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.     

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.     

The health status and health care use of elderly living in sheltered residences. A comparison with independently living elderly

A sheltered residence for older persons is a living arrangement in between independent living and a residential institution. There is little knowledge about the health of elderly living in these residences. We studied the physical, functional and psychosocial health of 401 persons living in a sheltered residence for elderly in Zwolle through a standardised interview. We compared the health of these elderly to the health of independently living elderly in the same region studied in the Longitudinal Aging Study Amsterdam and adjusted for sex, age and married state. We found an impaired functional health and more chronic illnesses among elderly living in a sheltered residence. In addition, more medication was used (OR = 2.4). The studied elderly felt more often depressed (OR = 1.9) or lonely (OR = 1.7). Their mental state was more frequently impaired (OR = 1.7), they visited health professionals more often and received more help for personal care (OR = 2.0) and housekeeping (OR = 1.6). We conclude that people living in sheltered residences form a distinct group of elderly, characterised by impaired physical, functional and psychosocial health. Planners of future care must be aware of this vulnerable group.     

Prevalencia y factores asociados a sospecha de malos tratos en la unidad geriátrica del área de urgencias del hospital

Objective

To know the prevalence of mistreatment and to identify the associated factors among elderly people without cognitive impairment, seen in the geriatric unit, located in the hospital emergency area.

Methods

Cross-sectional study of a population of 65 years or older assessed by the geriatric Interdisciplinary Social Welfare Functional Unit (ISSFU) of the emergency area in the Arnau de Vilanova hospital of Lleida. We excluded participants with cognitive impairment. The total number of participants was 127. The suspicion of mistreatment was measured using the Questionnaire of the American Medical Association (AMA) and the Canadian Task Force (CTF). The variables studied were social demographic characteristics and functional dependency.

Results

Prevalence of suspicion of mistreatment was 29.1% (95% CI: 0.21-0.37). The most frequent subtypes were neglect and psychological, and less frequent was negligence. Associated factors were being female, being in unpaid work, being a widow and living alone.

Conclusions

Three out of ten elderly people were identified as possible victims of abuse. Due to the relative isolation of many of the elderly who were abused, an unexpected visit to the emergency area may be the only opportunity for detection. Geriatric units located in this area should include the suspicion of mistreatment of this population in their comprehensive assessment. For this, it is necessary to have tool with a high degree of sensitivity and specificity for detection of abuse in the elderly.     

Old people not known to the general practitioner: low risk group.

The elderly patients in a large general practice aged 75 and over who lived at home (n = 877) were divided into two groups according to the general practitioner''s knowledge of their risk status and were designated "risk status known" (n = 679) and "risk status not known" (n = 198). Forty-three high risk patients in the risk status known group had a functional disability score and experience of mortality that was not dissimilar to those of elderly people in institutions. The medical and social characteristics of a random sample (n = 150) of the risk status known group, after excluding the high risk patients, were compared with the risk status not known group using a Barber Wallis questionnaire. A response rate of 90% was achieved from both groups and a cumulative risk score was calculated by totalling unfavourable replies to the questions. The risk status not known group, which comprised 14% of the patients who lived at home after correcting for the number who had died and moved, had appreciably less contact with the general practitioners, had an appreciably lower cumulative risk score, were confined at home less because of ill health, were less concerned about their health, and were less in need of nursing attention. The findings of this study suggest that the elderly patients who are not known to their general practitioners are in relatively good health when compared with the patients that the general practitioner knows well.     

Apex predator suppression is linked to restructuring of ecosystems via multiple ecological pathways

Removal of apex predators can drive ecological regime shifts owing to compensatory positive and negative population level responses by organisms at lower trophic levels. Despite evidence that apex predators can influence ecosystems though multiple ecological pathways, most studies investigating apex predators’ effects on ecosystems have considered just one pathway in isolation. Here, we provide evidence that lethal control of an apex predator, the dingo Canis dingo, drives shifts in the structure of Australia's tropical‐savannah ecosystems. We compared mammal assemblages and understorey structure at seven paired‐sites. Each site comprised an area where people poisoned dingoes and an area without dingo control. The effects of dingo control on mammals scaled with body size. Where dingoes were poisoned, we found greater activity of herbivorous macropods and feral cats, a mesopredator, but sparser understorey vegetation and lower abundances of native rodents. Our study suggests that ecological cascades arising from apex predators’ suppressive effects on herbivores and mesopredators occur simultaneously. Concordant effects of dingo removal across tropical‐savannah, forest and desert biomes suggest that dingoes once exerted ubiquitous top–down effects across Australia and provides support for calls that top–down forcing should be considered a fundamental process governing ecosystem structure.     

Data on periodontal health among elderly people in Bushland,Jharkhand, Magadha and Patna,India

It is of interest to report data on periodontal Health among elderly people in Bushland, Jharkhand, Magadha and Patna, India. The sample comprised of a 130 elderly people. The studies device comprised of a semi-structured survey with thirteen questions. Data shows that old people in Jharkhand suffered from advanced periodontal ailment (47.6%) with easy gingivitis (33.8%). Data also shows that grownups (88.2% grownup males, 64.5% girls in Jharkhand and 34.5% grownup males and 88.9% girls in Bihar) used toothpaste and toothbrush as their primary style for tooth cleansing. These data help in providing improved dental service to rural population in India.     

Trends in use of medical services by the elderly in British Columbia.

We analysed physician fee-for-service use in British Columbia from 1974-75 to 1985-86. Over the study period use increased by 5.3% per year. This can be factored into increases attributable to changes in the age structure of the population (0.4% per year), general population growth (1.8%, for a combined annual "population effect" of 2.2%) and age-specific increases in per-capita use (3% per year). The average annual increase for people aged 75 years or more was 5.5% per capita. The area with the fastest growth in use by the elderly was specialist care, particularly diagnostic services. The average number of specialists seen by people aged 75 years or more doubled over the study period. Our results suggest that increased per-capita use among the elderly that is unrelated to aging of the population should be the main focus of future policy attention. Additional analyses are needed to determine the underlying dynamics of this dramatic increase in rates of use among the elderly.     

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.     

Patterns of dental caries and treatment experience in elderly Lithuanians

Objective: The aim of the study was to evaluate patterns of caries experience in a representative sample of Lithuanians, aged 65‐74. Methods: This cross‐sectional study included 301 participants (response rate 54%). Information was obtained from a clinical examination (caries experience, stimulated salivary flow rates and oral hygiene levels) and a questionnaire. The questionnaire comprised questions about oral, general, physical, mental and social health and about background, knowledge, attitudes and lifestyle. The study had a multidimensional approach to negative consequences of disease and positive aspects of health. For bivariate testing, t‐test, ANOVA and Spearman's correlation were used. Factor analysis was combined with linear multiple regression for a multivariate study of caries experience patterns. Results: Elderly Lithuanians were found to have lower levels of edentulousness (range 11‐15%) than elderly people in other European countries. The mean number of missing teeth was also lower than in any of the neighbouring countries. A comparison of dentate and edentulous groups did not show any major differences. Those who reported that they had general disease had higher levels of oral health maintenance. In dentate elderly, caries experience differed according to place of residence, fluoride content in the drinking water, socio‐economic status, gender, lifestyle, and many other factors. The multivariate approach explained 52%. 61% and 55% of the variation in the number of filled or sound teeth (FS‐T), delayed (DT) and missing teeth (MT) respectively. Conclusion: Levels of oral health maintenance and caries experience show substantial variation among elderly Lithuanians, according to many health‐related characteristics. These elderly people require appropriate oral care, just as much as people in other population sub‐groups.     

High Differentiation among Eight Villages in a Secluded Area of Sardinia Revealed by Genome-Wide High Density SNPs Analysis

To better design association studies for complex traits in isolated populations it''s important to understand how history and isolation moulded the genetic features of different communities. Population isolates should not “a priori” be considered homogeneous, even if the communities are not distant and part of a small region. We studied a particular area of Sardinia called Ogliastra, characterized by the presence of several distinct villages that display different history, immigration events and population size. Cultural and geographic isolation characterized the history of these communities. We determined LD parameters in 8 villages and defined population structure through high density SNPs (about 360 K) on 360 unrelated people (45 selected samples from each village). These isolates showed differences in LD values and LD map length. Five of these villages show high LD values probably due to their reduced population size and extreme isolation. High genetic differentiation among villages was detected. Moreover population structure analysis revealed a high correlation between genetic and geographic distances. Our study indicates that history, geography and biodemography have influenced the genetic features of Ogliastra communities producing differences in LD and population structure. All these data demonstrate that we can consider each village an isolate with specific characteristics. We suggest that, in order to optimize the study design of complex traits, a thorough characterization of genetic features is useful to identify the presence of sub-populations and stratification within genetic isolates.     

Transient oral microflora in Greeks attending day centres for the elderly and residents in homes for the elderly

Objective: To examine the isolation frequency and the carriage of yeasts, Enterobacteriaceae, Staphylococcus and Enterococcus species in oral samples from elderly Greeks living alone or in institutions. Background: Ageing may promote changes in the oral ecosystem, which lead to colonisation of the mouth by microbes found less commonly or only transiently in younger subjects. Previous studies indicate a geographical variation in the isolation frequency of such bacteria in elderly populations. Materials and methods: Medical and dental records were obtained from 66 attenders at elderly people's day centres (EPDC), and 82 residents of elderly people's homes (EPH), 66–95 years old. Mucosa smear samples were cultured on appropriate media for enumeration of the above species. Microbial identification was performed by conventional microbiological tests. The results were analysed using the Multiple Correspondence Analysis (MCA), anova and other traditional statistical tests. Results: No statistically significant association was found between the place of residence and the wearing of dentures. The isolation frequencies of Staphylococcus aureus, Enterococcus and Enterobacteriaceae species were 21.6, 20.3 and 7.4% respectively. MCA, and further statistical analysis, revealed that the place of residence affected the isolation frequency of years (54.9% in EPH vs. 37.9% in EPDC). Moreover, anova showed that living in EPH increased the carriage of yeasts. Conclusions: Elderly Greeks exhibit a moderate to high oral carriage of transient bacteria compared with other elderly populations. Living in EPH seems to increase both the isolation frequency and carriage of yeasts.     

Low levels of ill health among elderly non-consulters in general practice.

The characteristics of random samples of elderly patients (over 65 years of age), designated as consulters (n = 200) and non-consulters (n = 196), in a group general practice were compared using a postal questionnaire that was validated by comparison with findings by general practitioners in a random sample of 58 responders. A response rate of 90% was obtained, and all non-responders were visited by their general practitioner. The questionnaire had a sensitivity of 79% and a specificity of 82% when compared with general practitioner findings. The use of hospital and social services by non-consulters was low in this practice. Measures of disability and state of health showed that non-consulters were a fit group of the aged. Case finding for problems among elderly people should initially be confined to consulters, who have a high prevalence of problems. Non-consulters are a low risk group that can be assessed only with special effort and extra resources. Once an effective case finding system has been developed it might then be reasonable to consider ways of finding the few patients who have problems but do not consult their doctor.     

Aids and adaptations for the elderly at home: underprovided,underused, and undermaintained

A random sample of 140 elderly people aged over 75 was selected from the age-sex register of an urban general practice to assess the provision and use of aids and adaptations in their homes. Many of the aids that the elderly had were faulty, including half of the walking aids and 15% of hearing aids, reading spectacles, and dentures, and up to half of the aids were not used. Yet despite this underuse there were many disabled elderly people who required aids for the bath and toilet.When screening of elderly people is carried out in general practice assessment of aids and adaptations should be included to see that they are provided where needed, are used, and are adequately maintained.     

Patch occupancy, population density and dynamics in a fragmented red squirrel Sciurusvulgaris population

We studied population dynamics of red squirrels in a group of small forest fragments, that cover only 6.5% of the total study area (4664 ha) and where distances to the nearest source population were up to 2.2 km. We tested effects of patch size, quality and isolation and supplementary feeding on patch occupation during 1995–99. Larger patches and patches with supplementary feeding had a higher probability of being occupied. No patch <3.5 ha was ever occupied. No effects of isolation were found, suggesting that the forest habitat in the study area is not sufficiently fragmented to influence red squirrel distribution across patches. For medium sized patches (3.7–21 ha), that were occupied some years, there was an increase in patch occupation over the years, even though overall population size tended to decrease. These patches had a high turnover, especially of males. Patches in which the squirrel population went extinct were recolonized within a year. For patches that were at least some years occupied, squirrel density depended on patch quality only. No effects of patch size, isolation and winter temperature on population density were found. These data suggest that in our study area habitat fragmentation has no effect on local squirrel density and that the random sample hypothesis explains the distribution pattern across patches.     

Comparison of fecal microflora of elderly persons in rural and urban areas of Japan

The Fecal microflora of 15 healthy elderly persons with a median age of 84 years in a rural area whose inhabitants tend to be long-lived (Yuzurihara-area, Uenohara, Yamanashi Prefecture) was compared with the microflora of individuals with a median age of 68 years in an urban area (Tokyo). The diet of the elderly persons in the Yuzurihara area is characterized by a high intake of dietary fiber. Total numbers of anaerobic bacteria were significantly smaller in the elderly persons in the Yuzurihara area than those in the Tokyo area. A significantly large number of bifidobacteria, but not of lecithinase-negative clostridia, was observed in the elderly persons in the Yuzurihara area. Large numbers and high incidences of bacilli and lecithinase-positive clostridia (mainly Clostridium perfringens) were found in the elderly persons in the Tokyo area. Twenty-five genera and over 81 species were isolated from the elderly persons in the Yuzurihara area, and 25 genera and over 92 species were isolated from the elderly persons in the Tokyo area. Furthermore, significantly larger numbers of Bifidobacterium adolescentis and Fusobacterium mortiferum strains were found in the Yuzurihara group, but significant reductions in the Bacteroides buccae-oris group, B. thetaiotaomicron, Bacteroides spp., C. coccoides, C. paraputrificum, and Clostridium spp. were observed in the same group. A significantly higher isolation rate of Bacillus subtilis was observed in the elderly persons in the Tokyo area. The difference in the fecal microflora between elderly persons in Yuzurihara and those in the Tokyo area might be due to a difference in the intake of dietary fiber.     

Comparison of fecal microflora of elderly persons in rural and urban areas of Japan.

The Fecal microflora of 15 healthy elderly persons with a median age of 84 years in a rural area whose inhabitants tend to be long-lived (Yuzurihara-area, Uenohara, Yamanashi Prefecture) was compared with the microflora of individuals with a median age of 68 years in an urban area (Tokyo). The diet of the elderly persons in the Yuzurihara area is characterized by a high intake of dietary fiber. Total numbers of anaerobic bacteria were significantly smaller in the elderly persons in the Yuzurihara area than those in the Tokyo area. A significantly large number of bifidobacteria, but not of lecithinase-negative clostridia, was observed in the elderly persons in the Yuzurihara area. Large numbers and high incidences of bacilli and lecithinase-positive clostridia (mainly Clostridium perfringens) were found in the elderly persons in the Tokyo area. Twenty-five genera and over 81 species were isolated from the elderly persons in the Yuzurihara area, and 25 genera and over 92 species were isolated from the elderly persons in the Tokyo area. Furthermore, significantly larger numbers of Bifidobacterium adolescentis and Fusobacterium mortiferum strains were found in the Yuzurihara group, but significant reductions in the Bacteroides buccae-oris group, B. thetaiotaomicron, Bacteroides spp., C. coccoides, C. paraputrificum, and Clostridium spp. were observed in the same group. A significantly higher isolation rate of Bacillus subtilis was observed in the elderly persons in the Tokyo area. The difference in the fecal microflora between elderly persons in Yuzurihara and those in the Tokyo area might be due to a difference in the intake of dietary fiber.     

Prospective study of symptoms and signs in acutely ill infants in general practice.

A study was made of all cases of acute illness in infants aged 6 months or less presenting in a Gosport practice over five months. The frequency in these patients of the well defined symptoms and signs suggested to be important by the preliminary report of the Department of Health and Social Security''s multicentre study of postneonatal mortality was recorded. During the study period there were 161 infants of this age in the practice, who gave rise to 69 consultations with acute illness. Thirty eight of these were given drug treatment and five were referred to a paediatric unit, one of them on social grounds. There were no infant deaths in the practice (total population 11,400), but two occurred in the Gosport area (total population 83,000). It would be unrealistic to refer all patients with any one of the symptoms and signs, even when well defined, in the age group 6 months or less. Analysis of the symptoms and signs found in those children who required admission did not show any pattern differentiating them from those who did not. Although the symptoms and signs studied are of value in assessment and should be sought in these patients, they cannot be used singly or in any pattern to indicate referral per se.     

Nephrotic Syndrome in the Elderly

Though the nephrotic syndrome is generally believed to be uncommon in the elderly, patients aged 60 years or more accounted for 25 out of 100 consecutive adult cases. Six (24%) of these had the minimal change lesion, compared with 16% of the younger adults. The incidence of membranous glomerulonephritis was similar in the two age groups, but proliferative glomerulonephritis was more common in the younger (29%) than in the older group (16%). Amyloidosis did not have a higher incidence in the higher age group. Five of the elderly patients with minimal change lesion were treated with prednisone—in four a complete remission from the nephrotic syndrome followed, while the fifth patient''s course is unknown.These results suggest that, when the patient''s other circumstances allow, the nephrotic syndrome in an elderly patient should be investigated and managed as in younger age groups.