Hospital care for the elderly in the final year of life: a population based study.

OBJECTIVES--To determine whether among people aged 65 and over those who died at advanced old age spent more of their last year of life in hospital than those who died younger, and whether the increase in longevity in the elderly between 1976 and 1985 was accompanied by increased time spent in hospital in the last year of life. DESIGN--Linkage of death records to abstracts of records of hospital inpatient care in the preceding year of patients'' lives. SETTING--Six health districts in England covered by the Oxford record linkage study. RESULTS--People who died at advanced ages (85 and over) were less likely than people who died at younger ages (65-84) to have been admitted to hospital in the last year of life. Once admitted the very old tended to spend longer in hospital than others. The mean total time spent in hospital by the elderly in the year before death (based on all deaths including those among people not admitted at all) showed no appreciable change over time. The median time in hospital based on all deaths increased by about three days between 1976 and 1985. During that time there was a gain in life expectancy in the population of about one year from the age of 65. CONCLUSION--The gain in life expectancy in this population was not at the expense of any substantial increase in time spent in hospital in the final year of life.     

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.     

"Don't let others design your future", new CMA president tells physicians. Interview by Nancy Robb.

Dr. Judith Kazimirski of Nova Scotia becomes the CMA''s 126th president during the association''s annual meeting in Sydney, NS, this month. She says her priority for the next year is to help the CMA play a lead role as the debate intensifies about the future of health and health care in Canada. "The time is right for a very public debate about what people want their system to be, what problems they''re having, and how reform is moving ahead," she says, "and physicians have a critical leadership role to play."     

The National Forum reports: Crisis? What crisis?

The National Forum on Health''s final report appears to have said what Canadians--and the federal Liberal government wanted to hear about the health care system. It called for preservation of the single-payer model and the 5 principles of the Canada Health Act, and also recommended that medicare be expanded to embrace pharmaceuticals and home care. Edmonton internist Tom Noseworthy, chair of the forum''s steering committee, said public anxiety about medicare is caused by the rapid pace of change, not its direction. However, the CMA''s Dr. Judith Kazimirski was quick to challenge Noseworthy and his criticism of those who say a crisis exists.     

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.     

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.     

Volunteers,doctors take palliative care into the community.

The face of palliative care is changing. In Ontario''s St. Catharines region there has been a concerted effort to make it more of a community-based procedure. A local college even teaches a 2-year course in palliative care. The trend is expected to continue because Canadians are living longer, and more frail elderly people will be dying at home. Dr. Sandra Hartman, a palliative-care consultant, says physicians interested in palliative care must remember that there is more to it than providing medical assistance. She considers bereavement counseling for the patient''s family a necessary part of follow-up preventive care.     

EXISTENCE: WHO NEEDS IT? THE NON‐IDENTITY PROBLEM AND MERELY POSSIBLE PEOPLE

In formulating procreative principles, it makes sense to begin by thinking about whose interests ought to matter to us. Obviously, we care about those who exist. Less obviously, but still uncontroversially, we care about those who will exist. Ought we to care about those who might possibly, but will not actually, exist? Recently, unusual positions have been taken regarding merely possible people and the non‐identity problem. David Velleman argues that what might have happened to you – an existent person – often doesn't merit moral consideration since the alternative person one would have been had what might have happened actually happened is a merely possible person about whom one has no reason to care. He argues that his way of thinking can eliminate the non‐identity problem. Caspar Hare argues that merely possible people have interests and are morally relevant. He argues that we can solve the non‐identity problem by rejecting the view that merely possible people are morally irrelevant. Both Hare and Velleman argue that focusing on one's de dicto rather than on one's de re children can help us avoid the non‐identity problem. I analyze the role that merely possible, nonexistent hypothetical entities ought to play in our moral reasoning, especially with regard to procreation. I refute both Velleman's and Hare's views and demonstrate the difficulties we encounter when we try to apply their views to common non‐identity cases. I conclude with the common‐sense view regarding who matters, morally: only those who do, did, or will exist.     

Respiratory poliomyelitis: a follow-up study.

Data from the medical records of 113 patients living in Manitoba who had contracted respiratory poliomyelitis between 1952 and 1959 were compared with information obtained from interviews with these patients in 1980. The study was designed to determine whether the patients'' respiratory function, mobility, ability to perform daily tasks, and employment, residential and marital status had changed between 1 year after the onset of polio and 1980. The patients'' dependence on mechanical aids and other people was also studied. More than half (56%) of the patients perceived their respiratory impairment to be the same as it was 1 year after the onset of polio, 27% perceived the impairment to be increased, and 17% perceived it to be decreased. There was an association between level of respiratory function, mobility and ability to perform daily tasks. The 69 patients who lived at home had better respiratory function, mobility and ability to perform daily tasks than the 24 patients who were assisted by a home care program and the 20 who lived in hospital. The latter group had the lowest levels of respiratory and functional ability.     

Babies with spina bifida treated without surgery: parents' views on home versus hospital care.

From 1971 to 1981, 98 babies born with meningomyelocoele at the North Staffordshire Hospital Centre''s district maternity hospital, were thought not suitable for surgery. Sixty three survived for more than one week. Over the period the hospital''s policy changed: initially all such babies were kept in hospital, but later parents were given the choice of taking their baby home for palliative and terminal care. In an attempt to determine parents'' views on the care of their baby the parents of 44 of the babies who survived to one week were traced in 1985-6, five to 14 years later; 80 of them were asked how they felt about the lives and deaths of their babies. Eighteen babies had been taken home, and they had lived longer than the 26 who had been cared for in hospital. Parents whose baby had remained in hospital were sadder than those who had taken their baby home when they looked back at their experiences, and they also considered that their baby''s life had been of poor quality. Most of those who had taken their baby home had a more positive view of their child''s life. The figures suggest that the bereavement process after a baby''s death is longer than has been thought, but despite residual sadness just over half of the parents interviewed thought that something positive had come out of their experience.     

Medical and social factors influencing admission to residential care.

The increasing number of people aged over 75 in Britain makes heavy demands on health and social services. To obtain accurate information for rational allocation of resources to domiciliary and residential services a group of 98 housebound women over 75 were compared with a group of 99 women of the same age in residential care. They had a similar range of physical disorders with the exception that deafness was more common among women in residential care. A much higher proportion in residential care were demented. Though in many respects women in residential care had less physical incapacity, a higher proportion needed help at times of crisis. Important social factors were that women at home were more likely to be living with others, and that the principal helper was more likely to be a husband or relative than a neighbour. Both groups received the same amount of support from home helps and community nurses. Any reduction in the number of residential care places for elderly women whose relatives are not available or are unable to cope would require the establishment of an effective community psychogeriatric service and a system for providing appropriate subjects with 24 hour care and supervision.     

Domiciliary care for the elderly sick--economy or neglect?

This paper reports an investigation of the costs of domiciliary care for 139 elderly sick patients under the care of the home nursing service. The data suggest that there may be little economic advantage in home care for seriously disabled elderly people. The revenue cost of domiciliary care was equal to or greater than the average associated with residential or hospital custodial care in such patients. Even so, the cost of services received at home did not disclose the real need for domiciliary care, since at present this is obscured by compulsory rationing and the separation of responsibility between health and social services. It is suggested that the supposed economic advantage of domiciliary care will depend increasingly on restricting such services, thus increasing the degree of neglect to some patients.     

General practitioner response to elderly patients discharged from hospital.

OBJECTIVE--To determine the effect of discharge information given to general practitioners on their management of newly discharged elderly patients. DESIGN--A random sample of 133 elderly patients who had unplanned readmission to a district general hospital within 28 days of discharge was compared with a matched control sample of patients who were not readmitted. Information was gathered from the hospital, the patients, the carers, and the general practitioners about the information that the hospital had sent the general practitioner and the general practitioners'' response to this information. SETTING--All specialties in a district general hospital. PATIENTS--266 Patients aged over 65 representative in the main demographic indices of the population of elderly patients admitted to hospital. RESULTS--Ten weeks after discharge the doctors had received notice of discharge about 169 of the patients, but fewer than half the discharge notices were received within the first week. General practitioners were dissatisfied with the information in 60 cases. A general practitioner visited 174 of the patients after their discharge from hospital and three quarters of the visits took place within two weeks of the discharge. These visits were more likely to have been initiated by patients or families than by the doctor, and this was not influenced by the doctor receiving notice of the patient''s discharge. Older patients and those who had carers were the most likely to be visited. Nearly half of the carers were dissatisfied with some aspect of general practitioner care, problems with home visiting being the commonest source of complaint. CONCLUSIONS--Hospital communications to general practitioners about the discharge of elderly patients still cause concern, particularly in the time they take to arrive. Written instruction to vulnerable elderly patients asking them to inform their general practitioner of the discharge might be helpful. Carers complained of lack of support, and it is clearly important for someone (either the general practitioner or another health worker) to visit elderly people shortly after their discharge.     

Assessment of patients aged over 75 in general practice.

OBJECTIVES--To evaluate the assessment scheme for people aged 75, to establish doctors'' and nurses'' views on the value of the assessment scheme, and to seek patients'' opinions on elderly assessments. DESIGN--Data on the assessment process were collected from individual practices. Questionnaires were sent to doctors and practice nurses undertaking assessments and to a sample of elderly patients. SUBJECTS--31,565 patients aged 75 and over and all doctors registered with Wiltshire Family Health Services Authority, as well as practice nurses assessing elderly patients. A 2% random sample of elderly patients was selected to answer questions on patient satisfaction. MAIN OUTCOME MEASURES--Numbers of patients accepting the invitation for assessment, who carried out the assessments and where, what unmet needs were identified, and by whom. RESULTS--20,192 patients (64%) accepted the assessment offer. Doctors carried out 8786 assessments and nurses 10,779. Although 12,317 (61%) were carried out in the home, nurses did most domiciliary assessments (7122/11,883). Nurses with extra qualifications identified the highest number of unmet needs (400/1000 visits). 155 of 228 (68%) doctors thought assessments unnecessary whereas 25 of 48 (52%) of nurses thought them important. 93% of patients found assessment useful. CONCLUSIONS--Doctors see no merit in the scheme; most undertake assessments opportunistically and pick up few new problems. Nurses who see it as important require further training to fit them to do home visits confidently. Patients who were assessed found it worth while. The case for developing a specialist community nurse for elderly people should be investigated.     

Which objectively assessed limitations in health status, activities of daily living, or in psychological and social spheres are decisive for referral to a nursing home or to a home for the aged

Which type of limitation is most decisive for a positive indication for a residential home or a somatic or psycho-geriatric nursing home, and to what extent do data on living situation (independent, adapted or intramural) and the social situation (alone or living together) influence this qualification? To obtain an answer to this question three experiments with an integrated, objective and independent assessment-for-care system were set up in the Netherlands. We studied one of them, in the town of Meppel, started in 1996. The study population consisted of all older people living in and around Meppel who had a positive indication for either a residential home, or a somatic or psycho-geriatric nursing home (N = 206 in 1998). Differences in limitations were computed by means of analysis of variance and the types of limitation and their impact on the type of allocated institutions were computed by logistic regression. The limitations only partially explain the types of indication. Indication for a residential home is based on physical limitations. When these increase they become a contra-indication for a residential home and a somatic nursing home indication is given. Mental limitations primarily yield indications for psycho-geriatric nursing homes. Social limitations have a higher incidence among persons with an indication for a somatic nursing home but cannot fully explain this indication. Persons with a residential home indication were significantly more often from an adapted living situation background. The living situation -alone or together-does not have an impact on the indication. We may not conclude that the assessment took place objectively, for, based on the registration it is impossible to conclude for what criteria a person was indicated for a specific type of institution. The objective of assessment, the allocation and distribution of collectively financed care in residential homes and nursing homes based on verifiable assessment methodology could not be realised.     

Parathyroid hormone and 25-hydroxyvitamin D concentrations in sick and normal elderly people.

Serum 25-hydroxyvitamin D and immunoreactive parathyroid hormone concentrations were measured in normal elderly subjects living at home and in sick elderly patients in hospital. Normal old people tended to have high 25-hydroxyvitamin D and low parathyroid hormone concentrations; in the sick elderly this pattern was reversed. The raised serum parathyroid hormone concentrations in the sick elderly were not due to poor renal function and may have been a response to vitamin D deficiency. A high serum parathyroid hormone concentration in an elderly patient must be interpreted in the light of the patient''s general health and nutritional state. Caution is needed in diagnosing primary hyperparathyroidism in this age group.     

General practitioner and long term care of patients with a spinal injury.

A questionnaire was sent to disabled people to ascertain what part their general practitioners played in their long term care. The average consultation rate was 4.40 per patient a year. Overall, it appeared that the patients were most concerned with the general practitioner''s attitude towards them and the general practitioner''s availability.     

The Age of Decline? Anxieties about Ageing in Japan

In the context of unprecedented life expectancy, the social position of the Japanese elderly is changing. Anxieties related to ageing are widely experienced by people of all ages and on a number of levels, including nationwide concerns over the ‘ageing population’ and its economic consequences; the ageing of local communities; on an interpersonal level, as older relatives may require care and support; and, finally, in relation to one's own ageing. These anxieties are examined based on ethnographic research in the city of Osaka. The concept of ikigai, often equated with purpose in life but closely associated with the elderly in public discourse, is used to illustrate how ageing implicates a number of apparently unconnected issues. It is argued that anxieties about ageing may ultimately achieve such prominence because they give focus to a range of fundamental human concerns with meaning, death, freedom, and isolation.     

Genetic Factors in Hashimoto's Struma

It has previously been established that there is a significant history of thyroid disorders in families of patients with Hashimoto''s struma or chronic thyroiditis. In the present study, 99 relatives of 20 patients with Hashimoto''s struma or chronic thyroiditis were studied with regard to the incidence of circulating thyroid autoantibodies; 42 of these 99 relatives were found to have such antibodies. Twenty of the 99 relatives were shown to have thyroid abnormalities (chiefly goitre); of this group of 20, antibodies were found in 12. In the remaining 79 persons (who had no clinical evidence of thyroid disease), 30 were found to have circulating antithyroid antibodies. The incidence of such antibodies among these relatives is very significantly greater than in the general population.From these and other similar studies, there is strong evidence favouring a genetic predisposition for Hashimoto''s struma and chronic thyroiditis. The mode of inheritance is not yet established, and the pathogenesis of the disease has not yet been elucidated.