Use of global assessment measures in dementia drug trials

I argue in this paper that the use of a global clinical impression of change as a primary measure in dementia drug trials is appropriate, given that we do not yet understand clearly enough what Alzheimer's disease looks like as it gets better.

Use of goal attainment scaling in measuring clinically important change in the frail elderly

The selection of appropriate outcome measures is important in evaluating specialized geriatric programs, but how the various measures compare, and which are most appropriate, are matters still largely unexplored. We compared several outcome measures, including goal attainment scaling, to assess their sensitivity to changes in the health status of frail elderly patients admitted to two geriatric medicine wards. GAS is a measurement approach which accommodates multiple individual patient goals, and has a scoring system which allows for comparisons between patients. Forty-five patients (mean age 81 years, 30 females) received comprehensive assessments. GAS yielded a mean 5 goals per patient. The mean gain in the GAS score was 22 points (SD = 7) which was compared with the change in the Barthel Index (r = 0.59), the Functional Independence Measure (r = 0.45), the Physical Self-Maintenance Scale (r = 0.54), the Katz Activities of Daily Living Index (r = 0.49) and the Spitzer Quality of Life Index (r = 0.38). The inter-rater reliability of scoring the GAS follow-up guides was 0.91. Using a relative efficiency statistic, GAS proved more efficient than any other measure. The effect size statistic also demonstrated an increased responsiveness to change of GAS compared with standard measures. GAS is an individualized measurement approach which shows promise as a responsive measure in frail elderly patients.

The occurrence and duration of symptoms in elderly patients with delirium

BACKGROUND

This study attempts to estimate the incidence, prevalence, and average duration of delirium in elderly patients; to assess the sensitivity of DSM-III and DSM-III-R in the diagnosis of delirium; and to compare the estimates of the duration of delirium using DSM-III and DSM-III-R criteria.

METHODS

A 12-month prospective descriptive study of 168 consecutively admitted patients and 5 additional patients with delirium was conducted in the Geriatric Assessment Unit of a teaching hospital. The duration in days of DSM-III and DSM-III-R symptoms for each delirious patient was assessed by two clinicians. The Barthel Index, Mini-Mental State Examination, and Trezpacz Delirium Symptom Rating Scale scores were also recorded.

RESULTS

The prevalence of delirium was 18% and the incidence was 7%. Compared to clinical judgment DSM-III-R showed 100% sensitivity. The mean duration of delirium was 8 +/- 9 days (DSM-III-R); the DSM estimate was 7 +/- 7 days. Complete symptom recovery was seen in only 52% of surviving patients. Prolonged memory impairment was common.

CONCLUSIONS

As operationalized in this study, DSM-III-R delirium criteria were more sensitive than DSM-III. Persistent symptoms are common in elderly patients with delirium.

One-year outcome of elderly and young patients admitted to intensive care units

OBJECTIVE

To compare the outcome of patients over and under age 65 admitted to two intensive care units (ICUs).

DESIGN

Prospective, two-center study. Convenience sample of all admissions to two adult ICUs for a 1-yr period, with a 1-yr follow-up.

SETTING

Adult multidisciplinary closed ICUs.

PATIENTS

All patients (n = 1,040) admitted to two ICUs during a 1-yr period were entered into the study, except patients with self-induced poisoning. Of these patients, 145 patients were lost to follow-up.

INTERVENTIONS

Admission statistics on all patients included demographic, case mix, and severity data. Variables associated with intensive care unit outcomes at discharge (length of stay, mortality) and at 1 yr from admission (mortality, functional capacity, health attitudes) were analyzed. Vital status was confirmed from both Alberta Vital Statistics and Alberta Health. Follow-up interviews were conducted with all available survivors.

RESULTS

The elderly group (> 65 yrs) comprised 46% of patients studied. Both age groups (> 65 yrs and < 65 yrs) had comparable demographics and illness severity measures. Although ICU and 1-yr mortality rates differed between groups (16% of > 65 yrs vs. 12.9% of < 65 yrs ICU mortality and 49% of > 65 yrs vs. 31% of < 65 yrs 1-yr mortality), age was not a major contributor to the variance in outcome. At 1 yr, 65% of patients admitted to the study were alive. Follow-up interviews were conducted with 75% of survivors. Assessment of activities of daily living showed that the elderly patients were similar to younger patients. The elderly demonstrated more positive health attitudes than younger survivors. Functional capacity was significantly associated with health attitudes of younger patients, but not for older survivors.

CONCLUSIONS

Age does not have an important impact on outcome from critical illness, which is most strongly predicted by severity of illness, length of stay, prior ICU admission and respiratory failure. Satisfaction with personal health should not be inferred from the functional status of elderly survivors of intensive care.

Preventive Care for the Elderly: Uncovering the unmet needs of this population

The practice of preventive medicine in the elderly population needs to be revitalized. A review of the existing literature of preventive medicine for recommendations for the elderly uncovers two problems: most screening studies have had few elderly subjects, and the focus has been mainly on early disease detection and prevention of mortality. Prevention of morbidity and of functional impairment should receive more emphasis.

The use of goal attainment scaling in a geriatric care setting

OBJECTIVE

Goal attainment scaling (GAS) is a measurement approach used extensively in mental health. It accommodates multiple individual patient goals, yet retains mathematical properties allowing comparisons between patients. This study was carried out to investigate the feasibility and measurement properties of GAS in a geriatric care setting.

DESIGN

Prospective descriptive study.

SETTING

The geriatric restorative care service and geriatric assessment unit at Camp Hill Hospital, a 350-bed tertiary care facility in Halifax, Canada.

PATIENTS

Fifteen patients aged 65 to 94 who were consecutively admitted to the two geriatric services (mean age 79 years, mean length of stay 37 days, 9 females).

INTERVENTION

Goal Attainment follow-up guides were developed independently for each patient by two geriatricians after a comprehensive assessment of the patient. These guides were later compared to assess level of agreement in goal setting and scale development. A single goal attainment follow-up guide was then developed for each patient by consensus of the two geriatricians. At the end of the follow-up, the guides were scored independently for each patient by one of the geriatricians and by the patient's primary care nurse.

MAIN OUTCOME MEASURES

GAS scores were determined on admission and discharge. Each patient also received admission and discharge ratings on the Barthel Index as well as a global rating of outcome (on a subjective 10-point scale) by a geriatrician who was blinded to the Goal Attainment follow-up score.

RESULTS

GAS proved feasible, requiring 15-20 minutes to scale an average of six goals per patient. GAS also appears reliable. Of 87 goals, 71 (82%) were identified independently by two geriatricians, and the remainder were determined by consensus. This is also a measure of content validity. The physician-nurse inter-rater reliability was 0.87 (intraclass correlation). Concurrent validity was assessed by correlation with the Barthel Index (r = 0.86) and the global clinical outcome rating (r = 0.82). Content validity was also assessed by comparing our goal areas with those identified in recent consensus reports on geriatric assessment. Of these 13 assessment areas, 12 appeared to be reasonably well covered while one assessment area (sexual problems) was not identified for any of the 15 patients.

CONCLUSIONS

GAS appears to be a feasible method of goal setting and outcome evaluation in geriatric care settings, with promising reliability and validity.

The impact of pacemaker implantation on cognitive functioning in elderly patients

OBJECTIVE

To describe and quantify the impact of pacemaker implantation on cognitive functioning in the elderly.

DESIGN

Prospective case-control, non-randomized trial. Data were collected from clinical and family interviews and from a psychological test battery.

SETTING

Pacemaker clinic in a tertiary care hospital.

PARTICIPANTS

Nineteen elderly (65+ years) patients undergoing new or replacement pacemaker implantation for dysrhythmias and volunteer controls matched for age, sex, and short Mental Status Questionnaire test results, without dysrhythmia or intervention.

MAIN OUTCOME MEASURES

Subjective and clinical impressions based on family interviews; results of psychological test battery before and 6-12 months after pacemaker implantation.

RESULTS

Prior to pacemaker implantation, three patients met DSM-III criteria for dementia and two for delirium. Paced patients demonstrated deficiency in immediate memory, language, memory for less structured information, and learning of abstract materials. These deficits were due primarily to the poor performance of patients with complete heart block. Despite clinical and subjective impressions of improvement, there was no change in psychologic test performance subsequent to pacemaker implantation.

CONCLUSIONS

Impaired cognitive functioning is not always clinically apparent but appears common in patients with cardiac dysrhythmias; it is not altered 6-12 months after pacemaker implantation.

Safe and Effective Prescribing for the Elderly: A look at factors linked with adverse drug reactions

Drug-induced iatrogenic disease is more common among elderly patients than in any other patient population. Factors associated with adverse drug reactions in the elderly include excessive and inappropriate prescribing practices (such as the failure to adjust drug dose to age or complex drug regimens), the aging process itself (altered pharmacokinetics and pharmacodynamics), and concurrent illness.

A phenomenology of scut

OBJECTIVE

To identify, describe, and quantify the night-call duties that residents in internal medicine call "scutwork" and to compare faculty and residents' perceptions of scutwork.

DESIGN

Prospective, cross-sectional study.

SETTING

General internal medicine training program at a university-affiliated tertiary care hospital.

PARTICIPANTS

Forty-eight residents who spent 3 months or more on an internal medicine teaching unit during the previous year and 41 faculty members who spent 2 months or more on one of these units.

INTERVENTIONS

Postcall surveys and night-call diaries were used to analyze residents' activities, to derive a definition of scutwork, and to estimate its prevalence. Residents and faculty then completed a detailed questionnaire that included ratings of the educational value, "scut content," and residents' responsibility for 20 specific tasks.

MAIN RESULTS

Eighty-three percent of residents found scutwork and education to be mutually exclusive for the 20 tasks, although 20% indicated that scutwork was an appropriate task for residents. Residents' ratings of tasks as scut varied according to the context of the task. For example, obtaining routine consent from someone else's patient was considered scutwork by 98% of residents, whereas obtaining such consent from the residents's own patient was rated as scutwork by only 52% (P less than 0.01). Similarly, performing intravenous cannulation at the request of ward staff was rated as scut by 94% of residents, whereas performing cannulation at another resident's request was rated as scut by 56% (P less than 0.01). Night-time admission of a patient for an elective procedure was rated as scut by 75% of residents, whereas admission of such a patient after discussion with a faculty member was labeled scut by only 44% (P less than 0.01). Faculty ratings of such admissions did not show the same variation (24% for both). Faculty were more likely than residents to assess tasks as educational (50% compared with 26%, P less than 0.01) but were less likely to consider tasks as scutwork (47% compared with 62%, P = 0.12) or as work that should be done by nonresidents (35% compared with 46%, P greater than 0.2).

CONCLUSIONS

Our results suggest that the characteristics of scutwork can be identified, that the perception of scut varies between faculty and residents, and that the context of a task often determines whether residents perceive it as scut.

Outcomes of admission to a psychogeriatric service

There is an increasing demand in Canada for improved care of elderly patients with psychiatric disorders. We report one year's experience, with a one year follow-up, of 130 consecutive admissions to the psychogeriatric service at Alberta Hospital, Edmonton. Approximately one-half of the patients came from the community and one-half from long term care institutions; 3 % were admitted via an acute care hospital. The median age was 76 years (range from 43 to 92). Aggression (45%) and wandering (29%) were the most common problems. Dementia was diagnosed in 58% and depression in 19% of patients; 17% had medical problems which precipitated or exacerbated the presenting symptoms. The median length of stay was 92 days (range from one to 365 days); patients admitted from long term care facilities were hospitalized for a longer period of time than those admitted from the community. The mortality rate was 16% in the hospital and five percent at one year follow-up. Approximately one-half of the patients were discharged back to their original residence. These results suggest that even very severely disturbed behaviour can be managed successfully and that a close link between medical diagnostic and treatment services is important. Innovations between these services and long term care facilities may reduce the need for prolonged hospitalization.

Delays in the discharge of elderly patients

This paper reports a prospective study of the incidence and magnitude of delays in the discharge of 80 elderly (65+ years old) patients admitted to two general medical services in teaching hospitals in Edmonton, Alberta. The average length of stay was 16.6 days. Discharges were delayed in 14% (11/80) patients, accounting for 21% of the total days stay. Patients whose discharge was delayed tended to be older, to have delirium and/or dementia, to more often come from or require transfer to long term care (LTC) institutions, and/or to be dependent in essential activities of daily living. The 4-Score, an index for predicting non-medical days, was useful in identifying patients at risk for delays in discharge, and had a sensitivity of 0.82, and a specificity of 0.90. Interventions to reduce delays in discharge must address the frail nature of the patients, their lack of support and existing administrative relationships with LTC institutions. Acute care hospitals will likely need to undertake formal programs for the long term care of many of these patients.

The prevalence of cognitive impairment in an elderly Canadian population

We investigated cognitive impairment in a study of the health of the elderly population of Saskatchewan. Surveys of elderly persons living at home (n = 1267) and living in long-term care facilities (n = 990) were conducted in 1981. Cognitive impairment was assessed by a short 10-item mental status questionnaire previously validated against a clinical diagnosis of dementia in an elderly Canadian population. The prevalence of clinically significant cognitive impairment was found to increase with age and with dependence level in long-term care facilities. We estimate that 7.8% of the elderly population have cognitive impairment consistent with a clinical diagnosis of dementia. Our estimates are compared with those derived from other studies. These findings affirm the importance of dementia as a cause of dependence in the elderly and the need for long-term care facilities to deal with dementia and its consequences. Also, since at least as many persons with cognitive impairment live at home as in long-term care facilities, health care planners must direct attention to the elderly with dementia at home.

Response bias in a health status survey of elderly people

This paper compares respondents and non-respondents from the community sample of the Saskatchewan Health Status Survey of the Elderly. Response bias was assessed by comparing the demographic characteristics and use of health care services of the two groups. A stratified two-stage area probability sample was drawn from a comprehensive sampling frame. There were 1614 subjects eligible; interviews were completed with 1267 (78.5%). In the very elderly (85+ years) cohort, disproportionately more urban dwellers and more males were interviewed; the sample was otherwise demographically representative of the elderly population. Non-respondents, especially the very elderly, used significantly more medical services than respondents, and had a higher number of hospital admissions. Non-respondents over age 75 experienced significantly longer average lengths of stay. On average, non-respondents used approximately 15% more hospital days. Non-respondents over age 75 appear to be more likely to experience ill health than respondents. Hence, statistics from this survey are conservative estimates of the ill health of the elderly.

Acute confusion in elderly medical patients

The acute confusional state (delirium) is a common presentation for a wide variety of medical conditions in the elderly. This paper reports a prospective study of acute confusion in elderly people admitted to general medical services in two acute care hospitals in Edmonton, Alberta. Eighty patients were studied, ranging in age from 65-91. Acute confusion was seen in one-fourth of these patients, who tended to be older, more ill, more likely to have chronic cognitive impairment and a higher mortality rate. In patients admitted with confusion, infection and congestive heart failure predominated. In those who developed confusion after hospitalization, iatrogenic disease was more common. Confusion was a sensitive sign of physical illness, and its resolution accompanied recovery. A diagnosis of the cause of the confusion state could be made in 22 of 24 cases. These findings support the aggressive investigation and treatment of acute confusion in the elderly.

Elderly long-stay surgical patients

This paper examines long hospital stays (more than 30 days) among 196 surgical patients over 65 years of age in two acute-care hospitals. Patients in the long-stay group--54 (28%) of the 196--were not demographically different from the others but showed a significantly (p less than 0.05) higher rate of cognitive impairment, dependence before admission and admission through the emergency department. Although these patients more often required catheterization and were nursed in bed or in "gerichairs", many were suitable for discharge to the community if appropriate accommodation could have been found.

Outcome of hospital admission of the very elderly

Hospital utilization by persons aged 85 or older before the development of a specialized geriatric service in a Canadian city is described. Admissions to surgical units slightly outnumbered those to medical units and were more likely to be elective admissions or interhospital transfers. Three fourths of the medical admissions were classified as "emergent," and half of the admissions came through the emergency department. Although a number of patients, particularly older women, came from extended care facilities, most patients had been living in the community before admission. The mean length of stay was 18.8 days and the in-hospital mortality rate was 13 per cent. The majority of patients were discharged to the community, and this placement appeared stable, in that less than 10 per cent of those discharged to the community entered an extended care facility within the one-year follow-up period.