healthy women suggested that BED has clinical significance and is not benign in terms of its impact on the health care system. It appeared, however, that despite the availability of effective treatments, few women with BED received psychotherapy.     

Abuse of elderly people by their carers.

OBJECTIVE--To assess the prevalence of abuse of elderly people by their carers and the characteristics of abusers and the abused. DESIGN--Information on abuse and risk factors was collected over six months from carers and patients. Risk factors were identified in the abused group and compared with those in a non-abused control group. SETTING--Carers were interviewed at home; patients were examined in the wards of Putney and Barnes geriatric hospitals, London. SUBJECTS--All patients referred from any source for respite care to the geriatric services over a six month period and their carers. MAIN OUTCOME MEASURES--Amount of physical and verbal abuse or neglect. Quantification of risk factors and correlation with the presence or absence of abuse. RESULTS--45% Of carers openly admitted to some form of abuse. Few patients admitted abuse. The most significant risk factor for physical abuse was alcohol consumption by the carer (p less than 0.001). Other significant risk factors were a poor pre-morbid relationship and previous abuse over many years. Abuse was often reciprocated and was associated with social dysfunction in many patients. Service delivery, respite care, and level of mental and physical disability were not significantly associated with abuse. CONCLUSION--The high level of abuse found in elderly patients in respite care was particularly associated with alcohol abuse and long term relationships of poor quality, which are difficult to change. Even with increased provision of services, care in the community may not be the best solution for these people.     

Allocating resources for health and social care in England.

The fair allocation of resources for health and social care in relation to the needs of the population in different parts of the United Kingdom has become particularly important since the implementation of the new arrangements for community care in April 1993. These depend on close collaboration between health authorities and local authority social services departments. Yet funding reaches these authorities by different means and according to different criteria. Most health authority funds come through a weighted capitation formula that overemphasises the effects of age, while family health services funding is largely not cash limited and hence demand led. Funds to local authorities for community care are being transferred from the social security budget but on a basis that partly reflects past provision of residential and nursing home care. None of these mechanisms responds to underlying needs that give rise to demands on the health and social care system as a whole, and none makes any attempt to compensate for defects in the others. The solution includes better research and a unified weighted capitation system for all sources of funding.     

Which physicians make home visits and why? A survey

BACKGROUND: Recent changes in the North American health care system and certain demographic factors have led to increases in home care services. Little information is available to identify the strategies that could facilitate this transformation in medical practice and ensure that such changes respond adequately to patients'' needs. As a first step, the authors attempted to identify the major factors influencing physicians'' home care practices in the Quebec City area. METHODS: A self-administered questionnaire was sent by mail to all 696 general practitioners working in the Quebec City area. The questionnaire was intended to gather information on physicians'' personal and professional characteristics, as well as their home care practice (practice volume, characteristics of both clients and home visits, and methods of patient assessment and follow-up). RESULTS: A total of 487 physicians (70.0%) responded to the questionnaire, 283 (58.1%) of whom reported making home visits. Of these, 119 (42.0%) made fewer than 5 home visits per week, and 88 (31.1%) dedicated 3 hours or less each week to this activity. Physicians in private practice made more home visits than their counterparts in family medicine units and CLSCs (centres locaux des services communautaires [community centres for social and health services]) (mean 11.5 v. 5.8 visits per week), although the 2 groups reported spending about the same amount of time on this type of work (mean 5.6 v. 5.0 hours per week). The proportion of visits to patients in residential facilities or other private residences was greater for private practitioners than for physicians from family medicine units and CLSCs (29.7% v. 18.9% of visits), as were the proportions of visits made at the patient''s request (28.0% v. 14.2% of visits) and resulting from an acute condition (21.4% v. 16.0% of visits). The proportion of physicians making home visits at the request of a CLSC was greater for those in family medicine units and CLSCs than for those in private practice (44.0% v. 11.3% of physicians), as was the proportion of physicians making home visits at the request of a colleague (18.0% v. 4.5%) or at the request of hospitals (30.0% v. 6.8%). Physicians in family medicine units and CLSCs did more follow-ups at a frequency of less than once per month than private practitioners (50.9% v. 37.1% of patients), and they treated a greater proportion of patients with cognitive disorders (17.2% v. 12.6% of patients) and palliative care needs (13.7% v. 8.6% of patients). Private practitioners made less use of CLSC resources to assess home patients or follow them. Male private practitioners made more home visits than their female counterparts (mean 12.8 v. 8.3 per week), although they spent an almost equal amount of time on this activity (mean 5.7 v. 5.2 hours per week). INTERPRETATION: These results suggest that practice patterns for home care vary according to the physician''s practice setting and sex. Because of foreseeable increases in the numbers of patients needing home care, further research is required to evaluate how physicians'' practices can be adapted to patients'' needs in this area.     

Medical home care services for the housebound elderly.

In our health jurisdiction the proportion of elderly people is more than double the national average, and there is a severe shortage of both home care services and long-term care beds. To help the many elderly housebound people without primary medical care we initiated a medical services home care program. The goals were patient identification, clinical assessment, medical and social stabilization, matching of the housebound patient with a nearby family physician willing and able to provide home care and provision of a backup service to the physician for consultation and help in arranging admission to hospital if necessary. In the program''s first 2 years 105 patients were enrolled; the average age was 78.9 years. More than 50% were widowed, single, separated or divorced, over 25% lived alone, and more than 40% had no children living in the city. In almost one-third of the cases there had never been a primary care physician, and in another third the physician refused to do home visits. Before becoming housebound 15% had been seeing only specialists. Each patient had an average of 3.2 active medical problems and was functionally quite dependent. Thirty-five of the patients were surveyed after 1 year: 24 (69%) were still at home, and only 1 (3%) was in a long-term care institution; 83% were satisfied with the care provided, and 79% felt secure that their health needs were being met. One-third of the patients or their families said that it was not easy to reach the physician when necessary. We recommend that programs similar to ours be set up in health jurisdictions with a high proportion of elderly people. To recruit and retain cooperative physicians hospital geriatric services must be willing to provide educational, consultative and administrative support.