Caregiver burden and nursing home admission of frail elderly persons.

The National Long-Term Care Survey, 1982-1984, and the Informal Caregivers Survey were used to test the importance of caregiver burden for risk of admission to a nursing home. This study was based on a subsample of 940 older persons with sole spouse or adult child caregivers in 1982. Using logistic regression, nursing home entrants (127) were compared to 624 continuous community residents. Characteristics of the older person included age, race (White), and number of instrumental activities of daily living limitations. Predictors related to the caregiving context included caregiver burden and use of formal services.     

Providing all-inclusive care for frail elderly veterans: evaluation of three models of care

Frail elderly veterans aged 55 and older who met state nursing home admission criteria were enrolled in one of three models of all-inclusive long-term care (AIC) at three Veterans Affairs (VA) medical centers (n=386). The models included: VA as sole care provider, VA-community partnership with a Program of All-inclusive Care for the Elderly (PACE), and VA as care manager with care provided by PACE. Healthcare use was monitored for 6 months before and 6 to 36 months after enrollment using VA, DataPACE, and Medicare files. Hospital and outpatient care did not differ before and after AIC enrollment. Only 53% of VA sole-provider patients used adult day health care (ADHC), whereas all other patients used ADHC. Nursing home days increased, but permanent institutionalization was low. Thirty percent of participants died; of those still enrolled in AIC, 92% remained in the community. VA successfully implemented three variations of AIC and was able to keep frail elderly veterans in the community. Further research on providing variations of AIC in general is warranted.     

Home care of the frail elderly

Statistics indicate that as the population ages, there will be an increased need for home care. Despite this increased need and the legal, clinical, and ethical obligations for physicians to participate, little training is available to physicians in the area of home care. This article provides physicians with an understanding of home care and how to incorporate it into clinical practice. The goals of this article are to (1) explain what home care is and what services are available, (2) teach physicians how to access these services and oversee their implementation, and (3) show how physicians can be reimbursed for this increasingly important part of their practice.     

An evaluation of a group program for spouses of frail elderly veterans.

We examined the effectiveness of a multicomponent group program for spouses of frail aging veterans that included support, education, problem solving, and stress reduction. Compared with caregivers who received no intervention, those in the group program showed significant increases in use of active behavioral coping strategies, knowledge of community resources, perceived independence in the marital relationship, and personal changes in the caregiving relationship. They also experienced significant decreases in subjective burden and the stress and severity of caregiving problems.     

Health care,cultural expectations and frail elderly Navajo grandmothers

This paper examines the interrelation of generations in the Navajo culture which has always included expectations as to care for the elderly. Many changes have occurred, however, over the past century and these changes bear on elders' position in the culture, and on their care. The study asked: How do cultural expectations influence the giving and receiving of care, and specifically, how are Navajo grandmothers who have been involved in fosterage or adoption of grandchildren cared for in old age and frailty? It concludes that reciprocity is an instrumental principle of interaction between generations. Grandmothers contribute to strong relationships with children and grandchildren in order to receive care when they are old.     

Adult day care for the frail elderly: outcomes, satisfaction, and cost

OBJECTIVES. To assess outcomes and satisfaction among frail elderly day care clients and their informal caregivers and the impact of adult day care on the cost of health services. METHODS. One-hundred eight elderly participants were randomly assigned to the experimental group (immediate admission to an adult day care center) and 104 participants to the control group (3 months on a waiting list). RESULTS. Participants' and caregivers' subjective perceptions of the day center's effects were positive. However, using standard research instruments, there was no evidence of an effect of day center attendance on the client's anxiety, depression, or functional status; on caregiver burden; or on the cost of health services. DISCUSSION. It is difficult to demonstrate objectively the benefits of programs and interventions that are perceived by clients, caregivers, and staff to have positive effects. In future studies, maintenance of high levels of participation should be incorporated as an explicit program goal.     

老年医学与衰弱老年人的医疗服务

目的 随着年龄的增长.人们发生多种健康问题的可能性增大.这些问题可被称作健康缺陷.健康缺陷越多.越容易引发健康方面的不良后果,例如健康状况恶化,甚至死亡.所渭衰弱,是指能够增加不良健康后果的危险的身体状态.健康缺陷度越高,身体衰弱度就越大.在临床上,通过临床衰弱量表-09的使用,可以对衰弱度进行逐级描述(此量表是加拿大健康与衰老研究课题所设计使用的临床衰弱量表的修订版).衰弱导致了健康问题的复杂化.由于老年人的健康问题较为复杂,而临床服务一般只侧重于诊治单一的问题,造成对老年患者的服务不够全面.老年专科医生应该是能够综合处理复杂问题的专家,应擅长诊治并存多种健康问题的老年患者.充分了解和认真研究健康需求的复杂性问题,老年专科医生才能最有效地帮助那些身体衰弱的老年患者.模式识别就是对付老年疾病复杂性的一种重要手段,它借助于老年综合性评估和对实际发病的衰弱老年人所表现出的症状特征的识别而加以实现.     

Subintensive care unit for the elderly: a new model of care for critically ill frail elderly medical patients

OBJECTIVE: An increasing number of elderly patients are admitted to the hospital for critical diseases and the gap between supply and demand of intensive care resources is a growing problem. To meet this challenge, 4 beds in a 24-bed acute care for the elderly (ACE) medical unit were dedicated to a subintensive care unit (SICU). Severely ill elderly medical patients, requiring a higher level of care than provided in ordinary wards, are admitted. The aim of the study was to describe the characteristics of the setting and to discuss its usefulness based on data obtained after the first period of implementation. METHODS: This article describes the development, management, economics and patient characteristics of the SICU. Patient care combines the ACE model with a highly specialised medical care. Patients admitted to the SICU are compared with patients treated in the ordinary ACE unit before the SICU opened. All patients received a multidimensional evaluation, including demographics, main diagnosis, number of chronic somatic diseases, Charlson index, APACHE II score, APACHE-APS subscore, number of currently administered drugs, serum albumin, cognitive status (Mini-Mental State Examination), depression (Geriatric Depression Scale) and functional status (basic and instrumental activities of daily living). Ward physicians performed assessment and collection of data. RESULTS: During the first 16 months, 489 patients were admitted, 401 according to the selection criteria (60 +/- years and APACHE II score > or =5 and/or APACHE-APS score > or =3). Mean age was 78.1 years, mean APACHE II score 14.5 (moderate severity) and non-invasive mechanical ventilation was received by 87 (21.7%). The most common diagnoses were respiratory failure, cardiac disease and stroke. Mean length of stay in the SICU was 61.8 h, and 6.0 days in the hospital. Compared with ACE-unit patients admitted during 2002 (n=1380), SICU patients were obviously more seriously ill (APACHE II score 14.5 vs 6.7). When comparing patients of same illness severity (APACHE-APS score > or =3) (n=125), patients treated in the SICU had lower in-hospital mortality than those treated in the ordinary ACE ward (12.5 vs 19.2%). Only a few patients (3.5%) were transferred to the intensive care unit as a consequence of increased severity of illness. CONCLUSIONS: The SICU is an innovative method to treat frail elderly patients with more severe conditions. Low hospital mortality compared with that of severe patients in the ACE unit supports the usefulness of this model. It could be implemented in medical units of large hospitals in order to give optimal care and advanced interventions to the frail elderly and to avoid intensive care unit overcrowding.     

Caregiver burden among Japanese informal caregivers of cognitively impaired elderly in community settings

Because dementia is a progressive disease, formal long-term care providers and care managers need information on how the severity of cognitive impairment affects caregiver burden in order to better assist family caregivers. However, research to guide care providers in behavioral symptom-management is not well developed. The purpose of this study was to examine the relationship between dementia status and burden of family caregivers. The subjects were 1875 community-dwelling elderly eligible for public long-term care insurance. The data we used in this analysis included the caregivers’ and dependents’ characteristics. The main outcome was subjective caregiver burden assessed by the Japanese version of the Zarit Burden Interview (J-ZBI). A total of 1559 pairs of dependents and caregivers were included in the analysis. The pairs were sorted into three mutually exclusive categories: no dementia, mild dementia, and severe dementia. Two hundred sixty-one dependents had severe dementia, and 725 had mild dementia. Although differences were found among the dementia categories in levels of caregiver burden according to the J-ZBI before and after adjusting for these baseline variables, the odds ratios equal nearly 1. The present study shows that severity of dementia is not associated with caregiver burden in Japan.     

Caregiver burden and depressive symptoms: analysis of common outcomes in caregivers of elderly patients

Despite widespread use of caregiver burden and depressive symptoms in caregiving research, the relationship between these two concepts and the way in which burden and depressive symptoms are affected are not clear. METHODS: The authors used structural equation modeling with an inception cohort of 488 family caregivers to examine the relationship between care recipients' mental and functional status and recency of care demands and caregivers' burden and depressive symptoms. RESULTS: Care recipients' mental and functional status and recency of care demands predicted caregiver burden; burden, in turn, was nearly significant in predicting depressive symptoms. Care recipients' mental status and recency of care demands had a near significant indirect effect on caregiver depressive symptoms. There were no significant direct paths between care recipients' mental status, functional status, recency of care demands, and caregivers' depressive symptoms. DISCUSSION: Health care practitioners should assist caregivers with new care demands stemming from care recipients' mental and functional status to decrease burdens and should monitor caregivers with higher levels of burden for the development of depressive symptoms.     

The systems of care for frail elderly persons: the case of Sweden

Sweden has a well-developed welfare system following the Nordic model and it maintains - even though there have been some reductions in the last decade - good economic security and comprehensive services for the elderly. The national policy for the elderly aims at enabling older persons to live independently with a high quality of life. A great majority of the elderly in Sweden live in ordinary homes - very few live with their grown-up children. The municipalities are responsible for providing long-term social services and care for the frail elderly in the form of home help services for those that live in ordinary housing, and special housing accommodation for those with extensive needs. The county councils are responsible for health care and provide home nursing care and rehabilitation. Sweden used to have the oldest population in the world. The proportion of 80+ years old in the population increased from 3% to over 5% between 1980 and 2000. Due to financial restrictions as a result of the economic recession in the last decade, the health and social services for the elderly have not been able to keep up with the population development. The previous generous allocation of care has been replaced by a more restrictive approach. This has mainly affected persons with lesser needs for help, younger elderly, and married persons. The number of elderly persons is expected to increase rapidly in the coming decades. However, due to improved health among the elderly, this will lead to a relatively limited increase of needs. Depending on assumptions concerning the health development, the required increase in volume of health and social services is expected to fall somewhere between 10-30% during the coming 30-year period.     

Individualization of the frail elderly people and use of health care services

The challenge of identifying frail elderly subjects is important to optimize the management of care for the old patients. The recognition of frailty allows clinicians to detect subjects whose autonomy is precarious in relation to decreased physical performances and\or vulnerability of their psychosocial stability. A better distinction of healthy old people from frail elderly in an emergency ward makes possible to target the medical care toward the individuals who are more likely to benefit from it and to work out the best strategies of prevention. However, assessment of frailty is time-consuming and there is no consensus on the diagnostic measures. Brief tools to assess the principal components of frailty, which could be included in the routine clinical examination of people over 75 years of age, are currently in progress of validation.     

The Medicare Prospective Payment System and the care of the frail elderly

The development of the Medicare Prospective Payment System based on diagnosis-relating groupings is reviewed. Special emphasis is placed on analysis of the provisions that have a potential impact on geriatric medicine and on the care of the frail elderly. The authors conclude that in its present form, the DRG system may systematically undercompensate hospitals for treating the frail elderly and, therefore, result in attempts by some hospitals to reduce or avoid altogether programs in geriatric medicine and admissions of frail elderly persons. These effects, together with federal and state efforts to limit nursing home and home care costs, may result in a major under-provision of care for the frail elderly and exclusion of clinical geriatric medicine from the medical care system.     

Long-term solutions for the continuous post-acute care of the frail elderly in internal medicine

Long-term care is a hospital unit, designed for frail elderly people, with ongoing physical challenges and in difficult social situations who have been suffering from multiple not-yet-stabilized pathologies. These subjects need medical-nursing and continuing care and/or treatments of rehabilitation which cannot be performed in extra-hospital situations. The aim of our study was to estimate a geriatric assessment of an old population hospitalized in a long-term care unit, using psychometric scales, paying attention to clinical, cognitive, functional, nutritional and social status. Two-hundred and ninety-seven patients of both sexes (middle age 81.3 +/- 8.6 years) divided into two groups of age (> or = 80 and < 80 years) were evaluated. The most important result of our study is a high index of disability (about five daily living activities were lost). These "functional deficits" were related to age, comorbidity, dementia, institutionalization and mortality. The study group showed a multiple pathology with various pharmacology therapy and, in 23.9% of cases, pressure ulcers were found and were related to mortality, as statistically noted. A serious cognitive impairment was found in 41.4% of the group (dementia was related to aging). As for residential destination, the most significant result is that almost half of the discharged patients went back to their home with a caregiver, who often was a woman. We finally underline the importance of increasing long-term care unit and the need for a higher integration in the territorial social-sanitary system, in order to guarantee care continuity for the frail and elderly.     

Characteristics of home care supporting clinics providing home care for frail elderly persons living alone in Japan

To explore the characteristics of home care supporting clinics providing home care for frail elderly persons living alone (EPLA), a self-administered questionnaire was mailed to 998 home care supporting clinics in the 23 wards of Tokyo, Japan between July and August 2009. Clinics providing home care for the frail EPLA significantly collaborated with 4 or more home visit nursing stations (42.5%) and 4 or more care managers (58.7%) and had sufficient medical care equipment, such as an oxygen inhaler, ventilator, and intravenous hyperalimentation. Sixty-one percent of the clinics which provided care for the 18 patients who died at home collaborated with 4 or more care managers. Our findings suggest that the factors enabling home care for frail EPLA are as follows: (1) collaboration with care managers, (2) collaboration with home visit nursing stations, (3) sufficient medical care equipment.     

Prediction of mortality in community-living frail elderly people with long-term care needs

OBJECTIVES: To develop and validate a prognostic index for mortality in community‐living, frail elderly people. DESIGN: Cohort study of Program of All‐Inclusive Care for the Elderly (PACE) participants enrolled between 1988 and 1996. SETTING: Eleven PACE sites, a community‐based long‐term care program that cares for frail, chronically ill elderly people who meet criteria for nursing home placement. PARTICIPANTS: Three thousand eight hundred ninety‐nine PACE enrollees. The index was developed in 2,232 participants and validated in 1,667. MEASUREMENTS: Time to death was predicted using risk factors obtained from a geriatric assessment performed by the PACE interdisciplinary team at the time of enrollment. Risk factors included demographic characteristics, comorbid conditions, and functional status. RESULTS: The development cohort had a mean age of 79 (68% female, 40% white). The validation cohort had a mean age of 79 (76% female, 65% white). In the development cohort, eight independent risk factors of mortality were identified and weighted, using Cox regression, to create a risk score: male sex, 2 points; age (75–79, 2 points; 80–84, 2 points; ≥85, 3 points); dependence in toileting, 1 point; dependence in dressing (partial dependence, 1 point; full dependence, 3 points); malignant neoplasm, 2 points; congestive heart failure, 3 points; chronic obstructive pulmonary disease, 1 point; and renal insufficiency, 3 points. In the development cohort, respective 1‐ and 3‐year mortality rates were 6% and 21% in the lowest‐risk group (0–3 points), 12% and 36% in the middle‐risk group (4–5 points), and 21% and 54% in the highest‐risk group (>5 points). In the validation cohort, respective 1‐ and 3‐year mortality rates were 7% and 18% in the lowest‐risk group, 11% and 36% in the middle‐risk group, and 22% and 55% in the highest‐risk group. The area under the receiver operating characteristic curve for the point score was 0.66 and 0.69 in the development and validation cohorts, respectively. CONCLUSION: A multidimensional prognostic index was developed and validated using age, sex, functional status, and comorbidities that effectively stratifies frail, community‐living elderly people into groups at varying risk of mortality.