Elderly patients discharged from acute hospital - a follow-up study

This follow-up study describes the situation of 333 patients aged 75 and over and living at home 3-5 months after discharge from acute hospital with regard to formal and informal help, changes in functional level, rehabilitation and health status. The study is based on a postal questionnaire sent to those still living at home, with a response rate of 91%. Mean age was 80.2 years (range, 75-97). Sixty percent were women. About half of the patients reported receiving formal home help and district nurse visits; even more had help from relatives. At discharge four-fifths of the patients were independent with regard to activities in daily living (ADL) and this increased slightly at follow-up. More than one-third of patients did some kind of exercise after discharge; as formal rehabilitation and as training by themselves,even in the oldest group, those aged 90+. Half of the patients were in good or very good health according to self-reported health assessment. When reporting poor health (17%),it was often related to functional deterioration after discharge and numerous health problems like pain, vertigo, and various mental problems, among others. Women reported more health problems (mean number, 5.3) than men (4.6) but problems were also common in the 80-84-year-old age group and these were of a varying nature. The importance of multidimensional assessment, involving medical, functional and psycho-social factors is stressed. The opportunities for rehabilitation of elderly patients discharged from acute hospital should be kept in mind, the ambition being maintenance of health and independence in daily living in the patient's own home for as long as possible.     

Leben Demenzkranke zu Hause länger als im Heim?

Many studies have shown that the number of new dementia diagnoses in Germany is increasing yearly. Thus, two social tasks are important: the adequate support and care of dementia patients, now and in the future, as well as covering the costs thereof. The survival period of dementia patients has a central meaning – especially for health policy planning. Therefore, the question of our 8-year follow-up study was whether living conditions affect the survival period of dementia patients? A total of 173 dementia outpatients (ICD-10 numbers F00 and F01) were screened for survival time and living conditions. For deceased patients, a close reference person was interviewed, and the exact date of death was recorded. For statistical evaluation, the Cox proportional hazard model was used and dying risks were determined. Our investigation shows that a clear difference exists in the survival period of dementia patients, according to whether they have lived at home or in a senior citizen’s home. Patients in senior citizen’s homes had a higher relative dying risk of around 53.1% (hazard ratio), than for those cared for at home (p=0.047). Prospective research is needed to gain more evidence about the impact of social factors, e.g., living conditions, on the survival time of demented patients.     

Education of preventive home visitors: the effects on change in tiredness in daily activities

The objective was to investigate whether a 3-year educational intervention towards primary health care professionals had effect on change in tiredness in daily activities during a 3-year intervention period in non-disabled older adults. The design was a controlled 3-year intervention study in 34 Danish municipalities with randomization and intervention at municipality level. The 17 intervention municipality visitors received regular education and general practitioners were introduced to a short assessment program. The effect was measured among old non-disabled individuals living in the municipalities by a validated scale on tiredness in daily activities at baseline and at the end of the intervention period. In total 2,515, 75- and 80-year-old men and women participated in all parts of the present study. Eighty-year-old non-disabled men and women who lived in the control municipalities had larger odds ratios of sustained tiredness during the 3-year intervention period compared with 80-year-olds living in intervention municipalities where both GPs and home visitors participated in the educational programme (OR = 3.48; 95% CI 1.51–8.00) and in intervention municipalities where only the home visitors (OR = 2.63; 95% CI 0.97–7.12) were educated. The intervention had no effect on stability and change in tiredness among the 75-year-old men and women. A brief, feasible educational intervention for primary care professionals has beneficial effect on changes in feelings of tiredness in non-disabled 80-year-old men and women.     

Variations in nutritional status of elderly men and women according to place of residence

OBJECTIVE: The purpose of this study was to assess comprehensively the nutritional status of elderly individuals in institutions and to compare it with that of community based dwellers in an urban setting in Lebanon. METHODS: Participants included 100 elderly men and women (aged 65 years and older) selected randomly from four institutions who were based on sex and neighborhood with 100 free-living individuals. Subjects were mentally and physically capable of responding to an interview schedule. Their nutritional status was assessed by anthropometric measurements, dietary food intake for a 3-day period, and hematological and biochemical variables. Energy and macro- and micronutrient intakes were compared with the US recommended dietary allowances (RDA) or dietary reference intakes (DRI) as appropriate. RESULTS: Elderly living at home had significantly higher mean body mass index and waist circumference than those living in institutions. Although the total energy intake was comparable between the two groups, the elderly in the institutions consumed more fat and had lower intake of dietary fibers. Deficiencies (below 2/3rd RDA/DRI intakes) in zinc, magnesium, alpha-tocopherol, vitamins A and D, and pyridoxine were noted in both study groups with overall higher proportions observed among the institutionalized elderly. These were also anemic (42.5%) and had low levels of albumin (27.5%). In contrast, those living at home showed a higher prevalence of obesity and a lower calcium intake. Multivariate analysis controlling for a number of potential covariates did not change the results observed. CONCLUSIONS: The results of the present study showed a higher prevalence of obesity in those living at home and varying deficiencies by place of residence with no evidence that duration of institutionalization in itself being associated with poor nutritional status. Awareness of the risks associated with these deficiencies and excesses should address the lay and health professionals working in the community and institutions alike.     

Relevance of readmission of elderly patients discharged from a geriatric unit

Eight percent of the elderly patients discharged from a geriatric unit in one year were readmitted within three months. Forty-six percent had been living alone and nearly all of these had received full community support at the time of discharge. Recurrent problems were the reason for readmission in 59% of cases, mainly due to falls, incontinence, and confusion. Only 54% of the readmitted patients were discharged home again--those with new additional problems tended to die in hospital, whereas those with recurrent problems often required institutional long-term care. It is concluded that even with careful discharge planning, a proportion of patients will require readmission, some of which will also require long-term institutional care. This number is quite small in terms of the total number of patients discharged from a geriatric unit and should not be a reason for seeking nursing home care at an early stage.     

Factors Associated with Home Versus Institutional Death Among Cancer Patients in Connecticut

OBJECTIVE: To assess the relationships between home death and a set of demographic, disease-related, and health-resource factors among individuals who died of cancer. DESIGN: Prospective cohort study. SETTING: All adult deaths from cancer in Connecticut during 1994. PARTICIPANTS: Six thousand eight hundred and thirteen individuals who met all of the following criteria: died of a cancer-related cause in 1994, had previously been diagnosed with cancer in Connecticut, and were age 18 and older at the time of death. MEASUREMENT: Site of death. RESULTS: Twenty-nine percent of the study sample died at home, 42% died in a hospital, 17% died in a nursing home, and 11% died in an inpatient hospice facility. Multivariate analysis indicated that demographic characteristics (being married, female, white, and residing in a higher income area), disease-related factors (type of cancer, longer survival postdiagnosis), and health-resource factors (greater availability of hospice providers, less availability of hospital beds) were associated with dying at home rather than in a hospital or inpatient hospice. CONCLUSIONS: The implications of this study for clinical practice and health planning are considerable. The findings identify groups (men, unmarried individuals, and those living in lower income areas) at higher risk for institutionalized death-groups that may be targeted for possible interventions to promote home death when home death is preferred by patients and their families. Further, the findings suggest that site of death is influenced by available health-system resources. Thus, if home death is to be supported, the relative availability of hospital beds and hospice providers may be an effective policy tool for promoting home death.     

Predictors of nursing home placement in Parkinson's disease: a population-based, prospective study

OBJECTIVES: To examine the rate and predictors of nursing home placement in patients with Parkinson's disease. DESIGN: Four-year prospective study. SETTING: A population-based study in western Norway PARTICIPANTS: 178 community-dwelling subjects with Parkinson's disease. MEASUREMENTS: Main outcome measure was the time from baseline to nursing home admission. Baseline evaluation of motor symptoms (Unified Parkinson's Disease Rating Scale, UPDRS), cognition (clinical dementia interview, Gottfries, Brane & Steen dementia scale, and Mini-Mental State Examination), depression (clinical interview and the Montgomery & Asberg Depression Rating Scale), and psychotic symptoms (UPDRS Thought Disorder item) were performed. RESULTS: Forty-seven patients (26.4%) were admitted to a nursing home during the 4-year study period. Institutionalized patients were older, had more advanced Parkinson's disease with more severe motor symptoms and impairment of activities of daily living, were cognitively more impaired, were more often living alone, and had more hallucinations than those who continued to live at home. Duration of disease, levodopa dose, and gender distribution did not differ between the two groups. A Cox proportional hazards linear regression analysis showed that old age, functional impairment, dementia, and hallucinations were independent predictors of nursing home admission. CONCLUSIONS: Both motor and neuropsychiatric symptoms contributed to institutionalization, but the presence of hallucinations was the strongest predictor. This finding indicates it is possible that effective treatment of hallucinations may reduce the need for institutionalization in patients with Parkinson's disease.     

Let's ask them: a national survey of definitions of quality of life and its enhancement among people aged 65 and over

This study aimed to explore older peoples' definitions of, and priorities for, a good quality of life for themselves and their peers. Nine hundred and ninety-nine people aged 65 and over, living at home in Britain, were interviewed for the study. Good social relationships were the most commonly mentioned constituent that gave respondents' lives quality (mentioned by 81 percent). Other important factors were social roles and activities, health, psychological outlook and well-being, home and neighborhood, finances, and independence. Poor health was most often mentioned as taking quality away from life (by 50 percent). Social relationships and health were judged to be the most important areas. Having health and enough money were the two most frequently mentioned things that would improve the quality of their own lives and those of their peers (though in different order of magnitude). The need for dynamic, multidimensional, and integrated models of quality of life in older age is suggested by these results.     

A randomised study of two policies for managing default in out-patients collecting supplies of drugs for pulmonary tuberculosis in a large city in South India

A randomized controlled study was undertaken to compare 2 policies of default management in out-patients with smear-negative pulmonary tuberculosis attending a large chest clinic in Madras city. All the patients were due to collect monthly supplies of drugs for a year, for daily self-administration at home. In the routine (R) policy, if a patient failed to collect the drug supply on a due date, a reminder letter was posted on the fourth day and, if necessary, a health visitor visited the home a week later. In the intensive (I) policy, a health visitor visited the home on the 4th day and, if necessary, a week later and at 1 and at 2 months. The main analyses concern 150 patients (75 R, 75 I), of whom 16 R and 15 I patients had a positive culture. A total of 29 patients (11 R, 18 I) did not default at any time. For the remaining 64 R and 57 I patients, the mean numbers of defaults were 3.0 and 2.3, and the mean numbers of defaulter retrieval actions were 4.3 and 3.8, respectively. The home visit as the first action (I series) was successful in retrieving defaulters on 65% of 132 occasions, while the reminder letter (R series) was successful in 56% of 193 occasions (P = 0.1). Following the second action, which was a home visit in both the series, these proportions became 80% and 84%, respectively. in the I series, 22 third and 18 fourth actions were taken, but the patient was retrieved in only 4 and 0 instances respectively. The mean number of drug collections during the year was significantly higher in the I series (9.8) than in the R series (8.6). Finally, the proportions of patients who made 12 collections in a 15-month period, a satisfactory target under Indian Programme conditions, were 69% and 52%, respectively (P = 0.07).     

Social functioning and survival: A 10-year follow-up study

Although otherwise extensively researched, one aspect of social functioning in older people that has received less attention is its association with staying at home for as long as possible. This 10-year follow-up examines factors of social functioning that support older people's independent living in their own homes and that reduce the risk of mortality. The data were collected in 1991 by a postal questionnaire that was sent to all residents of Turku, Finland, born in 1920. A physical examination was also conducted. Ten years later, in 2001, the mortality rate of this population was determined. The data were examined statistically. Female gender reduced the risk of mortality. In addition, daily outdoor activities, and not needing help (from different sources) were associated with a reduced risk of mortality. No need for help and a more positive attitude towards life reduced the risk of mortality of women. There were found only non-significant trends for men. Having plans for the future also reduced the risk of mortality. The findings of this study offer useful clues for planning the services provided by home health care personnel. In planning these services it is important that home health care workers take into account the differences between women and men customers: men may need and want different things from the home health care service than women do.     

Diarrhea prevention in people living with HIV: an evaluation of a point-of-use water quality intervention in Lagos, Nigeria

Diarrhea is a leading cause of morbidity and mortality in people living with HIV (PLHIV) in Africa. The impact of a point-of-use water chlorination and storage intervention on diarrheal-disease risk in a population of HIV-infected women in Lagos, Nigeria was evaluated. A baseline survey was performed, followed by six weeks of baseline diarrhea surveillance consisting of weekly home visits, distribution of free water chlorination products and safe storage containers to project participants, and continued weekly home-based diarrhea surveillance for 15 additional weeks. To confirm use of the water chlorination product, during each home visit, stored water was tested for residual chlorine. About 187 women were enrolled. At baseline, 80% of women had access to improved water supplies and 95% had access to sanitation facilities. Following distribution of the intervention, water stored in participants' households was observed to have residual chlorine during 50-80% of home visits, a sign of adherence to recommended water-treatment practices. Diarrhea rates in project participants were 36% lower in the post-intervention period than during the baseline period (p=0.04). Diarrhea rates were 46% lower in the post-intervention period than the baseline period among project participants who were confirmed to have residual chlorine in stored water during 85% or more of home visits (p=0.04); there was no significant difference in diarrhea rates between baseline and post-intervention periods in participants confirmed to have residual chlorine in stored water during less than 85% of home visits. The percent change in diarrhea rates between baseline and post-intervention surveillance periods was statistically significant among non-users of prophylactic antibiotics (-62%, p=0.02) and among persons who used neither prophylactic antibiotics nor antiretroviral treatment (-46%, p=0.04). Point-of-use water treatment was associated with a reduced risk of diarrhea in PLHIV. Regular water treatment was required to achieve health benefits.     

Day care for dementia patients: an analysis of a four-year program

A day care program for patients with dementia was developed by the Burke Rehabilitation Center in 1979. Sixty-nine patients have taken part in the program, some for as long as three years. The majority of patients stay in the program for one to two years. This pilot program was designed to provide a structured series of daily activities for the patient with dementia and to give those responsible for their care at home a period of freedom each week from the responsibilities of care. The program has been well received by the patients and appreciated by their families. It has not altered the steady progression of intellectual decline. It has made it possible for families to continue to keep patients at home and delay nursing placement or the hiring of additional help at home. It is cost effective when compared with the general alternative of nursing home placement. Similar programs could be conducted outside health care facilities at lower cost to patients and their families. Family support group discussions have eased the burden for the caregiver and have been useful in discovering new ideas for better patient management.     

How to start prophylaxis

Summary.  A cohort study was performed to assess the efficacy of a gradual introduction to primary prophylaxis by peripheral vein injections. Bleeding symptoms prior to the initiation of prophylaxis and during the time from the start of home treatment were investigated. Forty-seven boys with severe haemophilia, born between 1987 and 2000, were studied. The mean age at the start of prophylaxis was 16 months and the mean age for the boys on home treatment and full prophylaxis was 30 months. Our results show that primary prophylaxis with injections in a peripheral vein is possible in most patients (83%). Even with this early start, 59% of the children had been treated with clotting factor concentrate before prophylaxis was initiated. Seventy-two percent of the boys had no symptoms from the joints or muscles in the time from initiation to full prophylaxis every second (haemophilia A) or third day (haemophilia B). None of the patients developed cerebral bleeding during this period, but one patient had an epidural bleeding as the presenting symptom of haemophilia.     

Sampling and non-response bias on health-outcomes in surveys of the oldest old

Surveys of the oldest old population are associated with several design issues. Place of residence and possible physical or cognitive impairments make it difficult to maintain a representative study population. Based on a Swedish nationally representative survey among individuals 77+, the present study analyze the potential bias of not using proxy interviews and excluding the institutionalized part of the population in surveys of the oldest old. The results show that compared to directly interviewed people living at home, institutionalized and proxy interviewed individuals were older, less educated and more likely to be female. They had more problems with health, mobility and ADL, and a significantly increased mortality risk. If the study had excluded the institutionalized part of the population and/or failed to use proxy interviews, the result would have been severely biased and resulted in underestimated prevalence rates for ADL, physical mobility and psychologic problems. This could not be compensated for weighting the data by age and sex. The results from this study imply that accurate population estimates require a representative study population, in which all individuals are included regardless of their living conditions, health status, and cognitive ability.     

Emotional support from family members and subjective health in caregivers of the frail elderly at home in Japan

This study sought to determine the factors associated with subjective health in caregivers of the frail elderly living at home, using multivariate regression analysis. Data were collected from 130 caregivers of frail elderly persons listed on a roster for utilization of day service or short stay service from two Home Visit Nursing Care Stations, using self-administered questionnaire from January to February of 2005. Family caregivers were defined as co-residents family members who provided a minimum of 1 h of daily care for at least 3 months. Multiple logistic regression analysis was performed to examine the factors associated with subjective health in caregivers of the frail elderly at home. Subjects with good health had less depressive symptom (p=0.001), much emotional support (p=0.003) and low caregiver burden (p=0.03). Multivariate logistic regression analysis showed good health had a significantly positive association with only much emotional support after adjustment for confounders. Of the total effect of emotional support on subjective health, the direct effect (84.7%) was much greater than the indirect effect (15.3%). Results indicate that much emotional support from family member for caregiver is essential for better subjective health in caregivers.     

Home-based factor infusion therapy and hospitalization for bleeding complications among males with haemophilia

Information from the medical records of 2650 US males with haemophilia living in six states was used to examine the influence of infusing factor concentrate at home (home therapy) and other variables on rates of hospitalization for a haemorrhagic bleeding complication (HBC) over a 4-year period. Bleeding complications included actual and suspected haemorrhagic events but excluded elective admissions for procedures necessitated by haemorrhage (e.g. joint synovectomy). Other risk determinants considered in the analyses included age, race, employment status, health insurance type, care received in federally funded haemophilia treatment centres (HTCs), factor deficiency type and severity, amount of factor prescribed, prophylactic treatment, and presence of inhibitors at baseline. Survival analysis methods were used to evaluate relationships between baseline risk factors and subsequent hospitalization rates. During 8708 person years (PYs) of follow-up, 808 subjects (30.5%) had a total of 1847 bleeding-related hospitalizations; an overall rate of 21.2 admissions per 100 PYs. Using proportional hazards regression to adjust for all of the studied factors, we found that home therapy use (among residents of four of the states) and care in HTCs were independently associated with a decreased risk for a first HBC. Patients who had government-sponsored health insurance or who had no insurance, those of minority race or ethnicity, those with higher levels of factor use, and those with inhibitors were at increased HBC risk. We conclude that the use of home therapy and receipt of care in HTCs are each associated with a substantially lower risk for HBC among males with haemophilia.     

Effect of preventive home visits for ambulatory housebound elders in Japan: a pilot study

BACKGROUND AND AIMS: Programs of preventive home visits for ambulatory housebound elders have not yet become established in Japan. The aim of this randomized pilot study was to investigate effects of such visits by public health nurses in Japan. METHODS: A randomized controlled study with 18-month follow-up was conducted in a small Japanese agricultural town. Participants (n=119) were ambulatory housebound elders aged 65 and over, who were able to walk but who went outdoors less than three times a week at baseline survey. They were randomly assigned to intervention (n=59) or control group (n=60). Intervention group subjects received preventive home visits by public health nurses over 18 months (mean home visits=4.3). Control group subjects received usual primary and community care. Activities of daily living (ADLs), functional capacity, self-efficacy for daily activities, self-efficacy for health promotion, depression, and social support were collected via questionnaire at baseline and at the 18-month follow-up point. RESULTS: At follow-up, 81.4% of intervention group subjects were still living at home vs 73.3% of control group subjects (NS). Simple group comparisons following repeated measures (ANCOVA) showed that the intervention group had higher ADL scores than the control group at follow-up (p=0.044). CONCLUSIONS: These pilot results suggest that home visits by public health nurses may be effective in helping to reduce ADL decline among ambulatory housebound elders.     

The association between socioeconomic status, oral hygiene practice, denture stomatitis and oral status in elderly people living different residential homes

Oral hygiene practices and denture status of elderly people living in residential homes are different depending on the type of residential homes. In this study the elderly people living in three different residential homes were investigated for this purpose. A total of 269 subjects, 119 males (mean age 73.9 ± 8.8) and 150 females (mean age 78.5 ± 7.2) were involved in this study. All subjects were interviewed and clinically examined. Age, sex, educational status, financial status, general health, dental visiting, overnight denture wearing, brushing habits and frequency were recorded using a structured questionnaire. The prevalence of edentulism, the presence and type of dental prostheses, denture cleanliness and the presence of denture stomatitis were evaluated. Forty-one percent of subjects were non-educated. Fifty-one percent of subjects had low income. The majority of people (66.6%) were edentulous. Among the edentulous subjects 32% had full denture and 16% had no denture. Forty three percent of the subjects reported cleaning their dentures with water and 40% with a toothbrush only. Denture hygiene was good for 14% of the subjects. Denture stomatitis was observed in 44% of the subjects wearing dentures. There was statistically significant difference between residential homes and educational status, level of income, dental visiting, denture status, brushing methods and brushing frequency (p < 0.001). A positive relationship was observed between poor denture hygiene habits and the presence of denture-related stomatitis. The most important need within the residents of the residential home was the enhancement of oral care social insurance.     

不同养老方式下老年人心理健康状况的比较研究

目的 比较不同养老方式下老年人的心理健康状况，并分析其相关因素。方法 采用自编老年心理健康问卷，评定对象为441例年龄55～106岁集中养老者和1010倒年龄55～96岁北京城区居家养老者。结果 两类养老方式下老年人的心理健康状况具有类似特点；心理健康水平有随教育程度的提高而改善的趋势；年龄差异不显著，居家养老者心理健康状况明显好于集中养老者。结论 两类养老方式最大区别在于养老机构中亲情纽带作用减弱。老年人缺少天伦之乐，容易产生负性情绪。使心理健康水平下降，这提示当前养老机构应重视对老年人的精神慰藉，物质与精神养老相结合已提到日程     

A retrospective study on heat-related mortality in an elderly population during the 2003 heat wave in Modena, Italy: the Argento Project

BACKGROUND: Summer 2003 witnessed an excess in heat-related mortality in the elderly population. The Argento Project was planned to define risk factors for heat-related death in Modena, Italy, during the hottest month of 2003 (August). METHODS: We performed a retrospective, case-control study of a cohort of 394 older persons living in Modena, 197 dead (cases) and 197 survivors (controls). A questionnaire to collect information about demographic, social, environmental, and clinical characteristics and about causes of death was completed. RESULTS: Cases were more likely to be living in a nursing home and needing assistance (p =.024, and p <.001, respectively). Survivors were living on higher level floors (p =.046). Spending the summer in Modena was significantly related to poor outcomes (p <.01). A higher number of cases were using public health services (p <.001). Individuals who died had a greater degree of comorbidity and dependence (p <.001); they were cognitively impaired (p <.001), took a larger number of drugs (p <.001), and had a greater number of hospital admissions (p <.001). Multivariate analysis showed that patients who spent the summer in Modena had a higher mortality. Other predictors of death were the use of home public-integrated assistance, a higher comorbidity and a higher degree of disability; the loss of at least 1 Activity of Daily Living (ADL) represents the strongest risk factor of heat-related death. CONCLUSIONS: Our study identifies the major risk factors of heat-related death in the elderly population. With the creation of an up-to-date database, when a new heat wave will come, it will be possible to identify frail persons for preventive targeted strategies.