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.     

The Effects of a Therapy Dog on the Blood Pressure and Heart Rate of Older Residents in a Nursing Home

The aim of the present project was to investigate whether repeated visits by a therapy dog to nursing homes might affect the older residents’ systolic blood pressure and heart rate. A secondary aim was to investigate and compare effects (differences in responses) in older people with high and normal systolic blood pressure. The project consisted of two consecutive studies; the dog study (two researchers and a therapy dog with a handler visited the residents at three nursing homes, n = 13), and the control study (the two researchers alone visited the residents at three different nursing homes, n = 13). The studies were divided into three periods; period 1 (weeks 1–2), period 2 (weeks 3–4), and period 3 (weeks 5–6) and included two visits per week. The dog and her handler visited during periods 2 and 3 in the dog study. Participants’ heart rate and blood pressure were measured at 0 and 20 minutes at each visit. The data were analyzed using Friedman's two- way analysis of Variance by Rank with post-hoc analysis using Wilcoxon signed-rank tests with a Bonferroni correction, and also with the Mann-Whitney U test for independent samples. In the dog study, participants’ heart rate decreased significantly (p = 0.006) from period 1 to period 3. Participants with an initial systolic blood pressure ≥ 130 mmHg had a significant decrease in both systolic blood pressure (p = 0.009) and heart rate (p = 0.009). In the control study, participants’ heart rate and systolic blood pressure did not change significantly. The participants in the dog study had a significantly lower systolic blood pressure during period 3 (p = 0.016) compared with those in the control study. In conclusion, repeated visits by a therapy dog–handler team decreased the older adults’ heart rate, and for those with high initial systolic blood pressure, blood pressure also decreased. In addition, systolic blood pressure decreased significantly in the dog group when compared with the control group.     

Effects of preventive home visits to elderly people.

OBJECTIVES--To assess the effect of preventive home visits by public health nurses on the state of health of and use of services by elderly people living at home. DESIGN--Randomised controlled trial. SETTING--General population of elderly people in one of the southern regions of the Netherlands. SUBJECTS--580 subjects aged between 75 and 84 years randomly allocated to intervention (292) or control (288) group. INTERVENTIONS--Four visits a year over three years in intervention group. Control group received no home visits. MAIN OUTCOME MEASURES--Self rated health, functional state, well being, loneliness, aspects of the mental state (depressive complaints, memory disturbances), and mortality. Use of services and costs. RESULTS--Visits had no effect on the health of the subjects. In the group visited no higher scores were seen on health related measures, fewer died (42 (14%) v 50 (17%)), and community care increased slightly. In the control group more were referred to outpatient clinics (166 (66%) v 132 (55%)), and they had a 40% increased risk of admission (incidence rate ratio 1.4; 90% confidence interval 1.2 to 1.6). No differences were found in long term institutional care, and overall expenditure per person in the intervention group exceeded that in the control group by 4%. Additional analyses showed that visits were effective for subjects who initially rated their health as poor. CONCLUSIONS--Preventive home visits are not beneficial for the general population of elderly people living at home but might be effective when restricted to subjects with poor health.     

Controlled trial of respiratory health worker visiting patients with chronic respiratory disability.

Seventy five patients with chronic respiratory disability were randomised to a group visited by a respiratory health worker (42) or control group (33). The first group was visited monthly by a respiratory nurse, who gave education and support. The effect of the intervention was assessed in terms of quality of life (by questionnaires), the number and duration of admissions to hospital, and the number of deaths. The questionnaires on quality of life showed no changes in either group during the study, but nearly all of the group visited by a respiratory health worker said that they valued the visits and wished them to continue. Their knowledge about their condition also improved compared with that of the controls. The duration of stay in hospital for respiratory reasons in the group visited by a respiratory health worker was longer than that of control patients. This was explained by their being scored as more ill than the controls on admission. Fewer patients died in the group visited by a respiratory health worker than in the control group (p = 0.11). The patients in the group visited by respiratory health workers may have survived longer because they sought help rather than dying at home. If confirmed this could have implications for the cost of their care.     

La Geriatría de Enlace con residencias en la época de la COVID-19. Un nuevo modelo de coordinación que ha llegado para quedarse

Older people living in nursing homes fulfil the criteria to be considered as geriatric patients, but they often do not have met their health care needs. Current deficits appeared as a result of COVID-19 pandemic. The need to improve the coordination between hospitals and nursing homes emerged, and in Madrid it materialized with the implantation of Liaison Geriatrics teams or units at public hospitals. The Sociedad Española de Geriatría y Gerontología has defined the role of the geriatricians in the COVID-19 pandemic and they have given guidelines about prevention, early detection, isolation and sectorization, training, care homes classification, patient referral coordination, and the role of the different care settings, among others. These units and teams also must undertake other care activities that have a shortfall currently, like nursing homes-hospital coordination, geriatricians visits to the homes, telemedicine sessions, geriatric assessment in emergency rooms, and primary care and public health services coordination. This paper describes the concept of Liaison Geriatrics and its implementation at the Autonomous Community of Madrid hospitals as a result of COVID-19 pandemic. Activity data from a unit at a hospital with a huge number of nursing homes in its catchment area are reported. The objective is to understand the need of this activity in order to avoid the current fragmentation of care between hospitals and nursing homes. This activity should be consolidated in the future.     

Home visiting by general practitioners in England and Wales.

OBJECTIVE--To use data from the fourth national survey of morbidity in general practice to investigate the association between home visiting rates and patients'' characteristics. DESIGN--Survey of diagnostic data on all home visits by general practitioners. SETTING--60 general practices in England and Wales. SUBJECTS--502 493 patients visited at home between September 1991 and August 1992. MAIN OUTCOME MEASURES--Home visiting rates per 1000 patient years and home visiting ratios standardised for age and sex. RESULTS--10.1% (139 801/1 378 510) of contacts with general practitioners took place in patients'' homes. The average annual home visiting rate was 299/1000 patient years. Rates showed a J shaped relation with age and were lowest in people aged 16-24 years (103/1000) and highest in people aged > or = 85 years (3009/1000). 1.3% of patients were visited five or more times and received 39% of visits. Age and sex standardised home visiting ratios increased from 69 (95% confidence interval 68 to 70) in social class I to 129 (128 to 130) in social class V. The commonest diagnostic group was diseases of the respiratory system. In older age groups, diseases of the circulatory system was also a common diagnostic group. Standardised home visiting ratios for the 60 practices in the study varied nearly eightfold, from 28 to 218 (interquartile range 67 to 126). CONCLUSIONS--Home visits remain an important component of general practitioners'' workload. As well as the strong associations between home visiting rates and patient characteristics, there were also large differences between practices in home visiting rates. A small number of patients received a disproportionately high number of home visits. Further investigation of patients with high home visiting rates may help to explain the large differences in workload between general practices and help in allocation of resources to practices.     

Modeling the spread of methicillin-resistant Staphylococcus aureus in nursing homes for elderly

Methicillin-resistant Staphylococcus aureus (MRSA) is endemic in many hospital settings, including nursing homes. It is an important nosocomial pathogen that causes mortality and an economic burden to patients, hospitals, and the community. The epidemiology of the bacteria in nursing homes is both hospital- and community-like. Transmission occurs via hands of health care workers (HCWs) and direct contacts among residents during social activities. In this work, mathematical modeling in both deterministic and stochastic frameworks is used to study dissemination of MRSA among residents and HCWs, persistence and prevalence of MRSA in a population, and possible means of controlling the spread of this pathogen in nursing homes. The model predicts that: (i) without strict screening and decolonization of colonized individuals at admission, MRSA may persist; (ii) decolonization of colonized residents, improving hand hygiene in both residents and HCWs, reducing the duration of contamination of HCWs, and decreasing the resident∶staff ratio are possible control strategies; (iii) the mean time that a resident remains susceptible since admission may be prolonged by screening and decolonization treatment in colonized individuals; (iv) in the stochastic framework, the total number of colonized residents varies and may increase when the admission of colonized residents, the duration of colonization, the average number of contacts among residents, or the average number of contacts that each resident requires from HCWs increases; (v) an introduction of a colonized individual into an MRSA-free nursing home has a much higher probability of leading to a major outbreak taking off than an introduction of a contaminated HCW.     

Nursing dependency in registered nursing homes and long term care geriatric wards in Edinburgh.

There has been growing interest and public investment in registered nursing homes, apparently based on the assumption that these homes are the private equivalent of hospital long term care. We have tested this hypothesis in a survey comparing 400 patients in 18 registered nursing homes with 217 patients in 11 geriatric long term care wards in Edinburgh. The nursing home patients formed a distinct and separate group: 362 (92%) were women, 392 (98%) were single or widowed, and 358 (90%) were self financing, whereas in the geriatric long term care group 148 (68%) were women and 35 (16%) were still married. Patients in nursing homes were also far less dependent than those in geriatric long term care wards (p less than 0.005). This study suggests that there may be large differences between the patients in these two types of institution, particularly with regard to nursing dependency. This finding has important implications in the future planning of long term places for the dependent elderly.     

Utilisation by homeless people of acute hospital services in London.

OBJECTIVES--To estimate the numbers and distribution of homeless people in London; to quantify the utilisation of acute inpatient services by homeless people in two health authorities; and to predict the total numbers of admissions in homeless people in district health authorities across London. DESIGN--Data were collected from various sources on the distribution of homeless people across London boroughs. All unplanned acute inpatient admissions during November 1990 to relevant hospitals were identified. SETTING--Bloomsbury and Paddington and North Kensington, two former inner London district health authorities. SUBJECTS--Homeless people in London residing in bed and breakfast and private sector leased accommodation, residing in hostels, and of no fixed abode. MAIN OUTCOME MEASURES--Number and cost of acute unplanned admissions in homeless people in two health authorities in November 1990; predicted number of such admissions each year in district health authorities in London. RESULTS--There were at least 60,000 homeless people in London in March 1990. The majority were housed in temporary accommodation (55,412). There were at least 3295 hostel dwellers and 651 people sleeping rough. Homeless people accounted for 105 (8%) of the 1256 acute unbooked admissions in residents of Bloomsbury and Paddington and North Kensington health authorities in November 1990. Considerable variations in the pattern of acute unplanned admissions in homeless people were observed in the two districts with respect to housing status and specialty of admission. The total number of acute unplanned admissions in homeless people across London each year was estimated at 7598, ranging from 38 in Bexley to 1515 in Parkside. CONCLUSIONS--The results have fundamental implications for resource allocation across London. Allocation must take better account of the heterogeneity, uneven distribution, and extra health needs of homeless people.     

The Use and Nonuse of Companion Animals by Volunteers in Nursing Homes: A Comparative Study

Abstract

This report compares motivation and satisfaction of volunteers who visited residents in nursing homes accompanied by a dog with volunteers who visited the same residents but without a dog. The sample consisted of 40 people, 21 of whom were accompanied by a pet. A questionnaire of 111 items were developed and administered to all participants. Both groups of volunteers had equivalent volunteer experience and their reasons for volunteering were almost identical. No significant differences between the two groups were identified, possibly because of the small size of the sample, but an increased level of staff-volunteer interaction was reported for the pet group.     

Private rest homes in the care of the elderly.

Sixteen private rest homes were visited to assess their facilities and the types of disability of the residents. Apart from one home, which was a hotel for the elderly, all the homes provided care for physically and mentally frail elderly people over the long term. Although care was good the trends in the use of the homes are worrying, and stricter regulations are required to ensure appropriate levels of care. Greater support is also required from district nursing services.     

Reduction of femoral fractures in long-term care facilities: the Bavarian fracture prevention study

Background

Hip fractures are a major public health burden. In industrialized countries about 20% of all femoral fractures occur in care dependent persons living in nursing care and assisted living facilities. Preventive strategies for these groups are needed as the access to medical services differs from independent home dwelling older persons at risk of osteoporotic fractures. It was the objective of the study to evaluate the effect of a fall and fracture prevention program on the incidence of femoral fracture in nursing homes in Bavaria, Germany.

Methods

In a translational intervention study a fall prevention program was introduced in 256 nursing homes with 13,653 residents. The control group consisted of 893 nursing homes with 31,668 residents. The intervention consisted of staff education on fall and fracture prevention strategies, progressive strength and balance training, and on institutional advice on environmental adaptations. Incident femoral fractures served as outcome measure.

Results

In the years before the intervention risk of a femoral fracture did not differ between the intervention group (IG) and control group (CG). During the one-year intervention period femoral fracture rates were 33.6 (IG) and 41.0/1000 person years (CG), respectively. The adjusted relative risk of a femoral fracture was 0.82 (95% CI 0.72-0.93) in residents exposed to the fall and fracture prevention program compared to residents from CG.

Conclusions

The state-wide dissemination of a multi-factorial fall and fracture prevention program was able to reduce femoral fractures in residents of nursing homes.     

Evaluación de un programa de intervención en residencias geriátricas para reducir la frecuentación hospitalaria

Objectives

This study describes the outcomes of an intervention program in Nursing Homes and their effects on emergency room attendance, hospital admissions, and pharmaceutical expenditure.

Material and methods

This involved non-randomised community intervention in Nursing Homes with a control group. The program was implemented gradually from 2007 to 2009 in 10 Nursing Homes (857 beds) which participated voluntarily. The control group consisted of 14 Nursing homes (1,200 beds), which refused to participate or were not assigned to our Primary Care centres. Intervention consisted of comprehensive geriatric assessment and follow-up visits by trained personnel, review and adjustment of drug treatment, case management and staff training.

Results

In the Nursing Homes where the program was carried out, emergency room attendance decreased from 1165‰ (95%CI 1100-1240]) in 2006 to 674‰ (95%CI 620-730) in 2009, while in the control group it increased from 1071 (95%CI 1020-1130) to 1246‰ (95%CI 1190-1310). The hospital admissions also decreased from 48.4% (95%CI 45-52) in 2006 to 32.1% (95%CI 29-35) in 2009, while in the control group increased from 43.5% (95%CI 41-46) to 55.8% (95%CI 53-59). There was also a 9% reduction in pharmacy cost compared with an increase of 11.9% in the control group.

Conclusions

The intervention has proved effective at reducing hospital admissions and emergency room attendance in institutionalised patients, thereby streamlining pharmacy costs.     

Cost-Effectiveness of an Intervention to Reduce Emergency Re-Admissions to Hospital among Older Patients

Background

The objective is to estimate the cost-effectiveness of an intervention that reduces hospital re-admission among older people at high risk. A cost-effectiveness model to estimate the costs and health benefits of the intervention was implemented.

Methodology/Principal Findings

The model used data from a randomised controlled trial conducted in an Australian tertiary metropolitan hospital. Participants were acute medical admissions aged >65 years with at least one risk factor for re-admission: multiple comorbidities, impaired functionality, aged >75 years, recent multiple admissions, poor social support, history of depression. The intervention was a comprehensive nursing and physiotherapy assessment and an individually tailored program of exercise strategies and nurse home visits with telephone follow-up; commencing in hospital and continuing following discharge for 24 weeks. The change to cost outcomes, including the costs of implementing the intervention and all subsequent use of health care services, and, the change to health benefits, represented by quality adjusted life years, were estimated for the intervention as compared to existing practice. The mean change to total costs and quality adjusted life years for an average individual over 24 weeks participating in the intervention were: cost savings of $333 (95% Bayesian credible interval $ -1,932∶1,282) and 0.118 extra quality adjusted life years (95% Bayesian credible interval 0.1∶0.136). The mean net-monetary-benefit per individual for the intervention group compared to the usual care condition was $7,907 (95% Bayesian credible interval $5,959∶$9,995) for the 24 week period.

Conclusions/Significance

The estimation model that describes this intervention predicts cost savings and improved health outcomes. A decision to remain with existing practices causes unnecessary costs and reduced health. Decision makers should consider adopting this program for elderly hospitalised patients.     

Private nursing homes: contribution to long stay care of the elderly in the Brighton Health District.

Two surveys of private nursing homes, designated geriatric wards, and a sample of social service part III homes were carried out in the Brighton Health District using questionnaires supplemented (in the second survey) by some interviews. The dependency of old people in the private nursing homes was more like that of long stay hospital patients rather than that of residents in social services homes. In the private nursing homes, however, a smaller proportion of patients were in the medium to heavy nursing category (178 (31%) compared with 158 (63%) in the hospital long stay wards) and a larger proportion in the heavy nursing category (170 (30%) compared with 44 (17%) in the long stay wards). Of the patients in private nursing homes, 401 (82%) were local residents, 488 (86%) were long stay, and 459 (88%) were women; their mean age was 88 years. Two thirds of the patients were over 80. There were no significant differences between the private nursing homes and the wards in nursing workloads or staffing, except for a slightly higher provision of state registered nurses in the private sector. In the private nursing homes 348 (63%) of the patients had fees paid by private funds, 26 (5%) were in contract beds paid for by the National Health Service, and 176 (32%) were subsidized by the Department of Health and Social Security. Private nursing homes make a substantial contribution to the care of the elderly in the Brighton Health District, and the health authority should develop a more active partnership with this sector.     

家庭干预对喉癌患者术后生活质量的影响

目的:探讨家庭干预对喉癌术后患者生活质量的影响。方法:将66例喉癌术后患者随机分为干预组和时照组,两组病人均进行常规治疗和护理,干预组在此基础上对患者实施针对性家庭干预。采用Terrell生活质量调查表分别在实施干预前及实施干预后进行评估。结果:干预组患者干预后对健康知识掌握率显著高于对照组(P<0.05),生活质量明显高于对照组(P<0.05)。结论:对喉癌术后病人实施针对性家庭干预,可以提高喉癌术后病人生活质量。     

Deprescribing in Frail Older People: A Randomised Controlled Trial

Objectives

Deprescribing has been proposed as a way to reduce polypharmacy in frail older people. We aimed to reduce the number of medicines consumed by people living in residential aged care facilities (RACF). Secondary objectives were to explore the effect of deprescribing on survival, falls, fractures, hospital admissions, cognitive, physical, and bowel function, quality of life, and sleep.

Methods

Ninety-five people aged over 65 years living in four RACF in rural mid-west Western Australia were randomised in an open study. The intervention group (n = 47) received a deprescribing intervention, the planned cessation of non-beneficial medicines. The control group (n = 48) received usual care. Participants were monitored for twelve months from randomisation. Primary outcome was change in the mean number of unique regular medicines. All outcomes were assessed at baseline, six, and twelve months.

Results

Study participants had a mean age of 84.3±6.9 years and 52% were female. Intervention group participants consumed 9.6±5.0 and control group participants consumed 9.5±3.6 unique regular medicines at baseline. Of the 348 medicines targeted for deprescribing (7.4±3.8 per person, 78% of regular medicines), 207 medicines (4.4±3.4 per person, 59% of targeted medicines) were successfully discontinued. The mean change in number of regular medicines at 12 months was -1.9±4.1 in intervention group participants and +0.1±3.5 in control group participants (estimated difference 2.0±0.9, 95%CI 0.08, 3.8, p = 0.04). Twelve intervention participants and 19 control participants died within 12 months of randomisation (26% versus 40% mortality, p = 0.16, HR 0.60, 95%CI 0.30 to 1.22) There were no significant differences between groups in other secondary outcomes. The main limitations of this study were the open design and small participant numbers.

Conclusions

Deprescribing reduced the number of regular medicines consumed by frail older people living in residential care with no significant adverse effects on survival or other clinical outcomes.

Trial Registration

Australian New Zealand Clinical Trials Registry ACTRN12611000370909     

PSYCHOLOGICAL PROBLEMS OF AGING

The increasing number of older persons in the United States is having far-reaching economic, social, political and psychological effects. Patients over 60 make up more than a fourth of current admissions to California''s state mental hospitals. Biological, personal, cultural and economic problems are present in each elderly person and must be considered in the treatment of such individuals. Neurotic reactions are much more frequent that the psychoses, and these may be treated by the same therapeutic tools utilized with younger persons.Not all the psychoses in the aged group are such as to necessitate mental hospital care. Many of the patients could be cared for in suitable nursing homes. An adequate mental hygiene program, maintenance of physical health, opportunities for work, and the development of hobby and recreation centers may help ward off many of the difficult problems that the aged now present.     

腹腔镜下小儿疝气手术的护理干预及效果分析

目的分析腹腔镜下小儿疝气手术的护理干预方法及效果。方法选取2015年6月~2016年5月我院收治的98例腹腔镜下小儿疝气手术患者为研究对象,随机分为观察组和对照组各49例。对照组给予常规护理干预,观察组给予针对性护理干预,观察比较两组治疗效果及并发症发生情况。结果观察组患儿的下床活动时间、住院时间与术后疼痛水平均优于对照组,组间差异具有统计学意义(P0.05);观察组患儿术后牵拉疼痛、尿潴留与切口感染等并发症发生率低于对照组,差异具有统计学意义(P0.05)。结论腹腔镜下小儿疝气手术配合针对性护理干预有助于促进病情恢复、预防并发症的发生,具有较高的临床应用价值。     

Oral Health and Treatment Needs of Patients in Two Communal Nursing Homes

The aim of this study was to describe the oral status of patients in two communal nursing homes and to assess the need of those patients for dental treatment. The study was based on a sample that included all patients in the nursing homes of two typical Finnish rural communes. Data were collected for the 132 patients who were examined by a dentist in the nursing homes. As background data for the study we used patient records and interviews. Fifty percent of the patients had no teeth. Among the totally edentulous, every second man and every fourth woman either did not have or did not use dentures. Only half of the patients could be classified as eligible for dental treatment. The main treatment need was prosthetic care treatment. The total estimated number of visits needed per patient was 2.4. The total cost of this treatment series was estimated to be 71 US$/patient. Based on this evaluative study, the dental treatment for nursing home patients could easily be organized by using one dental unit for three weeks.