Are elderly people living alone an at risk group?

OBJECTIVE

To test the hypothesis that elderly people living alone are an at risk group with a high level of morbidity that makes high demands on health and social services.

DESIGN

Secondary analysis of data from a community survey of 239 people aged 75 and over, identified from general practitioners' age-sex registers.

SETTING

Nine practices in the London boroughs of Brent and Islington.

MAIN OUTCOME MEASURES

Scores on the mini-mental state examination; stated satisfaction with life; assessment of mobility; numbers of diagnoses of major physical problems; numbers of prescribed drugs taken; urinary incontinence; alcohol consumption; contacts with general practitioners and hospital outpatient and inpatient services; contact with community health and social services.

RESULTS

There were significantly more women among those living alone (93/120 (78%) v 63/119 (53%); p < 0.0005) and the median age of elderly people living alone was higher (81 v 80; p < 0.04). Those living alone and those living with others showed no significant differences in measures of cognitive impairment, numbers of major physical diagnoses, impaired mobility, or use of general practitioner or hospital services. Stated satisfaction with life was somewhat higher in those living alone. Elderly people living alone were significantly more likely to have contact with chiropody, home help, and meals on wheels services and less likely to have someone they could contact in an emergency or at night. Living alone increased the likelihood of contact with one or more community health professionals (district nurses, health visitors, or chiropodists) considered as a group and also increased the likelihood of contact with social services as a whole. There was a tendency for more of those living alone than those living with others to have home visits from their general practitioners, but there were no significant differences in contact with hospital services between the two groups.

CONCLUSIONS

Elderly people living alone do not have an excess of morbidity compared with those living with others and do not seem to be an at risk group requiring specifically targeted assessments. More help is needed to provide elderly people living alone with a point of contact in case of emergency.

Outcome of planned home births in an inner city practice

OBJECTIVE

To assess the outcome of pregnancy for women booking for home births in an inner London practice between 1977 and 1989.

DESIGN

Retrospective review of practice obstetric records.

SETTING

A general practice in London.

SUBJECTS

285 women registered with the practice or referred by neighbouring general practitioners or local community midwives.

MAIN OUTCOME MEASURES

Place of birth and number of cases transferred to specialist care before, during, and after labour.

RESULTS

Of 285 women who booked for home births, eight left the practice area before the onset of labour, giving a study population of 277 women. Six had spontaneous abortions, 26 were transferred to specialist care during pregnancy, another 26 were transferred during labour, and four were transferred in the postpartum period. 215 women (77.6%, 95% confidence interval 72.7 to 82.5) had normal births at home without needing specialist help. Transfer to specialist care during pregnancy was not significantly related to parity, but nulliparous women were significantly more likely to require transfer during labour (p = 0.00002). Postnatal complications requiring specialist attention were uncommon among mothers delivered at home (four cases) and rare among their babies (three cases).

CONCLUSIONS

Birth at home is practical and safe for a self selected population of multiparous women, but nulliparous women are more likely to require transfer to hospital during labour because of delay in labour. Close cooperation between the general practitioner and both community midwives and hospital obstetricians is important in minimising the risks of trial of labour at home.

Assessment of elderly people in general practice. 3. Confiding relationships

Little is known about the importance of confiding relationships in elderly people. Associations between lack of confiding relationships and depression, lifestyle characteristics, medication use, and contacts with doctors were studied by interviewing a random sample of 235 elderly people aged 75 years and over registered with nine general practices in inner London. It was found that men were not significantly more likely than women to report lack of confiding relationships. Married people of both sexes were more likely to have confiding relationships than those who were single, separated, divorced or widowed. Depression was not associated with lack of a confiding relationship, but those lacking such relationships were significantly more likely to smoke, and were prescribed significantly more medicines than those with confiding relationships. Individuals without a confiding relationship were significantly less likely to admit to any alcohol consumption in the previous three months, suggesting that alcohol consumption in this age group is largely a social phenomenon. Confiding relationships do not appear to confer strong protection against depression and a question on confiding relationships should not therefore be routinely incorporated into surveillance programmes for elderly people in the community.

Out of hours work in general practice

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Alcohol consumption by elderly people: a general practice survey

A random sample of 241 patients from General Practice registers in London were interviewed to assess alcohol consumption, cognitive impairment, depression and other factors. Fifty-one per cent of men and 22% of women reported use of alcohol in the previous 3 months. No significant association was found between reported drinking status and age, score on a depression scale, falls in the previous 3 months, attendance at outpatient clinics or inpatient care in the previous year. In the men abstainers were significantly more likely to show cognitive impairment than were drinkers. Amongst those respondents who admitted to drinking within the previous 3 months, total stated weekly alcohol consumption was not associated with age, cognitive impairment and scores on the depression scale, and there was no association with falls, or with outpatient or inpatient care. Only three men (3.6%) and five women (3.2%) admitted consuming more than 21 and 14 units of alcohol per week, respectively.

Assessment of elderly people in general practice. 1. Social circumstances and mental state

A survey of patients aged 75 years and over registered with general practitioners in north and north west London was carried out by trained interviewers to investigate cognitive impairment. A random sample of 239 patients was selected for the more detailed home assessment. General practitioners had seen nearly two thirds (65.3%) of their patients aged 75 years and over in the three months prior to the study, the majority of these consultations (82.1%) being initiated by the patient and occurring at the surgery. Half of the patients lived alone (50.2%), nearly one in three had no living siblings (31.9%), a similar proportion had no living children (29.5%), and contact with neighbours and relatives was relatively infrequent. One in five elderly patients had evidence of depression (22.0%) although this appeared to be severe in only two cases, and 36 participants (15.1%) had scores on the mini-mental state examination suggesting cognitive impairment. General practitioners underdiagnosed both dementia and depression. The population contained a small group of people who consumed alcohol on a daily basis (10.5%). This study showed that an annual assessment of elderly people as required by the new general practitioners' contract would yield much new evidence of depression and dementia and assist in the identification of heavy drinkers. Up to 30% of patients aged 75 years and over are likely to require further assessment on the basis of screening tests for depression and cognitive impairment, although it remains unclear to what extent identification of these patients will lead to improvements in outcome for them or their carers.

Assessment of elderly people in general practice. 2. Functional abilities and medical problems

A random sample of 239 patients aged 75 years and over registered with general practitioners in north and north west London was selected for home assessment to determine the functional abilities and medical problems of this group of patients. Nearly one in five of the patients were incontinent of urine (18.4%), although this was on a daily basis for only 4.1%. Around one in 20 patients were incontinent of faeces (5.9%), yet only one patient had laundry service support. Unassisted mobility outdoors was reported as possible by 81.2% of the patients. Fourteen different types of aids were present in the participants' homes, the commonest being walking sticks, bath aids and stair rails. Only a small proportion of aids seemed to be currently unused. The major functional problems were bathing, housework, shopping, washing and ironing, and cooking main meals, but the level of demand for extra help was low. One in five patients had a hearing aid (19.8%) but for only 30% of these patients was it in continuous use. Polypharmacy was common, with 29.7% of patients taking three or more prescribed medicines. The workload implications of this approach to anticipatory care of elderly people are considerable. In an average practice of 2000 patients with 130 patients aged 75 years and over the primary care team would need over 150 hours of face-to-face contact per year with these patients to fulfil the new contractual obligation and the yield of new information leading to effective medical or social intervention is limited.(ABSTRACT TRUNCATED AT 250 WORDS)

Screening for cognitive impairment in the elderly using the mini-mental state examination

The use by non-medical staff of a brief screening instrument (the mini-mental state examination) to detect cognitive impairment among the elderly in primary care is described. Patients aged 75 years and over registered with nine general practices in north and north west London were invited by their general practitioners to take part in the study and 1170 patients participated, a response rate of 90%. The prevalence of possible or probable cognitive impairment (score below 25 on the mini-mental state examination) was 12.8%. Six per cent of patients scored below 19, at which score a high probability of dementia exists, although less than a third of this group had a diagnosis of dementia in their medical records. There was no significant difference between men and women or by social class in the proportion of patients with low scores, but the proportion with dementia rose from 2.5% in those aged 75-79 years to 29.0% among those aged 90 years and over. Under the new general practitioner contract there is a requirement to provide annual services to the elderly, including a 'mental assessment'. In a practice with a list size of 2000 around 130 patients are likely to be aged 75 years and over. Of these around 17 would require further assessment for possible dementia on the basis of results obtained using the mini-mental state examination.

Developments in British general practice

The essential characteristics of British general practice--a defined list of patients for each practitioner, the pivotal role of general practice in controlling access to specialist services, and the primary care team--all are likely to be preserved for the foreseeable future. New government legislation will attempt to increase the accountability of general practitioners, to reward "good practice", and to encourage greater emphasis on preventive activities. This article provides an overview of general practice in the United Kingdom, including administrative issues, reimbursement structures, research directions, and government policies.