Health checks on patients 75 years and over in Nottinghamshire after the new GP contract.

OBJECTIVE--To investigate annual health checks for patients of 75 years and over required by the 1990 contract for general practitioners. DESIGN--Visits to practices to collect information on how assessments were organised and carried out; completion of questionnaires for every patient who had been assessed in a sample month, using information provided by the practice records. SETTING--20 general practices in one family health services authority. SUBJECTS--Patients of 75 years and over in 20 general practices. RESULTS--Three practices (15%) had not performed checks. Thirteen practices sent a letter to invite patients to undergo a check. Of these practices, seven followed up non-responders. Two practices visited patients'' homes unannounced, and two did checks on an opportunistic basis only. Sixteen practices used a checklist. Sixteen practices involved their practice nurses; at eight of these, doctors also performed checks; in six practices the nurses undertaking the checks had no training in assessing old people. Ten practices assessed more than 75% of their old people in the first year of the new contract. Practices that did not follow up patients who had not responded to the invitation for assessment completed significantly fewer checks. During the sample month, 331 patients were assessed in the 17 practices. 204 new problems were discovered in 143 patients. Significantly more problems per patient were found in inner city areas. CONCLUSIONS--The way health checks were performed varied greatly, both in their organisation and the practices'' attitudes. Many old people did not respond to letters asking if they wanted an assessment but very few refused one if followed up. Forty three per cent of those assessed had some unmet need. The number of new problems found per patient may reduce over the next few years if the assessments are successful. The need for annual assessment should be kept under review and adequate resources made available for the needs uncovered. Improved training for practice nurses in assessment is needed. Effectiveness of the checks must be monitored. If most unmet need falls in particular high risk groups it would seem sensible to modify the annual check to target these groups.     

Informing the debate on oral health care for older people: a qualitative study of older people’s views on oral health and oral health care

doi: 10.1111/j.1741‐2358.2009.00274.x
Informing the debate on oral health care for older people: a qualitative study of older people’s views on oral health and oral health care Background: Older people represent a growing and diverse section of the population. As age increases, people are more likely to experience health and mobility problems and be at higher risk of developing oral disease. Nevertheless, few older people utilise primary oral healthcare services. It is therefore important to understand the value older people place on oral health and dental services to inform providers and planners of oral health care. This research was conducted as part of a study to identify potential ways of minimising barriers to oral health care in older people. Objectives: To explore perceptions of oral health and oral healthcare services amongst older people living in a socially deprived inner city area and how these are related to service utilisation. Methods: A qualitative approach was utilised to explore the range of issues related to older people’s perceptions of oral health and their views on health care. This involved a combination of focus groups and semi‐structured individual interviews with older people and their carers. Data analysis was conducted using the Framework approach. Results:

• ? Response: Thirty‐nine older people and/or their carers participated in focus groups.
• ? Oral health perception: Oral health was associated with the presence of natural teeth, the absence of pain, practical/social functioning, preferably supported by positive assessment by a dentist.
• ? Oral health life‐course: Older people have a long and complex dental history. Past negative experiences with oral health care, especially in childhood, strongly influenced present attitudes towards dentistry and dental personnel.
• ? Citizenship and right to health care: There was a strong perception that, as ‘British citizens’, older people should have a right to free health care and that the National Health Service (NHS) should support them in this phase of their life.

Conclusions: The oral health life‐course of older people is an important influence on their perceptions of oral health and dental attendance. They consider oral health of importance and place great emphasis on their citizenship and rights of access to state funded oral health care. This raises important issues for the funding and delivery of NHS oral health care for older people.     

Functional decline in old age

Functional decline is a common condition, occurring each year in nearly 12% of Canadians 75 years of age and older. The model of functional health proposed by the World Health Organization (WHO) represents a useful theoretical framework and is the basis for the SMAF (Système de measure de l''autonomie fonctionelle or Functional Autonomy Measurement System), an instrument that measures functional autonomy. The functional decline syndrome, in which functional autonomy is diminished or lost, may present as an acute condition, i.e., a medical emergency for which the patient must be admitted to a geriatric assessment unit. The subacute form is a more insidious condition in which the patient requires comprehensive assessment and a rehabilitation program. A preventive approach based on screening of those at risk and early intervention should prevent or delay the appearance of functional decline or diminish its consequences. Effective strategies for the prevention of or rehabilitation from functional decline will help reduce the incidence of disabilities and the period of dependence near the end of life. These strategies are absolute prerequisites for controlling sociohealth expenses and, most importantly, for allowing people to live independently in old age.     

Quantitative traits for the tail suspension test: automation, optimization, and BXD RI mapping

Immobility in the tail suspension test (TST) is considered a model of despair in a stressful situation, and acute treatment with antidepressants reduces immobility. Inbred strains of mouse exhibit widely differing baseline levels of immobility in the TST and several quantitative trait loci (QTLs) have been nominated. The labor of manual scoring and various scoring criteria make obtaining robust data and comparisons across different laboratories problematic. Several studies have validated strain gauge and video analysis methods by comparison with manual scoring. We set out to find objective criteria for automated scoring parameters that maximize the biological information obtained, using a video tracking system on tapes of tail suspension tests of 24 lines of the BXD recombinant inbred panel and the progenitor strains C57BL/6J and DBA/2J. The maximum genetic effect size is captured using the highest time resolution and a low mobility threshold. Dissecting the trait further by comparing genetic association of multiple measures reveals good evidence for loci involved in immobility on chromosomes 4 and 15. These are best seen when using a high threshold for immobility, despite the overall better heritability at the lower threshold. A second trial of the test has greater duration of immobility and a completely different genetic profile. Frequency of mobility is also an independent phenotype, with a distal chromosome 1 locus. Electronic supplementary material The online version of this article (doi: ) contains supplementary material, which is available to authorized users.     

Psychiatric Problems Affecting Dental Care of the Elderly1

The author reviews the major psychiatric disorders that can affect the dental care of the aged. Depression and dementia are the most common problems in the upper age groups. Other less frequent disorders include paranoid states, anxiety states, and alcohol abuse. All of these illnesses have both symptomatic and specific treatments so that a thorough evaluation and aggressive treatment plan should be pursued when psychiatric symptoms present in any elderly patient. Their treatment can have a considerable influence on the patient's dental care. Ageism, orality, preventive dentistry, xerostomia and periodontal disease are discussed in the context of these psychiatric illnesses of the aged.     

Perspectives on providing good access to dental services for elderly people: patient selection,dentists’ responsibility and budget management

doi: 10.1111/j.1741‐2358.2012.00646.x Perspectives on providing good access to dental services for elderly people: patient selection, dentists’ responsibility and budget management Objectives: To suggest a model for organizing and financing dental services for elderly people so that they have good access to services. Background: There are few studies on how dental services for elderly people should be organized and financed. This is surprising if we take into consideration the fact that the proportion of elderly people is growing faster than any other group in the population, and that elderly people have more dental diseases and poorer access to dental services than the rest of the adult population. In several countries, dental services are characterized by private providers who often operate in a market with competition and free price‐setting. Private dentists have no community responsibility, and they are free to choose which patients they treat. Material and methods: Literature review and critical reasoning. Results: In order to avoid patient selection, a patient list system for elderly people is recommended, with per capita remuneration for the patients that the dentist is given responsibility for. The patient list system means that the dentist assumes responsibility for a well‐defined list of elderly people. Conclusion: Our model will lead to greater security in the dentist/patient relationship, and patients with great treatment needs will be ensured access to dental services.     

Fiscal implications of population ageing.

In all developed countries the fiscal ties of the tax and benefit system serve to complement, and sometimes substitute for, traditional family bonds between young and old. Older people are major recipients of public pensions and public health care systems. Since these public transfers and services are financed primarily from the taxes paid by people of working age, the welfare system in effect transfers resources from young to old. But rather than see the fiscal interdependency between young and old as being analogous to the ties that bind children, parents and grandparents together in familial networks, it is often interpreted as an oppressive burden that the old place on the young. This paper examines arguments that population ageing will exacerbate this burden, and may lead to the collapse of public welfare systems. It shows that the financial problems currently associated with public pensions are a function of system design rather than demographic change, and that wholesale privatization of pension systems will do little to solve the major dilemma--of persuading people to transfer a larger part of their lifetime income to their later years in order to sustain a reasonable standard of living throughout an ever lengthening period of retirement.     

Diagnosis and treatment difficulties in 18-year-old male patient with hereditary hemochromatosis, chronic hepatitis B, Gilbert syndrome and ulcerative colitis

Among possible causes of chronic hepatitis in adolescents most common are infections, autoimmune disorders and metabolic diseases. Thus, diagnostic procedures should be multidirectional. This study reports diagnosis and treatment difficulties in an 18-year-old male patient with hereditary hemochromatosis (HH), ulcerative colitis (UC), chronic hepatitis B (CHB) and Gilbert syndrome. The presented case illustrates problems in diagnostics related to the presence of numerous disease conditions in one patient. It should be taken into consideration that these diseases coexisting in one patient can mutually affect their symptoms creating specific diagnostic difficulties.     

Structural state of rat liver mitochondrial and microsomal membranes in aging and after treatment with thyroxine

Rotation mobility of stearic acid spin labelling in mitochondria and microsomes of 24 months old rats is shown to decrease in comparison with that of 1 month rats. This decrease correlates with an increase in the free cholesterol content in membranes. The phospholipid composition is practically unchanged. With age the osmoresistance of organelles decreases and the cryoresistance increases, supporting indirectly the existence of structural changes in membranes with ageing. The most pronounced activation of NADPH-cytochrome C reductase in the microsomal membrane after the treatment with triton X-100 is observed in case of old animals. The thyroxine treatment of old rats causes a "rejuvenative" effect on the structural state of mitochondrial and microsomal membranes, evidencing for the important role of hormonal regulation in mechanisms of their age rearrangement.     

The uptake of dental services by elderly Germans

Objective: The aim of the study was to assess the uptake of dental services by the old and very old population within the scope of the Berlin Aging Study (Berliner Altersstudie BASE ). Design: A multi‐disciplinary structured interview was performed on 928 subjects, aged from 70 to 103 years of whom 516 persons volunteered to take part in a 14‐session intensive protocol. Six representative study groups were matched for age and gender. Subjects were asked to recall the timing of their most recent dental visit. Data were validated by sending for dental records and compared with all study participants from the multi‐disciplinary intake assessment. Data were related to age group, dental state, dementia and education. Results: Reported last contact with dental services ranged from 2 weeks to 52 years (median 18 months) with a higher time lapse in the study groups aged 85 and older. Dentate subjects had seen their dentist more recently than edentate subjects. Higher education correlated with an increased dental utilisation. Subjective memory on the time lapse since the last dental appointment coincided in 13% of the subjects with available dental records (n=84), was misjudged between one and six months in 55%, and by more than six months in the remainder. Moderately or severely demented subjects who remembered their last dental appointment (n=48 of 70) showed no consistently different utilisation to healthy or mildly demented studs participants. Conclusion: Edentate old and very old subjects show the least frequent utilisation of dental services. Data on motivation and barriers to care are needed to develop strategies to improve the use of dental services and thus promote oral health in late life.     

Mice, the Motor System, and Human Motor Neuron Pathology

Motor neurons are among some of the most unusual cells in the body becaue of their immense size and their role as the critical link between the motor centers of the brain and the muscles. In addition to their intrinsic biological interest, it is vital that we gain a better understanding of these cells and their pathology, since motor neuron degenerative diseases are lethal disorders that affect young and old and are relatively common. For example, one form of spinal muscular atrophy (SMA) is the most common genetic killer of children in the developed world. Amyotrophic lateral sclerosis (ALS), another form of motor neuron degeneration, is the third most common neurodegenerative cause of adult death, after Alzheimer's disease and Parkinson's disease, and is significantly more common than multiple sclerosis (Motor Neurone Disease Association 1998). Currently, approximately 1 in 500 people in England and Wales who die have a form of motor neuron disease (Motor Neurone Disease Association 1998). Each year, 5000 Americans are diagnosed with ALS, and of these, 10% are under 40 years old. Mouse models of motor neuron degeneration are essential for understanding the causes and mechanisms of motor neuron pathology. These mice are yielding important information that will ultimately lead to treatments and potentially cures for these diseases. Received: 5 June 2000 / Accepted: 27 July 2000     

Measurements of tooth wear among Australian aborigines: II. Intrapopulational variation in patterns of dental attrition

The possible implications of variations in dental attrition patterns have necessitated a detailed assessment of the types, ranges, and causes of tooth wear. Hear we employ measurements of postcanine occlusal wear facets from a sample population of extant Australian aborigines. A principal components analysis was applied as a tool in determining common types of attritional patterns. It was concluded that the range of intrapopulational variation in dental wear patterns must be attributed to a multiplicity of sources in addition to such commonly cited causes as dietary variations, gender, age, and developmental eruption sequences.     

Clinical assessment of the elderly patient.

The examination of an elderly patient often requires special techniques and attention to the patient''s comfort and ease. This paper outlines a reasonable approach to each phase of the interview and discusses the particular medical problems of this age group. Older people are often slow to bring their troubles to medical attention because their symptoms are vague or because they accept their disability as part of old age. Sometimes they have difficulty in communicating effectively with the physician. Simple patience can ease an otherwise frustrating situation.     

What do patients with medically unexplained physical symptoms (MUPS) think? A qualitative study

Context Medically unexplained physical symptoms (MUPS) are frequently encountered in family medicine, and lead to disability, discomfort, medicalisation, iatrogenesis and economic costs. They cause professionals to feel insecure and frustrated and patients to feel dissatisfied and misunderstood. Doctors seek answers for rather than with the patient.Objectives This study aimed to explore patients'' explanations of the medically unexplained physical symptoms that they were experiencing by eliciting their own explanations for their complaints, their associated fears, their expectations of the consultation, changes in their ideas of causality, and the therapeutic approach that they considered would be useful.Methodology A qualitative analysis was under-taken of interviews with 15 patients with MUPS in a family medicine unit, 6 months after diagnosis.Results Experience is crucial in construction of the meaning of symptoms and illness behaviour. Many patients identify psychosocial causes under-lying their suffering. These patients received more medication and fewer requests for diagnostic examinations than they had expected. Normalisation is a common behaviour in the clinical approach. Normalisation without explanation can be effective if an effective therapeutic relationship exists that may dispense with the need for words. Listening is the procedure most valued by patients. Diagnostic tests may denote interest in patients'' problems. The clinician''s flexibility should allow adaptation to the patient''s phases of acceptance of the significance of their physical, emotional and social problems.Conclusion Patients with MUPS have explanations and fears associated with their complaints. The patient comes to the consultation not because of the symptom, but because of what he or she thinks about the symptom. The therapeutic relationship, therapeutic listening, and flexibility should be the basis for approaching patients with MUPS. Patients do not always expect medication, although it is what they most often receive. Diagnostic tests, although used sparingly, can be a way to maintain and build a relationship. Drugs and tests can be a ritual statement of clinical interest in the patient and their symptoms.     

Periodontal Diseases in the Elderly: A Critical Evaluation of Current Information1

The proportion of elderly persons in the American population is increasing significantly, and the number of individuals losing all or some of their teeth is decreasing. Consequently, the number of teeth in the elderly at risk for developing periodontis is growing. The prevalence and severity of periodontitis apparently increase with increasing age. These facts have led to the widely held supposition, that periodontitis in elderly people is an ever-increasing burden that society and the dental profession must face. A careful assessment of the data, especially the most recent, shows that this may in fact not be the case. Elderly people have a type of periodontitis that, at any given site, usually progresses infrequently and slowly. The enhanced prevalence and severity among older people may not result from an enhanced susceptibility, but rather, most likely reflect the accumulation of lesions over time. The most recent epidemiological studies indicate that the prevalence of gingivitis, the precursor to periodontitis, is decreasing significantly, especially in the younger segments of the population, and that this may translate into a markedly decreased prevalence of periodontics as these same individuals enter the older age groups. The types of therapy most needed in dealing with periodontitis in older people are not complex and the capacity to perform them does not require specialized periodontal training; it can, in fact, for the most part, be performed by auxillaries such as dental hygienists. Thus, the treatment burden on the dental profession will probably not be as great as in currently anticipated. The numerous gaps in our knowledge about periodontitis in the elderly include a poor understanding of its true prevalence and severity as well as its likelihood of occurrence and rate of progression. We have almost no knowledge about the flora at normal and periodontally diseased sites. Except for the immune system, we have but little knowledge about how the host defense mechanisms change during the aging process. Resolution of these questions would aid greatly in planning prevention and treatment programs and in improving therapeutic decision-making in individual cases.     

Associations between self-assessed masticatory ability and some general health factors in a Swedish population

Objectives : The aims of this study were 1) to describe changes in self-assessed masticatory ability over a 14 year period (1975–89); and 2) to describe associations between self-assessed masticatory ability and age, dental state and some other background factors in a sample of the Swedish population in 1988/89. Design: The Swedish National Central Bureau of Statistics investigates annually the living conditions of the Swedish population by means of interviews by trained persons. The data were analysed by means of stepwise logistic regression and calculation of adjusted relative risks. Subjects: In the investigation in 1988/89, 12901 people above 16 years of age participated and the response rate was 80%. Results: In comparison between the investigations, the prevalence of reported impairment was lower in 1988/89 than in 1975 and 1980/81. Prevalence of reported impairment of chewing ability increased with ageing from 2% in young adults (16–34 years old) to 44% in older elderly (>85 years old). In most age groups, edentulous people reported the highest prevalence, and dentate people the lowest. Relative risks for impaired masticatory ability, independent of age, gender and dental state, were higher for people in rural areas, with low income and living single, as well as for those with skeletal, gastrointestinal, psychiatric and tumour diseases. In the elderly, results from the logistic regression showed that some disability and psychosocial factors were also associated with masticatory ability. Conclusions : The results indicated that there was a group of elderly people who reported several functional and health problems including impaired masticatory ability.     

Antidepressant‐like effects and basal immobility depend on age and serotonin transporter genotype

Monoamine uptake inhibitors are common treatments for depression; however, the therapeutic efficacy of these drugs varies widely. Two factors that are commonly linked to clinical outcome are age and serotonin transporter (SERT) genotype. Mouse models provide powerful tools to study consequences of age and genotype on antidepressant‐like efficacy; however, to date, systematic studies of this nature are lacking. Here, we used the tail suspension test (TST), a preclinical assay for antidepressant efficacy, to gain insight into age and SERT genotype dependency of immobility time in the TST under control conditions (saline injection) and in response to the tricyclic antidepressant, desipramine (DMI). Immobility after saline injection in juvenile, adolescent, adult, mature adult and middle‐aged mice (postnatal days 21, 28, 90, 210 and 300, respectively) significantly increased with age; however, the rate of increase was slower for SERT null (?/?) mice than for wild‐type (+/+) or heterozygote (+/?) mice. Desipramine reduced immobility across ages and SERT genotypes. Middle‐aged, but not adult, SERT^?/? mice were significantly more sensitive to DMI than age‐matched SERT^+/+ or SERT^+/? mice. Desipramine was less potent in middle‐aged SERT^+/+ and SERT^+/? mice than in adult SERT^+/+ or SERT^+/? mice. Regardless of age, DMI's maximal effects were greater in SERT^?/? mice than in SERT^+/+ or SERT^+/? mice. These results show that immobility time in the TST varies as a function of age and SERT genotype, underscoring the utility of the TST as a potential model to examine age‐ and SERT genotype‐dependent influences on antidepressant response.     

Twins and the paradox of dental-age estimations: A caution for researchers and clinicians

The biological age difference among twins is frequently an issue in studies of genetic influence on various dental features, particularly dental development. The timing of dental development is a crucial issue also for many clinicians and researchers. The aim of this study was therefore to verify within groups of twins how dental development differs, by applying Demirjian's method, Mincer's charts of development of third molars and two of Cameriere's methods for dental age estimation, which are among the most popular methods both in the clinical and the forensic scenario. The sample consisted of 64 twin pairs: 21 monozygotic, 30 dizygotic same-sex and 13 dizygotic opposite-sex with an age range between 5.8 and 22.6 years. Dental age was determined from radiographs using the mentioned methods. Results showed that dental age of monozygotic twins is not identical even if they share all their genes. The mean intra-pair difference of monozygotic pairs was low and similar to the difference in dizygotic same-sex twins; the maximum difference between monozygotic twins, however, was surprisingly large (nearly two years). This should lead to some circumspection in the interpretation of systematic estimations of dental age both in the clinical and forensic scenario.     

Problemas de seguridad relacionados con la aplicación de dispositivos de restricción física en personas mayores

The use of physical restraint devices on frail elderly could have significant negative consequences on their health. Apart from complications due to prolonged immobility, the use of this procedure is associated with other serious adverse effects which occur when a person is restricted in a position which carries a risk of asphyxiation. The devices most implicated in these incidents are bedrails, vests and restraining belts. Physical restraint could also be associated as much with the sudden death of patients, due to the stress that it causes, as with injuries from falling. This article presents the recommendations which experts, manufacturers and institutions dealing with the quality of health care have issued for the safest use of this procedure. It stresses the need for better training of professionals, as well as the importance of investigating the factors which can lead to accidents with the aim of preventing them.     

Safety problems associated with using physical restraint devices on the elderly

The use of physical restraint devices on frail elderly could have significant negative consequences on their health. Apart from complications due to prolonged immobility, the use of this procedure is associated with other serious adverse effects which occur when a person is restricted in a position which carries a risk of asphyxiation. The devices most implicated in these incidents are bedrails, vests and restraining belts. Physical restraint could also be associated as much with the sudden death of patients, due to the stress that it causes, as with injuries from falling. This article presents the recommendations which experts, manufacturers and institutions dealing with the quality of health care have issued for the safest use of this procedure. It stresses the need for better training of professionals, as well as the importance of investigating the factors which can lead to accidents with the aim of preventing them.