Medication use and potentially inappropriate medications in those with limited prognosis living in residential aged care

AIM

To compare the prevalence in residential aged care (RAC) of preventative and potentially inappropriate medications (PIMs) in those who died within 12 months versus those alive after 12 months.

METHODS

Firstly, a cross-sectional survey of 6196 people living in RAC in Auckland. Secondly, a research physician searched electronic hospital records in one District Health Board for a sub-sample (n = 222) of these residents. Classes of medications and dates of death were obtained from the Ministry of Health databases. Those who died versus those alive at 12 months were compared.

RESULTS

Over half of the 6196 participants received antihypertensives and/or antiplatelet agents. Cardiovascular preventative medications were significantly more common in those who died within 12 months. Seventy percent in high-level care received psychotropics. PIMs were commonly used.

CONCLUSIONS

Use of preventative medications is common in RAC, especially during the last year of life. Psychotropics are very commonly used, despite being potentially inappropriate.

Progress towards predicting 1-year mortality in older people living in residential long-term care

BACKGROUND

frail older people living in residential long-term care (LTC) have limited life expectancy. Identifying those with poor prognosis may improve management and facilitate transition to a palliative approach to care.

OBJECTIVE

to develop methods for predicting mortality in LTC.

DESIGN

a population-based cohort study.

SETTING

LTC facilities, Auckland, New Zealand.

SUBJECTS

five hundred randomly selected older people in a census-type survey of those living in LTC in 2008.

METHODS

mortality data were obtained from New Zealand Ministry of Health. Two methods for assessing mortality risk were developed using demographic, functional and health service information: (i) two geriatricians blinded to identifying data and to mortality, independently reviewed survey, medications and pre-survey hospitalisations data, and grouped residents according to perceived risk of death within 12 months; (ii) multivariate logistic regression model used the same survey and medication items as the geriatricians.

RESULTS

for the geriatricians' assessment, each quintile of perceived risk was associated with a significant increase in mortality (P < 0.001). Area under the curve (AUC) for both physicians was 0.64. The logistic regression model included age, gender, assistance with feeding and requiring night attention, all variables which are easily available from LTC records. AUC for the model was 0.70, but when validated against the entire OPAL cohort, it was 0.65. When either or both geriatrician and the model together predicted high risk of death, 1-year mortality was >50%.

CONCLUSION

two methods with the potential to identify older people with limited prognosis are described. Use of these methods allowed identification of over half of those who died within 12 months.

Demographics and trends in the acute presentation of diverticular disease: a national study

BACKGROUND

Diverticular disease (DD) is a major health problem in the Western world. The aim of this study was to describe demographics and trends in acute DD admissions in New Zealand.

METHODS

Information pertaining to acute hospital admissions between January 2000 and June 2012 for a primary diagnosis of large bowel DD was retrieved from a national database.

RESULTS

There were 25,167 admissions for acute DD. Mean age of presentation decreased from 65.9 years in 2000 to 64.1 years in 2012 (P < 0.001). Mean age was lower in men than women (61.4 versus 67.4 years, P < 0.001). Although men comprised 45.2% of the cohort they were over-represented in the 18-44 years stratum (68.6 versus 31.4%; P < 0.001). Europeans accounted for 84.8% of admissions and presented at an older age (65.8 years) than Māori (56.2 years), Pacific Islanders (58.4 years) or Asians (58.9 years) (P < 0.001). Acute DD admissions were higher in more deprived populations (P < 0.001). Mean length of hospital stay (LOS) reduced from 5.8 days in 2000 to 4.1 days in 2012 (P < 0.001). LOS increased with age (P < 0.001) and deprivation (P = 0.013), but did not differ between ethnicities (P = 0.088). Computed tomography scanning of acute admissions doubled from 2000 to 2012 (29.7-59.2%; P < 0.001) with a halving in the use of acute in-patient colonoscopy (26.1-13.2%; P < 0.001) and emergent surgery (14.8-7.2%; P < 0.001). Percutaneous drain use increased from 0.6% in 2000 to 1.1% in 2012 (P = 0.003).

CONCLUSION

Acute DD is a source of considerable morbidity in New Zealand and there have been significant changes in its admission demographics and trends over the last decade.

The Aged Residential Care Healthcare Utilization Study (ARCHUS): a multidisciplinary, cluster randomized controlled trial designed to reduce acute avoidable hospitalizations from long-term care facilities

OBJECTIVE

To assess effect of a complex, multidisciplinary intervention aimed at reducing avoidable acute hospitalization of residents of residential aged care (RAC) facilities.

DESIGN

Cluster randomized controlled trial.

SETTING

RAC facilities with higher than expected hospitalizations in Auckland, New Zealand, were recruited and randomized to intervention or control.

PARTICIPANTS

A total of 1998 residents of 18 intervention facilities and 18 control facilities.

INTERVENTION

A facility-based complex intervention of 9 months' duration. The intervention comprised gerontology nurse specialist (GNS)-led staff education, facility bench-marking, GNS resident review, and multidisciplinary (geriatrician, primary-care physician, pharmacist, GNS, and facility nurse) discussion of residents selected using standard criteria.

MAIN OUTCOME MEASURES

Primary end point was avoidable hospitalizations. Secondary end points were all acute admissions, mortality, and acute bed-days. Follow-up was for a total of 14 months.

RESULTS

The intervention did not affect main study end points: number of acute avoidable hospital admissions (RR 1.07; 95% CI 0.85-1.36; P = .59) or mortality (RR 1.11; 95% CI 0.76-1.61; P = .62).

CONCLUSIONS

This multidisciplinary intervention, packaging selected case review, and staff education had no overall impact on acute hospital admissions or mortality. This may have considerable implications for resourcing in the acute and RAC sectors in the face of population aging. Australian and New Zealand Clinical Trials Registry (ACTRN12611000187943).

Biases in describing residents in long-term residential aged care

AIM

In New Zealand, no reliable information describes use of long-term residential aged care. Instead, when estimating use, records of government subsidy payments are upscaled to adjust for private payers. This paper assesses consequential bias in reporting use of long-term care and considers the implications.

METHODS

Data from OPAL, a census-type survey of residents of aged-care facilities in Auckland in 2008, linked to routinely-collected hospitalisation, mortality and subsidy data from national databases. Demographic, functional and service use characteristics of unsubsidised residents were compared to subsidised.

RESULTS

Records of 5961 OPAL residents aged 65+ years were matched with subsidy data; 25% were unsubsidised. In low-level care (51% of all), unsubsidised residents had similar care needs to subsidised residents, but were 1.7 years older on average (p<0.001) with shorter length of stay. In high-level care (41% of all), unsubsidised residents had significantly lower care needs on six different measures and were less likely to die during the follow-up period. Upscaling yields undercounts at all care levels.

CONCLUSIONS

National reports derived from current upscaling methods undercount residents. Stratification by region and age group would improve estimates. Age and care needs are misrepresented. Population policies that depend upon upscaled counts should, where possible, ascertain the biases introduced.

Selecting long-term care facilities with high use of acute hospitalisations: issues and options

BACKGROUND

This paper considers approaches to the question "Which long-term care facilities have residents with high use of acute hospitalisations?" It compares four methods of identifying long-term care facilities with high use of acute hospitalisations by demonstrating four selection methods, identifies key factors to be resolved when deciding which methods to employ, and discusses their appropriateness for different research questions.

METHODS

OPAL was a census-type survey of aged care facilities and residents in Auckland, New Zealand, in 2008. It collected information about facility management and resident demographics, needs and care. Survey records (149 aged care facilities, 6271 residents) were linked to hospital and mortality records routinely assembled by health authorities. The main ranking endpoint was acute hospitalisations for diagnoses that were classified as potentially avoidable. Facilities were ranked using 1) simple event counts per person, 2) event rates per year of resident follow-up, 3) statistical model of rates using four predictors, and 4) change in ranks between methods 2) and 3). A generalized mixed model was used for Method 3 to handle the clustered nature of the data.

RESULTS

3048 potentially avoidable hospitalisations were observed during 22 months' follow-up. The same "top ten" facilities were selected by Methods 1 and 2. The statistical model (Method 3), predicting rates from resident and facility characteristics, ranked facilities differently than these two simple methods. The change-in-ranks method identified a very different set of "top ten" facilities. All methods showed a continuum of use, with no clear distinction between facilities with higher use.

CONCLUSION

Choice of selection method should depend upon the purpose of selection. To monitor performance during a period of change, a recent simple rate, count per resident, or even count per bed, may suffice. To find high-use facilities regardless of resident needs, recent history of admissions is highly predictive. To target a few high-use facilities that have high rates after considering facility and resident characteristics, model residuals or a large increase in rank may be preferable.

Reports of the proportion of older people living in long-term care: a cautionary tale from New Zealand

OBJECTIVE

Population ageing is driving many countries to review health and social care policies. For many, an important component is residential long-term care (LTC). This study uses New Zealand to ascertain the extent different reports provide consistent and accurate estimates of LTC use.

METHODS

We searched for available cross-sectional information about use of LTC by people aged 65 years or over in NZ's population since 1988. In addition, for one geographic region, Auckland, we compared research survey data at three time-points with the nearest census estimates.

RESULTS

Fifty-eight national-level estimates (census, subsidy payments and population surveys) were found. Since 2000, estimates of the proportion of older people reportedly living in long-term care ranged from 3.4% to 9.2%. Comparisons with Auckland studies demonstrated improved reporting in the 2006 census.

CONCLUSION

Estimates of the proportion of people living in residential LTC varied widely. OECD reports, often used for cross-national comparisons, were particularly inconsistent.

IMPLICATIONS

While estimates of the proportion of people living in residential LTC in NZ are inconsistent, improvements are evident in census and subsidy data. Reconciling new data with previous reports prior to publication may reduce variations in reporting. Improved reliability will assist understanding of within-country trends and international comparisons, and better inform decisions shaping health services for older people.

Engagement and recruitment of Māori and non-Māori people of advanced age to LiLACS NZ

OBJECTIVES

Life and Living in Advanced Age: A Cohort Study in New Zealand (LiLACS NZ) aims to determine the predictors of successful advanced ageing and understand the trajectories of wellbeing in advanced age. This paper reports recruitment strategies used to enrol 600 Māori aged 80-90 years and 600 non-Māori aged 85 years living within a defined geographic boundary.

METHODS

Electoral roll and primary health lists of older people were used as a base for identification and recruitment, supplemented by word of mouth, community awareness raising and publicity. A Kaupapa Māori method was used to recruit Māori with: dual Māori and non-Māori research leadership; the formation of a support group; local tribal organisations and health providers recruiting participants; and use of the Māori language in interviews. Non-Māori were recruited through local health and community networks. Six organisations used differing strategies to invite older people to participate in several ways: complete full or partial interviews; complete physical assessments; provide a blood sample and provide access to medical records.

RESULTS

During 14 months in 2010-2011, 421 of 766 (56%) eligible Māori and 516 of 870 (59%) eligible non-Māori were enrolled. Participation and contribution of information varied across the recruitment sites.

CONCLUSION

Attention to appropriate recruitment techniques resulted in an acceptable engagement and recruitment for both Māori and non-Māori of advanced age in a longitudinal cohort study.

IMPLICATIONS

There is high potential for meaningful results useful for participants, their whānau and families, health agencies, planners and policy.

Life and living in advanced age: a cohort study in New Zealand--e Puāwaitanga o Nga Tapuwae Kia Ora Tonu, LiLACS NZ: study protocol

BACKGROUND

The number of people of advanced age (85 years and older) is increasing and health systems may be challenged by increasing health-related needs. Recent overseas evidence suggests relatively high levels of wellbeing in this group, however little is known about people of advanced age, particularly the indigenous Māori, in Aotearoa, New Zealand. This paper outlines the methods of the study Life and Living in Advanced Age: A Cohort Study in New Zealand. The study aimed to establish predictors of successful advanced ageing and understand the relative importance of health, frailty, cultural, social & economic factors to successful ageing for Māori and non-Māori in New Zealand.

METHODS/DESIGN

A total population cohort study of those of advanced age. Two cohorts of equal size, Māori aged 80-90 and non-Māori aged 85, oversampling to enable sufficient power, were enrolled. A defined geographic region, living in the Bay of Plenty and Lakes District Health Board areas of New Zealand, defined the sampling frame. Rūnanga (Māori tribal organisations) and Primary Health Organisations were subcontracted to recruit on behalf of the University. Measures--a comprehensive interview schedule was piloted and administered by a trained interviewer using standardised techniques. Socio-demographic and personal history included tribal affiliation for Māori and participation in cultural practices; physical and psychological health status used standardised validated research tools; health behaviours included smoking, alcohol use and nutrition risk; and environmental data included local amenities, type of housing and neighbourhood. Social network structures and social support exchanges are recorded. Measures of physical function; gait speed, leg strength and balance, were completed. Everyday interests and activities, views on ageing and financial interests complete the interview. A physical assessment by a trained nurse included electrocardiograph, blood pressure, hearing and vision, anthropometric measures, respiratory function testing and blood samples.

DISCUSSION

A longitudinal study of people of advanced age is underway in New Zealand. The health status of a population based sample of older people will be established and predictors of successful ageing determined.

International comparison of long-term care resident dependency across four countries (1998-2009): a descriptive study

AIM

To describe an international comparison of dependency of long-term care residents.

METHODS

All Auckland aged care residents were surveyed in 1998 and 2008 using the 'Long-Term Care in Auckland' instrument. A large provider of residential aged care, Bupa-UK, performed a similar but separate functional survey in 2003, again in 2006 (including UK Residential Nursing Home Association facilities), and in 2009 which included Bupa facilities in Spain, New Zealand and Australia. The survey questionnaires were reconciled and functional impairment rates compared.

RESULTS

Of almost 90,000 residents, prevalence of dependent mobility ranged from 27 to 47%; chronic confusion, 46 to 75%; and double incontinence, 29 to 49%. Continence trends over time were mixed, chronic confusion increased, and challenging behaviour decreased.

CONCLUSION

Overall functional dependency for residents is high and comparable internationally. Available trends over time indicate increasing resident dependency signifying care required for this population is considerable and possibly increasing.

Residential aged care in Auckland, New Zealand 1988-2008: do real trends over time match predictions?

BACKGROUND

in Auckland, New Zealand in 1988, 7.7% of those aged over 65 years lived in licenced residential aged care. Age-specific rates approximately doubled for each 5-year age group after the age of 65 years. Even with changes in policies and market forces since 1988, population increases are forecast to drive large growth in demand. This study shows previously unrecognised 20-year trends in rates of care in a geographically defined population.

METHODS

four cross-sectional surveys of all facilities (rest homes and hospitals) licenced for long-term care of older people were conducted in Auckland, New Zealand in 1988, 1993, 1998 and 2008. Facility staff completed survey forms for each resident. Numbers of licenced and occupied beds and trends in age-specific and age-standardised rates in residential aged care are reported.

RESULTS

over the 20-year period, Auckland's population aged over 65 years increased by 43% (from 91,000 to 130,000) but actual numbers in care reduced slightly. Among those aged over 65 years, the proportion living in care facilities reduced from 1 in 13 to 1 in 18. Age-standardised rates in rest-home level care reduced from 65 to 33 per thousand, and in hospital level care, from 29 to 23 per thousand. Had rates remained stable, over 13,200 people, 74% more than observed, would have been in care in 2008.

CONCLUSION

growth predicted in the residential aged care sector is not yet evident. The introduction of standardised needs assessments before entry, increased availability of home-based services, and growth in retirement villages may have led to reduced utilisation.

Agreement between ethnicity recorded in two New Zealand health databases: effects of discordance on cardiovascular outcome measures (PREDICT CVD3)

OBJECTIVES

To assess agreement between ethnicity as recorded by two independent databases in New Zealand, PREDICT and the National Health Index (NHI), and to assess sensitivity of ethnic-specific measures of health outcomes to either ethnicity record.

METHOD

Patients assessed using PREDICT form the study cohort. Ethnicity was recorded for PREDICT and an associated NHI ethnicity code was identified by merge-match linking on an encrypted NHI number. Agreement between ethnicity measures was assessed by kappa scores and scaled rectangle diagrams.

RESULTS

A cohort of 18,239 individuals was linked in both PREDICT and NHI databases. The agreement between ethnicity classifications was reasonably good, with overall kappa coefficient of 0.82. There was better agreement for women than men and agreement improved with age and with time since the PREDICT system has been operational. Ethnic-specific cardiovascular (CVD) hospital admission rates were sensitive to ethnicity coding by NHI or PREDICT; rate ratios for ethnic groups, relative to European, based on PREDICT were attenuated towards the null relative to the NHI classification.

CONCLUSIONS

Agreement between ethnicity was moderately good. Discordances that do exist do not have a substantial effect on prevalence-based measures of effect; however, they do on measurement of the admission of CVD.

IMPLICATIONS

Different categorisations of ethnicity data from routine (and other) databases can lead to different ethnic-specific estimates of epidemiological effects. There is an imperative to record ethnicity in a rational, systematic and consistent way.

Trends in Ethnic Disparities in Stroke Incidence in Auckland, New Zealand, During 1981 to 2003

Background and Purpose— Although geographical variations in stroke rates are well documented, limited data exist on temporal trends in ethnic-specific stroke incidence.

Methods— We assessed trends in ethnic-specific stroke rates using standard diagnostic criteria and community-wide surveillance procedures in Auckland, New Zealand (NZ) in 1981 to 1982, 1991 to 1992, and 2002 to 2003. Indirect and direct methods were used to adjust first-ever (incident) and total (attack) rates for changes in the structure of the population and reported with 95% CIs. Ethnicity was self-defined and categorized as “NZ/European,” “Maori,” “Pacific peoples,” and “Asian and other.”

Results— Stroke attack (19%; 95% CI, 11% to 26%) and incidence rates (19%; 95% CI, 12% to 24%) declined significantly in NZ/Europeans from 1981 to 1982 to 2002 to 2003. These rates remained high or increased in other ethnic groups, particularly for Pacific peoples in whom stroke attack rates increased by 66% (95% CI; 11% to 225%) over the periods. Some favorable downward trends in vascular risk factors, such as cigarette smoking, were counterbalanced by increasing age, body mass index, and diabetes in certain ethnic groups.

Conclusions— Divergent trends in ethnic-specific stroke incidence and attack rates, and of associated risk factors, have occurred in Auckland over recent decades. The findings provide mixed views as to the future burden of stroke in populations undergoing similar lifestyle and structural changes.

Trends in Stroke Incidence in Auckland, New Zealand, During 1981 to 2003

BACKGROUND AND PURPOSE

Long-term trends in stroke incidence in different populations have not been well characterized, largely as a result of the complexities associated with population-based stroke surveillance.

METHODS

We assessed temporal trends in stroke incidence using standard diagnostic criteria and community-wide surveillance procedures in the population (approximately 1 million) of Auckland, New Zealand, over 12-month calendar periods in 1981-1982, 1991-1992, and 2002-2003. Age-adjusted first-ever (incident) and total (attack) rates, and temporal trends, were reported with 95% confidence intervals (CIs). Rates were analyzed by sex and major age groups.

RESULTS

From 1981 to 1982, stroke rates were stable in 1991-1992 and then declined in 2002-2003, to produce overall modest declines in standardized incidence (11%; 95% CI, 1 to 19%) and attack rates (9%; 95% CI, 0 to 16%) between the first and last study periods. Some favorable downward trends in vascular risk factors such as cigarette smoking were counterbalanced by increasing age and body mass index, and frequency of diabetes, in patients with stroke.

CONCLUSIONS

There has been a modest decline in stroke incidence in Auckland over the last 2 decades, mainly during 1991 to 2003, in association with divergent trends in major risk factors.

Very Long-Term Outcome After Stroke in Auckland, New Zealand

Background and Purpose— Limited information exists on the long-term outcome from stroke. We aimed to determine survival and health status at 21-year follow-up of patients who participated in a population-based stroke incidence study undertaken in Auckland, New Zealand.

Methods— During 12 months beginning March 1, 1981, half of all residents of Auckland with acute first-ever or recurrent stroke (n=680) were assessed and followed up prospectively during the next 2 decades. In 2002, their vital status and health-related quality of life (HRQoL) using the 36-item short-form questionnaire (SF-36) were determined by telephone interviews. Kaplan–Meier survival probabilities for the stroke cohort were compared with life table estimates for the New Zealand population. The SF-36 profile of 21-year stroke survivors was compared with a standardized New Zealand population.

Results— Overall, 626 of the original cohort had died and 4 were lost to follow-up, leaving 50 (7%) individuals (57% male; mean age 70 years) available in 2002, of whom 12% were residents of an institutional care facility and 19% required help with everyday activities. The stroke cohort had nearly twice the mortality rate of the New Zealand population, but the SF-36 profile of very long-term stroke survivors was broadly similar to the general population.

Conclusions— Because stroke is generally a disease of older people and has a high case fatality, it is not surprising that <1 in 10 people survive 2 decades after onset. However, of those who do, their HRQoL profile suggests that they meld relatively successfully within the general population, despite ongoing disability and a higher mortality risk.

Does melatonin improve sleep in older people? A randomised crossover trial

STUDY OBJECTIVE

to determine whether melatonin will improve quality of sleep in healthy older people with age-related sleep maintenance problems.

DESIGN

a double blind randomised placebo controlled crossover trial in healthy older volunteers.

SETTING

a largely urban population, Auckland, New Zealand.

PARTICIPANTS

participants were part of the larger Possible Role of Melatonin in Sleep of Elders study. People 65 years or more of age were recruited through widespread advertising. We screened 414 potential participants by mail using the Pittsburgh Sleep Quality Index, and selected 194 for clinic interview. Exclusions included depression, cognitive impairment, hypnosedative medications, sleep phase abnormalities, medical and/or environmental problems that might impair sleep. Twenty normal and 20 problem sleepers were randomly allocated for this study from a larger sample of 60 normal and 60 problem sleepers.

MEASUREMENTS AND RESULTS

24-hour urine 6-sulphatoxymelatonin was measured to estimate melatonin secretion in each participant. Five milligrams of melatonin, or matching placebo were each taken at bedtime for 4 weeks, separated by a 4-week washout period. Sleep quality was measured using sleep diaries, the Leeds Sleep Evaluation Questionnaire, and actigraphy. There was a significant difference between the groups in self-reported sleep quality indicators at entry, but no difference in melatonin secretion. Melatonin did not significantly improve any sleep parameter measured in either group.

CONCLUSION

5 mg of fast release melatonin taken at bedtime does not improve the quality of sleep in older people with age-related sleep maintenance problems.

Melatonin in older people with age-related sleep maintenance problems: a comparison with age matched normal sleepers

STUDY OBJECTIVES

To determine whether older people with age-related sleep maintenance problems have significantly lower melatonin levels than comparable normal sleepers.

DESIGN

Case-control study.

SETTING

A largely urban population, Auckland, New Zealand.

PARTICIPANTS

People over the age of 65 years, who either slept normally, or had age-related sleep maintenance problems. Participants were recruited through media advertising, and local interest groups. Initial screening was by mail (Pittsburgh Sleep Quality Index), followed by interviews at a hospital day clinic. Exclusions included those with depression, cognitive impairment, medical and/or environmental problems which might impair sleep.

INTERVENTIONS

N/A.

MEASUREMENTS AND RESULTS

A metabolite of plasma melatonin, 6-sulphatoxymelatonin (aMT6s) was measured in the urine of 57 normal sleepers, and 53 people with age-related problems over 24 hours in three aliquots: 12:00-19:00h, 19:00-07:00h, 07:00-12:00h. There were clear differences in self reported quality of sleep but no difference in mean aMT6s 24 hour or total night excretory levels, or night/day ratios.

CONCLUSIONS

Older people with age-related sleep maintenance problems do not have lower melatonin levels than older people reporting normal sleep.

Is there a temporal pattern in the occurrence of subarachnoid hemorrhage in the southern hemisphere? Pooled data from 3 large, population-based incidence studies in Australasia, 1981 to 1997

BACKGROUND AND PURPOSE

Publications on the temporal pattern of the occurrence of subarachnoid hemorrhage (SAH) have produced conflicting results. Variations between studies may relate to the relatively small numbers of SAH cases analyzed, including those in meta-analyses.

METHODS

We identified all cases of SAH from 3 well-designed population-based studies in Australia (Adelaide, Hobart, and Perth) and New Zealand (Auckland) during 3 periods between 1981 and 1997. The diagnosis of SAH was confirmed with CT, cerebral angiography, cerebrospinal fluid analysis, or autopsy in all cases. Information on the time of occurrence of each event was obtained. Risk ratios (RRs) and 95% CIs were calculated using Poisson regression, with age, sex, smoking status, and history of hypertension entered in the model as covariates.

RESULTS

A total of 783 cases of SAH were registered. Age- and sex-adjusted RRs of SAH occurrence were highest in the period between 6 AM and 12 MIDNIGHT (RR 3.2, 95% CI 2.4-4.3) and in winter and spring (RR 1.3, 95% CI 1.1-1.5; RR 1.3, 95% CI 1.1-1.5; respectively). No particular pattern of SAH occurrence was observed according to the day of the week. Restriction of the analyses to proved aneurysmal SAH did not substantially change the point estimates.

CONCLUSIONS

Circadian and circaseptan (weekly) fluctuations of SAH occurrence in the southern hemisphere are similar to those in the northern hemisphere, but the occurrence of SAH in Australasia exhibits clear seasonal (winter and spring) peaks.

Health-related quality of life among long-term survivors of stroke : results from the Auckland Stroke Study, 1991-1992

BACKGROUND AND PURPOSE

The consequences of stroke are a major health concern. This study was conducted to compare the health-related quality of life among long-term survivors of stroke with that of the general population.

METHODS

Our data are taken from a population-based case-control study of all 6-year survivors of stroke with an age- and sex-matched control population. SF-36 mean scores for cases were compared with raw and standardized control and New Zealand norm mean scores.

RESULTS

Of the original 1761 registered cases, 639 were still alive at 6-year follow-up, and all of these participated in the study. Case patients were more likely than control subjects to be dependent in all basic activities of daily living. Crude mean scores were lower for women; as age increased; for those living in institutions; when the SF-36 was completed by proxy; and when help was required with the activities of daily living. Cases had statistically lower mean scores than both the control group and New Zealand norms for physical functioning and general health. After standardization for age and sex, no differences were found between cases and controls in mental health and bodily pain.

CONCLUSIONS

Health-related quality of life appears to be relatively good for the majority of patients 6 years after stroke. Despite significant ongoing physical disability, survivors of stroke appear to adjust well psychologically to their illness.

Shared responsibility for ongoing rehabilitation: a new approach to home-based therapy after stroke

OBJECTIVE

To assess the efficacy of a programme of continuing self-directed exercises for people discharged home after a stroke, supervised once a week by therapists.

DESIGN

A randomized controlled trial of 100 patients discharged from hospital after a stroke, requiring ongoing therapy. The control group received outpatient or day hospital therapy; the experimental group were visited once a week by an occupational and/or physiotherapist who prescribed a programme of exercises and activities for the following week. Subjects were studied for the first three months after discharge from hospital.

SETTING

A district general hospital, or the homes of subjects randomized to the experimental group, in New Zealand.

MAIN OUTCOME MEASURES

(1) Characteristics of the groups, (2) gait speed, limb function, activities of daily living, (3) time with therapists, (4) mood of both subjects and caregivers, (5) anticipation of outcome at entry, compared with perceived outcome at exit.

RESULTS

No statistical differences between the control and experimental groups in characteristics, or in any outcomes measured, except that the contact time period, but not the number of visits, was longer in the experimental group (p = 0.003).

CONCLUSIONS

A supervised home-based programme is as effective as outpatient or day hospital therapy.

Prevalence of stroke and stroke-related disability. Estimates from the Auckland stroke studies

BACKGROUND AND PURPOSE

To provide estimates of the prevalence of stroke and stroke-related disability for international comparisons and for planning purposes.

METHODS

Estimates of prevalence were derived from two population-based studies conducted 10 years apart in Auckland, New Zealand. The first, carried out in 1981, included information on survival and stroke-related disability to 14 years after stroke, and the second, undertaken in 1991 to 1992, included this information up to 3 years after stroke. An actuarial model was developed that took into account changes in incidence, long-term survival, and population structure.

RESULTS

Overall, it was estimated that 7491 people (3793 men and 3698 women) living in Auckland (total population 945,000) in 1991 had experienced a stroke at some stage in the past. This represents an age-standardized rate of 833 per 100,000 (991 per 100,000 in men and 706 per 100,000 in women) in the population aged 15 years and older. When only those who have made an incomplete recovery are considered, prevalence falls to 461 per 100,000. Of this group, one third (173 per 100,000 population 15 years and older) required assistance in at least one self-care activity.

CONCLUSIONS

Usual estimates of stroke prevalence, which include all people who have ever experienced a stroke, may overestimate by almost twofold the prevalence of stroke-related disability, since many have either recovered or have no continuing dependency related to stroke. Overall prevalence does not provide information with sufficient precision for planning and purchasing ongoing services for stroke patients.

Early management and outcome of acute stroke in Auckland

BACKGROUND

Studies of acute stroke management in stroke units and tertiary referral hospitals may not accurately reflect practice within the population. Reliable information on the management of stroke within a population is sparse.

AIMS

To compare clinical practice in acute stroke management in Auckland with guidelines for the management and treatment of stroke in other countries; to provide a baseline measure against which future changes in management can be evaluated.

METHODS

All new stroke events in Auckland residents in 12 months were traced through multiple case finding sources. For each patient, a record of investigations and treatment during the first week of hospital admission was kept.

RESULTS

One thousand eight hundred and three stroke events (including subarachnoid haemorrhages) occurred in 1761 patients in one year. Twenty-seven per cent of all events were managed outside hospital and 73% of the stroke events were treated in an acute hospital. Of the 1242 stroke events admitted to an acute hospital in the first week, only 6% were managed on the neurology and neurosurgery ward, 83% were managed by a general physician or geriatrician and 42% had computed tomography (CT). Of 376 validated ischaemic strokes, 44% were treated with aspirin and 12% with intravenous heparin. Of the 690 unspecified strokes (no CT or autopsy), 38% received aspirin and 0.5% heparin. The 28 day in-hospital case fatality for all stroke events admitted to an acute hospital during the first week was 25%.

CONCLUSIONS

In Auckland, management of acute stroke differed from clinical guidelines in the high proportion of patients managed in the community, the low rate of neurological consultation, and the low frequency of CT scanning. Despite these deficiencies in management, the 28 day hospital case fatality in Auckland was similar to other comparable studies which had a high proportion of cases evaluated by a neurologist and CT.