Vulnerability to winter mortality in elderly people in Britain: population based study

Objective To examine the determinants of vulnerability to winter mortality in elderly British people.Design Population based cohort study (119 389 person years of follow up).Setting 106 general practices from the Medical Research Council trial of assessment and management of older people in Britain.Participants People aged ≥ 75 years.Main outcome measures Mortality (10 123 deaths) determined by follow up through the Office for National Statistics.Results Month to month variation accounted for 17% of annual all cause mortality, but only 7.8% after adjustment for temperature. The overall winter:non-winter rate ratio was 1.31 (95% confidence interval 1.26 to 1.36). There was little evidence that this ratio varied by geographical region, age, or any of the personal, socioeconomic, or clinical factors examined, with two exceptions: after adjustment for all major covariates the winter:non-winter ratio in women compared with men was 1.11 (1.00 to 1.23), and those with a self reported history of respiratory illness had a winter:non-winter ratio of 1.20 (1.08 to 1.34) times that of people without a history of respiratory illness. There was no evidence that socioeconomic deprivation or self reported financial worries were predictive of winter death.Conclusion Except for female sex and pre-existing respiratory illness, there was little evidence for vulnerability to winter death associated with factors thought to lead to vulnerability. The lack of socioeconomic gradient suggests that policies aimed at relief of fuel poverty may need to be supplemented by additional measures to tackle the burden of excess winter deaths in elderly people.     

Effect of preventive home visits by a nurse on the outcomes of frail elderly people in the community: a randomized controlled trial

BACKGROUND: Timely recognition and prevention of health problems among elderly people have been shown to improve their health. In this randomized controlled trial the authors examined the impact of preventive home visits by a nurse compared with usual care on the outcomes of frail elderly people living in the community. METHODS: A screening questionnaire identified eligible participants (those aged 70 years or more at risk of sudden deterioration in health). Those randomly assigned to the visiting nurse group were assessed and followed up in their homes for 14 months. The primary outcome measure was the combined rate of deaths and admissions to an institution, and the secondary outcome measure the rate of health services utilization, during the 14 months; these rates were determined through a medical chart audit by a research nurse who was blind to group allocation. RESULTS: The questionnaire was mailed to 415 elderly people, of whom 369 (88.9%) responded. Of these, 198 (53.7%) were eligible, and 142 consented to participate and were randomly assigned to either the visiting nurse group (73) or the usual care group (69). The combined rate of deaths and admissions to an institution was 10.0% in the visiting nurse group and 5.8% in the usual care group (p = 0.52). The rate of health services utilization did not differ significantly between the 2 groups. Influenza and pneumonia vaccination rates were significantly higher in the visiting nurse group (90.1% and 81.9%) than in the usual care group (53.0% and 0%) (p < 0.001). INTERPRETATION: The trial failed to show any effect of a visiting nurse other than vastly improved vaccination coverage.     

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.     

Effectiveness of paramedic practitioners in attending 999 calls from elderly people in the community: cluster randomised controlled trial

Objective To evaluate the benefits of paramedic practitioners assessing and, when possible, treating older people in the community after minor injury or illness. Paramedic practitioners have been trained with extended skills to assess, treat, and discharge older patients with minor acute conditions in the community.Design Cluster randomised controlled trial involving 56 clusters. Weeks were randomised to the paramedic practitioner service being active (intervention) or inactive (control) when the standard 999 service was available.Setting A large urban area in England.Participants 3018 patients aged over 60 who called the emergency services (n=1549 intervention, n=1469 control).Main outcome measures Emergency department attendance or hospital admission between 0 and 28 days; interval from time of call to time of discharge; patients'' satisfaction with the service received.Results Overall, patients in the intervention group were less likely to attend an emergency department (relative risk 0.72, 95% confidence interval 0.68 to 0.75) or require hospital admission within 28 days (0.87, 0.81 to 0.94) and experienced a shorter total episode time (235 v 278 minutes, 95% confidence interval for difference −60 minutes to −25 minutes). Patients in the intervention group were more likely to report being highly satisfied with their healthcare episode (relative risk 1.16, 1.09 to 1.23). There was no significant difference in 28 day mortality (0.87, 0.63 to 1.21).Conclusions Paramedics with extended skills can provide a clinically effective alternative to standard ambulance transfer and treatment in an emergency department for elderly patients with acute minor conditions.Trial registration ISRCTN27796329.     

Adverse reactions to influenza vaccine in elderly people: randomised double blind placebo controlled trial.

OBJECTIVE--To assess the frequency and type of side effects after influenza vaccination in elderly people. DESIGN--Randomised double blind placebo controlled study. SETTING--15 general practices in the southern Netherlands. SUBJECTS--1806 patients aged 60 or older, of whom 904 received influenza vaccine and 902 placebo. MAIN OUTCOME MEASURES--Adverse reactions reported on postal questionnaire completed four weeks after vaccination. RESULTS--210 (23%) patients given vaccine reported one or more adverse reactions compared with 127 (14%) given placebo. The frequency of local adverse reactions were 17.5% in the vaccine group and 7.3% in the placebo group (p < 0.001). There was no difference in systemic adverse reactions (11% v 9.4%; p = 0.34). In general, men reported fewer side effects than women. CONCLUSION--Only local side effects were more common in vaccinated patients and all side effects were mild.     

Acute viral infections of upper respiratory tract in elderly people living in the community: comparative,prospective, population based study of disease burden.

OBJECTIVE: To evaluate the disease burden of upper respiratory infections in elderly people living at home. DESIGN: Prospective surveillance of elderly people. INTERVENTION: None. SETTING: Leicestershire, England SUBJECTS: 533 subjects 60 to 90 years of age. MAIN OUTCOME MEASURES: Pathogens, symptoms, restriction of activity, duration of illness, medical consultations, interval between onset of illness and medical consultation, antibiotic use, admission to hospital, and death. RESULTS: 231 pathogens were identified for 211 (43%) of 497 episodes for which diagnostic specimens were available: 121 (52%) were rhinoviruses, 59 (26%) were coronaviruses, 22 (9.5%) were influenza A or B, 17 (7%) were respiratory syncytial virus, 7 (3%) were parainfluenza viruses, and 3 (1%) were Chlamydia species; an adenovirus and Mycoplasma pneumoniae caused one infection each. Infections occurred at a rate of 1.2 episodes per person per annum (95% confidence interval 1.0 to 1.7; range 0-10) and were clinically indistinguishable. Lower respiratory tract symptoms complicated 65% of upper respiratory infections and increased the medical consultation rate 2.4-fold (chi 2 test P < 0.001). The median interval between onset of illness and medical consultation was 3 days for influenza and 5 days for other infections. Rhinoviruses caused the greatest disease burden overall followed by episodes of unknown aetiology, coronaviruses, influenza A and B, and respiratory syncytial virus. CONCLUSIONS: Respiratory viruses cause substantial morbidity in elderly people. Although respiratory syncytial virus and influenza cause considerable individual morbidity, the burden of disease from rhinovirus infections and infections of unknown aetiology seems greater overall. The interval between onset of illness and consultation together with diagnostic difficulties raises concern regarding the role of antiviral drugs in treating influenza.     

Risk factors for lower respiratory complications of rhinovirus infections in elderly people living in the community: prospective cohort study.

OBJECTIVE: To assess the role of rhinoviruses in elderly people living in the community. DESIGN: Prospective community based surveillance of elderly people, without intervention. Subjects were telephoned weekly to identify symptomatic upper respiratory tract infections. Symptoms and impact of illnesses were monitored, and specimens were collected for diagnostic serology and human rhinovirus polymerase chain reaction. SETTING: Leicestershire, England. SUBJECTS: 533 subjects aged 60 to 90. MAIN OUTCOME MEASURES: Symptoms, restriction of activity, medical consultations, and antibiotic use during 96 rhinovirus infections. Adjusted odds ratios for lower respiratory syndromes with respect to smoking and health status. RESULTS: A viral cause was established in 211 (43%) of 497 respiratory illnesses; rhinoviruses were identified in 121 (24%) and as single pathogens in 107. The median duration of the first or only rhinovirus infection in the 96 people with 107 rhinovirus infections was 16 days; 18 of the 96 patients were confined to bed and 25 were unable to cope with routine household activities. Overall, 60 patients with rhinovirus infections had lower respiratory tract syndromes; 41 patients consulted their doctor, 31 of them (76%) receiving antibiotics. One patient died. Logistic regression analysis showed that chronic medical conditions increased the estimated probability of lower respiratory rhinovirus illness by 40% (95% confidence interval 17% to 68%) and smoking by 47% (14% to 90%). There were almost six times as many symptomatic rhinovirus infections as influenza A and B infections. CONCLUSIONS: Rhinoviruses are an important cause of debility and lower respiratory illness among elderly people in the community. Chronic ill health and smoking increase the likelihood of lower respiratory complications from such infections. The overall burden of rhinovirus infections in elderly people may approach that of influenza.     

Consequences of assessment and intervention among elderly people: a three year randomised controlled trial.

Over three years 285 randomly selected subjects aged 75 years or more and living in a suburb of Copenhagen were visited every three months in their own homes (the intervention group) to assess whether scheduled medically and socially preventive intervention would influence the number of admissions to hospitals or nursing homes, the number of contacts with general practice, or mortality. A randomly selected group of 287 people of the same age and sex were visited during the final three months of the study (the control group). Two hundred and nineteen admissions to hospitals (4884 bed days) were registered for the intervention group compared with 271 (6442 bed days) for the control group. Especially during the second half of the study, a significant reduction in the number of admissions to hospitals was seen in the intervention group. Twenty people in the intervention group and 29 in the control group moved into nursing homes (p greater than 0.05). The corresponding numbers of deaths were 56 and 75 (p less than 0.05). No difference was seen in the number of contacts with general practice. Significantly fewer emergency medical calls, however, were registered for the intervention group. Subjects in the intervention group benefited from the regular visits and the increased distribution of aids and modifications to their homes to which these led. The regular visits probably also produced an important increase in confidence.     

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.     

Evaluation of compressive strength in the first premolars between young and elderly people: ex vivo study

doi: 10.1111/j.1741‐2358.2011.00583.x Evaluation of compressive strength in the first premolars between young and elderly people: ex vivo study Objective: This study evaluated the compressive strength of first maxillary premolars from young and elderly people. Background: Findings have revealed that changes happening on dental structure lead to a higher susceptibility of tooth fracture. Materials and methods: Thirty teeth were divided into four groups as follows: G I (n = 7) premolars of elderly patients with fused roots, G II (n = 8) premolars of elderly with separate roots, G III (n = 7) pre‐molars of young people with fused roots and G IV (n = 8) premolars of young people with roots separated. The roots were placed in polyvinyl chloride (PVC) cylinder and embedded in acrylic resin. Afterward, the samples were subjected to fracture by compressive strength in a universal testing machine. Loads were applied in continuous and progressive speed of 0.5 mm/min until the moment of fracture. The values found underwent statistical analysis (anova α = 0.05). Results: With regard to age, there was a statistical difference, the teeth of the elderly being more susceptible to fracture (p < 0.05). With regard to root morphology, no significant differences between both groups were observed (p > 0.05). Conclusion: It was concluded that with the methodology employed, the age factor was important with regard to fracture resistance to compression.     

Improving the health behaviours of elderly people: randomised controlled trial of a general practice education programme

ObjectivesTo establish the effect of an educational intervention for general practitioners on the health behaviours and wellbeing of elderly patients.DesignRandomised controlled trial with 1 year follow up.SettingMetropolitan general practices in Melbourne, Australia.Subjects42 general practitioners and 267 of their patients aged over 65 years.InterventionEducational and clinical practice audit programme for general practitioners on health promotion for elderly people.ResultsPatients in the intervention group had increased (a) walking by an average of 88 minutes per fortnight, (b) frequency of pleasurable activities, and (c) self rated health compared with the control group. No change was seen in drug usage, rate of influenza vaccination, functional status, or psychological wellbeing as a result of the intervention. Extrapolations of the known effect of these changes in behaviour suggest mortality could be reduced by 22% if activity was sustained for 5 years.ConclusionsEducation of the general practitioners had a positive effect on health outcomes of their elderly patients. General practitioners may have considerable public health impact in promotion of health for elderly patients.

Key messages

• Few educational interventions for doctors have shown benefit to the health of patients
• Elderly people were identified in the UK health initiatives as in need of additional attention, and levels of health protective behaviours were low in community surveys
• A multifaceted educational intervention for general practitioners was effective in improving walking behaviour, self rated health status, and the frequency of social contacts in elderly patients
• General practitioners are effective in improving health and health behaviours in their elderly patients