Variation in general practice medical admission rates for elderly people

BACKGROUND: Emergency medical admissions are rising, particularly in the elderly. Variation in admission rates between general practices has received little attention, and requires explanation. METHODS: A retrospective review was carried out of emergency medical admissions to the District General Hospital (DGH) and the Community Hospitals (CHs) in West Gloucestershire in subjects over 75 years of age during 3 years. A survey of general practitioner (GP) attitudes to emergency admissions was carried out. RESULTS: A five-fold spread in DGH and CH admission rates for elderly medical emergencies was found, and a three-fold spread of overall admission rates. Rates were consistent within a practice each year. The spreads of practice mortality rates and myocardial infarction admission rates were smaller. The variation between practices was not explained by the Jarman Index or by attitudes identified in GPs. Practices with high admission rates had slighter higher annual hospital mortality rates, but lower episode fatality rates. CONCLUSION: Admission rates show considerable variation between practices, which is only partly explained by morbidity rates, and consistency over 3 years.     

Homeless people's experiences of medical respite care following acute hospitalisation in Denmark

The aim of this study was to explore homeless people's health perspectives and experiences of a 2‐week medical respite care programme following acute hospitalisation. There is a high level of health inequality when comparing the health status of homeless people to the general population, including increased mortality and morbidity. Homelessness predisposes an increased risk of infectious disease, cancer and chronic illness, such as diabetes and cardiovascular disease. Moreover, homeless people have a higher frequency of acute hospitalisation than general population estimates. In order to facilitate the transition from hospitalisation back to life on the streets, homeless people who were acutely hospitalised in the Capital Region of Denmark were offered 2 weeks of medical respite care from the day of discharge by a non‐governmental organisation. This is a qualitative study with a phenomenological hermeneutical approach based on narrative interviews of 12 homeless people who received medical respite care from 1 March 2016 to 30 September 2016. Data were collected through individual semi‐structured interviews and analysed according to Lindseth and Norberg's presentation of Paul Ricoeur's theory of interpretation. The analysis identified four themes: (i) basic needs are of highest priority; (ii) a safe environment provides security and comfort; (ii) social support is just as important as healthcare; and (iv) restitution facilitates reflection. The findings indicated that the medical respite care centre provided a place of rest and restitution following hospitalisation, which made room for self‐reflection among the homeless people regarding their past and present life, and also their wishes for a better future. This study also indicates that a medical respite care stay can contribute to the creation of a temporary condition in which the basic needs of the homeless people are met, enabling them to be more hopeful and to think more positively about the future.     

Factors related to admission or institution among the frail elderly with a home-visit nursing service

OBJECTIVE: To evaluate factors associated with admission of frail elderly to hospitals or nursing homes with a home-visit nursing service. DESIGN: Retrospective cohort study. SUBJECTS: 395 consecutive frail elderly who were receiving domiciliary visits by nurses from St. Mary's home-visit nursing station between April 1993 and March 1998. RESULTS: 1) During the six-month follow-up, malignancy was positively related to admission to either hospitals or nursing homes while severe disability curtailing activities of daily living was negatively related to admission. During both one-year and two-years follow-up, severe disability of daily living was negatively related to admission. 2) Elderly people consulting doctors at general hospitals were more commonly hospitalized or institutionalized than those consulting family doctors in clinics. 3) The need for a short-stay service (i.e., "temporary nursing home assistance") was a risk factor for admission during the six months, one-year and two-years follow-up periods. CONCLUSION: The frail elderly should consult family doctors in clinics in order to avoid admission to hospitals or nursing homes.     

老年急性缺血性脑血管病患者出现轻度认知功能损害的预测研究

目的探讨老年急性缺血性脑血管病患者出现轻度认知损害的相关危险因素,并建立概率预测模型。方法选择收治的87例老年急性缺血性脑血管病患者,对可能影响其认知功能水平的危险因素进行多元Logistic回归分析。结果患者年龄、文化程度、起病时临床神经功能缺损程度、病灶数量、伴发高血压、糖尿病等为影响患者发病后出现轻度认知损害的危险因素（P〈0.05）。其中年龄、神经缺损程度和病灶数量是危险暴露因子,高血压和糖尿病病史则是保护因子。结论建立的认知功能损害概率预测模型对老年急性缺血性脑血管病患者出现轻度认知损害的治疗和护理具有一定的指导意义。     

Post-acute service use following acute myocardial infarction in the elderly

This exploratory study examined the extent to which factors beyond characteristics of the patient, such as discharging hospital attributes and State factors, contributed to variations in post-acute services use (PASU) in a cohort of elderly Medicare patients following acute myocardial infarction (AMI). Thirty-seven percent of this cohort received PAS within 30 days of discharge and home health care was the most common type of service used. Patient severity of illness at hospital discharge, for-profit ownership of the discharging hospital, and discharging hospital provision of home health services were shown to be important predictors of PASU. After adjusting for many patient and hospital characteristics, however, variation in PASU remained across States.     

Hospital services models for acute care of elderly people

Although the implementation of geriatric services is an emerging priority in Brazil, little emphasis has been put on the type of acute care that should be provided for elderly patients in the hospital setting. The objective was to review some models of acute hospital care for elderly people, focusing on the role of geriatric medicine and its relationship with other specialties. Medline database (1989-1999), textbooks of geriatrics and gerontology, and other health publications were consulted in an attempt to identify all relevant publications about hospital services providing acute care to elderly people. The features of each model were compiled and discussed taking into account their suitability to the Brazilian health system. Some examples of interventions, with their effectiveness demonstrated by systematic reviews, were also mentioned. The models more frequently described were: long-time traditional, age-defined, unspecialized and integrated care. Variants of such models were frequently reported. There is no evidence pointing to one as the best model, but models favoring the integration of geriatrics with general medicine seemed to be particularly suitable to the Brazilian setting. With the aging of the population, there is a need to restructure the health services to face the increasing demands of elderly people. Given that the design of hospital services is an important factor for the effectiveness of geriatric care, this issue should be studied as priority in Brazil.     

Predictors of stroke mortality in elderly people from the general population. The CArdiovascular STudy in the ELderly

Stroke occurs particularly frequently in elderly people and, being more often disabling than fatal, entails a high social burden. The predictors of stroke mortality have been identified in 3282 subjects aged 65 years, taking part in the CArdiovascular STudy in the ELderly (CASTEL), a population-based study performed in Northeast Italy. Historical and clinical data, blood tests and 14-year fatal events were recorded. Continuous items were divided into quintiles and, for each quintile, adjusted relative risk (RR) with 95% confidence intervals [CI] was derived from multivariate Cox analysis. Age, historical stroke (RR: 5.2; 95% CI: 3.18–8.6) and coronary artery disease (RR: 1.38; CI: 1.18–2.1), atrial fibrillation (RR: 2.40; CI: 1.42–4.0), arterial hypertension (RR: 1.33; CI: 1.15–1.76), systolic blood pressure 163 mmHg (RR: 1.84; CI: 1.20–2.59), pulse pressure 74 mmHg (RR: 1.50; CI: 1.13–2.40), cigarette smoking (RR: 1.60; CI: 1.03–2.47), electrocardiographic left ventricular hypertrophy (RR: 1.72; CI: 1.10–2.61), impaired glucose tolerance (IGT, RR: 1.83; CI: 1.10–3.0), uric acid (UA) >0.38 mmol/l (RR: 1.61; CI: 1.14–2.10), serum potassium 5 mEq/l (RR: 1.70; CI: 1.24–2.50) and serum sodium 139 mEql/l (RR: 1.34; 1.10–2.10) increased the risk of stroke. In the CASTEL, stroke was the first cardiovascular cause of death. Some independent predictors usually unrelated to stroke mortality (namely pulse pressure, pre-diabetic IGT, UA and blood electrolytes disorders) have been identified.     

Effects of community-care networks on psychiatric emergency contacts, hospitalisation and involuntary admission

BACKGROUND: Community-care networks are a partnership between the local police force, housing corporations, general social services, specialised home care and mental healthcare services. The networks were set up to improve the healthcare for patients with (chronic) psychiatric problems through local cooperation between different agencies operating in underprivileged areas. OBJECTIVE: To evaluate the effects of community-care networks on psychiatric emergency contacts, hospitalisation and involuntary admission. DESIGN: An ecological intervention design was used, comparing neighbourhoods with and without a community-care network. Mean numbers and standardised ratios of psychiatric emergency contacts, hospitalisation rates and involuntary admissions were assessed over a 10-year period, covering the early stages and the years in which community-care networks were fully operational. SETTING: Underprivileged neighbourhoods in the city of Rotterdam, The Netherlands. PATIENTS: Inhabitants aged 20-64 years living in these neighbourhoods. RESULTS: Standardised ratios for contact with psychiatric emergency services were higher in the neighbourhoods where community-care networks were set up (standardised ratios = 137, 95% CI 121 to 145 in the network neighbourhoods vs standardised ratios = 107, 95% CI 96 to 119 in the control neighbourhoods). Number of admissions and standardised ratios for involuntary admissions were lower in the community-care network neighbourhoods than in the control neighbourhoods (standardised ratios = 123, 95% CI 95 to 157 vs standardised ratios = 152, 95% CI 120 to 191). CONCLUSIONS: Community-care networks have a significant impact on the use of mental healthcare services. These networks may be an important tool in the prevention of involuntary admissions.     

Plasma carotenoid concentrations in relation to acute respiratory infections in elderly people

A high plasma carotenoid concentration could improve the immune response and result in decreased risk of infectious diseases. However, data on the relationship of plasma carotenoid concentration with acute respiratory infections, which occur frequently in elderly people, are scarce. We investigated, therefore, the relationship of plasma concentrations of six major carotenoids (beta-carotene, alpha-carotene, beta-cryptoxanthin, lycopene, lutein and zeaxanthin) with the incidence and severity of acute respiratory infections. Baseline data from an intervention trial were used. Participants were 652 non-institutionalized elderly people (> or =60 years old) enrolled via two community-based sampling strategies in the Wageningen area of The Netherlands in 1998-99. Plasma carotenoid concentrations were divided into quartiles, the lowest being the reference. Frequency and severity of episodes during the previous 1 year, i.e. staying in bed, medical consultation and episode-related medication, were self-reported by means of a questionnaire. On average 1.6 episodes per person were recorded. The incidence rate ratio of acute respiratory infections at high beta-carotene status was 0.71 (95 % CI 0.54-0.92) as compared with the low beta-carotene concentration group. No association was observed between beta-carotene and illness severity. alpha-Carotene, beta-cryptoxanthin, lycopene, lutein and zeaxanthin were not related to incidence or severity of the infections. We conclude that elderly people with a high plasma beta-carotene concentration may have a lower occurrence of acute respiratory infections.     

Predictors of nursing home admission in a biracial population.

Racial differences in predictors of institutionalization were studied in a biracial North Carolina cohort (n = 4074). During 3 years of follow-up, 8.5% of Whites and 6.4% of African Americans were admitted to nursing homes. African Americans were one half as likely as Whites to be institutionalized after adjustment for other risk factors. Among Whites, impaired activities of daily living and cognition were the strongest predictors; among African Americans, impaired instrumental activities of daily living and prior history of nursing home use were strongest. Racial differences in nursing home use were not explained by financial and social support or physical and cognitive impairment.     

Hypernatremic dehydration in the elderly on admission to hospital

Dehydration is the most common cause of fluid and electrolyte disturbances in the elderly. This condition is related to the lack of increase in water intake in the presence of an increased fluid loss. The aim of this study was to evaluate the prevalence of hypernatremic dehydration in elderly patients admitted to the hospital. We retrospectively studied 2,894 subjects admitted to the acute ward of the Geriatric Section of the Department of Medical and Surgical Disciplines of the University of Torino from January 1990 to July 1995. Among them 84 (2.9%) patients, mean age 77.3 +/- 9.8 years, had serum sodium levels and blood urea nitrogen greater than 145 mEq/L and 25 mg/dL respectively with serum creatinine below 3 mg/dL. The prevalence of hypernatremic dehydration increases with age. Only 1.6% of the subjects under 65 years old are affected by this condition, against 5.3% of those over 85 years. The mortality rate observed during hospitalization is 29.8%. Mortality is positively related to serum sodium levels. We found mortality rates of 33.3% and 71.4% respectively in subjects with serum sodium levels from 151 to 153 mEq/L and in those with values over 154 mEq/L. Both serum sodium levels and age are independent risk factors for mortality (O.R. 1.31 and 1.07 respectively).     

衰弱的内涵及其概念框架

  目的  了解高龄老人的衰弱进程、日常照护及精神慰藉需求状况,分析衰弱程度与日常照护及精神慰藉需求的相关性。  方法  于2016年7月 — 2017年1月采用分层随机整群抽样方法抽取河北省唐山市2家医院的10个社区卫生服务中心辖区≥ 75岁老年人,使用衰弱综合评估工具（CFAI）、日常生活能力量表（ADL）、孤独量表进行（UCLA）评测。  结果  3 448名高龄老人衰弱率为100 %,随年龄的增加其衰弱程度呈加重趋势,差异有统计学意义（χ² = 133.355,P < 0.001）;日常照护低需求者860人（24.9 %）,高需求者804人（23.3 %）,而高龄老人自评需要生活照护者占61.0 %,高于ADL评估结果,选择需要子女照顾者2 021人次,占58.6 %;精神慰藉低需求1 071人（31.06 %）,中等需求1 598人（46.35 %）,中上等需求679人（19.69 %）,高需求100人（2.90 %）,精神照护中等及以上需求者占68.94 %,远高于日常生活照顾需求者。而高龄老人自评需要精神照护者2 441人,占70.17 %,2组数据基本持平。选择需要子女提供精神照护者1 906人次,占78.08 %。多因素分析显示,年龄、衰弱程度是高龄老人日常照护和精神慰藉需求的影响因素。  结论  应加强对高龄老人日常生活和精神生活的照护,依据衰弱程度提供相应的照护。     

Predictors of cancer mortality in elderly subjects

Cancer mortality was analysed in 3282 elderly subjects aged 65 years from 2 cohorts of general population having different life-style patterns. They took part in the CASTEL (CArdiovascular STudy in the ELderly), a 12-year lasting prospective Italian study. The aim of the present analysis was to identify the items able to influence cancer mortality. A biochemical profile and a questionnaire on lifestyle were collected. Continuous items were averaged and compared with analysis of variance, frequencies with the Pearson's ² test. Mortality was recorded yearly for 12 years from the Registrar's Office and causes of death double-checked by consulting medical case sheets and family doctors' files. The influence of items on mortality was evaluated with the Cox multivariate analysis. Relative risk (RR) of each item was adjusted for confounders. Age, gender, tobacco smoking, the presence of respiratory symptoms, low body mass index in males, serum alanine transaminase (ALT) and alkaline phosphatase (ALP), as well as the town of residence, were powerful predictors of cancer mortality. In the entire population, 12-year overall mortality was 49.4%, cardiovascular 22.8%, and neoplastic 11%; the latter was higher in males than in females (15.7% vs. 7.9%, p < 0.00001). In subjects with respiratory symptoms neoplastic mortality was 11.6% (RR: 1.47) vs. 9.7% in those without symptoms (p < 0.01). Subjects with very low cholesterol ( 178 mg/dl), those with high uric acid ( 8.7 mg/dl) and males with low body mass index ( 22.7 kg/m²) has an increased risk of cancer mortality. RR of cancer mortality increased with increasing ALT or ALP. It was 1 in those having ALT and ALP between 9 and 41.2U/I, 1.41 in those exceeding this latter level and < 1 in those below 9U/I. RR of ALP had a similar trend, the best protective cut-off value being <106 and the worst one > 177U/I. When both serum enzymes were simultaneously raised, RR of cancer mortality increased to 2.84.     

Contribution of drug related problems to hospital admission in the elderly

Purpose  

To investigate the frequency and type of drug related problems (DRPs) in geriatric patients (> 65 years), and to assess their contribution to hospital admission; to explore the appropriateness of drug therapy according to the Beers’ criteria.