The geriatric "medical and public health" imperative revisited

Prevention of urinary incontinence in adults: population-based strategies

BACKGROUND

Urinary incontinence (UI) affects large numbers of adults, especially older adults, with an estimated 200 million adults worldwide having this life-altering condition.

OBJECTIVES

To identify key populations at risk for urinary incontinence and propose population-based strategies to promote continence with a substantive focus on UI prevention.

METHODS

Critical review of extant literature and iterative synthesis were undertaken to generate an action plan to guide future UI prevention research.

RESULTS

Key populations identified to be at risk for UI are women in selected occupations, childbearing women, older adults with lifestyle risk factors, older adults with comorbid conditions, and nursing home residents. Population-based research activities are proposed. Growing evidence supports the benefit of pelvic floor muscle training to prevent childbirth and prostatectomy-related UI. Bladder training has demonstrated preventive capacity.

CONCLUSIONS

Because of its high prevalence and chronic but preventable nature, UI is most appropriately considered a public health problem. Nursing research is needed to test prevention programs for UI using a population-based public health focus.

Primary prevention research on incontinence in older adults

Primary prevention research on urinary incontinence in older adults is in its nascent phase. Most clinical research has focused on secondary or tertiary prevention, that is, testing interventions to cure, improve, or manage incontinence. When urinary incontinence is recognized as a public health issue, resources become available to reduce the risk of incontinence and prevent its occurrence. Methodological issues that face nurse researchers desiring to conduct primary prevention research include inadequate theory and outcome development, need for gender and culturally sensitive measurement instruments, and sampling and design issues. Rather than viewing primary prevention as a futile endeavor, nurse researchers must combine the roles of researcher and advocate, articulating the vision for primary prevention, and developing sound clinical studies to prevent urinary incontinence in the older adult population.

Evaluation of a guided protocol for quality improvement in identifying common geriatric problems

OBJECTIVES

Many common geriatric problems are underrecognized and undertreated. A simple and reliable tool to facilitate a standard approach to evaluating geriatric patients might improve the quality of medical care delivered to geriatric patients. The objective of this study was to evaluate a standardized, semistructured quality-improvement protocol (the guided geriatric care protocol) for the assessment of common geriatric problems.

DESIGN

Sequential comparison cohorts, with chart review to evaluate study measures before and after introduction of the guided geriatric care protocol.

SETTING

The outpatient consultative geriatric assessment center of Yale-New Haven Hospital in New Haven, Connecticut.

PARTICIPANTS

One hundred consecutive new patients before and 100 consecutive new patients after introduction of the guided geriatric care protocol.

MEASUREMENTS

Number and type of problems identified and recommendations made during the clinical encounter, duration of the clinical encounter, clinician acceptance.

RESULTS

The two patient groups were similar in sociodemographics, cognitive and functional status, and reasons for evaluation. Significantly more problems were identified after (mean 5.51) than before (mean 3.49) introduction of the guided geriatric care protocol (P< .001); likewise, significantly more recommendations were made after (mean 10.45) than before (mean 8.48) introduction of the protocol (P< .001). The duration of the clinical encounter did not differ significantly between the two groups. The protocol was well accepted by participating clinicians.

CONCLUSIONS

Use of the guided geriatric care protocol assured a standard approach to evaluating common geriatric problems and may have led to the identification and treatment of more problems than usual care without increasing the duration of the clinical encounter. A quality-improvement tool that standardizes the evaluation of common geriatric problems, if validated in other clinical settings, holds the potential to improve the quality of care for vulnerable older patients.

Use of potentially inappropriate drugs in nursing homes

STUDY OBJECTIVES

To examine patterns and determine predictors of inappropriate drug use in nursing homes.

DESIGN

Retrospective study.

SETTING

One thousand four hundred ninety-two nursing homes in five states.

PATIENTS

A total of 44,562 residents admitted to nursing homes over 1 year.

METHODS

Frequency of discontinuation and initiation of potentially inappropriate drugs over the first 90 days after admission to a nursing home was calculated. Data were collected using the minimum data set.

RESULTS

On admission, 33% of residents were receiving at least one potentially inappropriate drug. After 90 days, the drug was discontinued in 16% of these residents. Of those not receiving a potentially inappropriate drug on admission, one was begun in 18%. Demographic factors and number of drugs taken by patients were associated with the use of potentially inappropriate drugs. CONCLUSIONS; Use of potentially inappropriate drugs was prevalent on admission and at 90 days after admission. Discontinuation was highest among patients with conditions for which potentially safer therapeutic alternatives existed.

Outcomes of a small group educational intervention for urinary incontinence: episodes of incontinence and other urinary symptoms

OBJECTIVES

This community-based intervention to reduce urinary incontinence (UI) in elderly women used a small group educational approach. This article reports on change in episodes of incontinence and other urinary symptoms.

METHODS

Participants were randomly assigned to intervention or wait control condition. This article is restricted to 49 intervention and 59 control participants with acceptable diaries.

RESULTS

There was a significant treatment effect for a number of incontinent episodes. In the intervention group, 61% had a 50% or greater reduction in episodes, with more than one third having 100% reduction; 38% of the control group had a reduction of 50% or greater. One year postprogram, 75% of treated women reported subjective improvement. There was a reduction in frequency of daily, but not nocturnal, micturition.

DISCUSSION

This community-based intervention is an encouraging option for behavioral treatment of UI. Public health models may be particularly appropriate with moderate levels of urinary incontinence.

Managed care and multilevel long-term care providers: reluctant partners

Managed care is reshaping our health care system, although long-term care is only beginning to feel its effects. We report on the managed care involvement of 492 multilevel, long-term care facilities (MLFs; including skilled nursing and assisted/independent living) nationally. Organizational structure and culture and especially environmental characteristics are associated with whether facilities have contracts with managed care organizations (MCOs), plan to have contracts, are only gathering information on MCOs, or intend to do nothing in the near future. Resource dependence theory best explains MCO contracting patterns with MLFs appearing to be responding more to survival than to growth.

The effect of visual and hearing impairments on functional status

OBJECTIVES

To describe the prevalence of visual and auditory impairment in frail older persons and to evaluate the association between sensory impairment and overall functional status.

DESIGN

Prospective patient evaluation and retrospective analysis of data.

SETTING

The outpatient geriatric assessment clinic of a university medical center.

PARTICIPANTS

Consecutive patients seen in the University of Nebraska Medical Center Outpatient Geriatric Assessment Clinic from 1986 to 1992 for whom both vision and hearing information were available (n = 576).

MEASUREMENTS

Visual acuity was measured by the Lighthouse Near Visual Acuity Test, and auditory acuity was evaluated with the whisper test. Functional status was determined by Lawton-Brody activities of daily living (ADL) and instrumental activities of daily living (IADL) scales. Comorbid illness was classified by the Cumulative Illness Rating Scale, and mental status was assessed by the Folstein Mini-Mental State Exam.

RESULTS

Eighteen percent of patients had visual impairment of 20/70 or worse. Hearing impairment was found in 64%. The mean ADL and IADL scores were 20/24 and 12/23, respectively, for patients with visual acuity better than 20/70, compared with 18/24 and 8/23 for visually impaired patients (P < .001 for both comparisons). ADL and IADL scores were also higher in hearing intact patients compared with those with hearing impairment: respectively, 21/24 vs 19/24 (P < .001) and 13/23 vs 11/23 (P < .001). The effects of visual acuity and hearing acuity on IADL score are independent of mental status and comorbid illness (P < .001). The effect of visual acuity on ADL score is independent of mental status and comorbid illness (P < .001), whereas the effect of hearing on ADL score is not. Subjects with both hearing and vision impairment had mean IADL (P < = .05) and ADL (P < = .05) scores significantly lower than those with no impairment

CONCLUSIONS

Impairments of vision and hearing are common in this frail older outpatient population. Functional status, as measured by IADL and ADL scores, is diminished for sensory impaired subjects. Combined vision and hearing impairments have a greater effect on function than single sensory impairments and influence functional status independent of mental status and comorbid illness. Overall, these results suggest that interventions to improve sensory function may improve functional independence.

Identifying and treating urinary incontinence. The crucial role of the primary care physician

Urinary incontinence is a widespread problem that often goes undiagnosed and untreated. Many patients are unwilling to discuss it with their physician because of embarrassment or the belief that nothing can be done. Consequently, physicians need to routinely inquire about symptoms so incontinent patients can be identified. Physicians should reassure patients that urinary incontinence is usually a symptom of a correctable problem. Careful evaluation and office tests to determine the type and cause of urinary incontinence, together with appropriate treatment, often lead to improvement in symptoms or return to continence.

Characterization of older adults who attribute functional decrements to "old age"

OBJECTIVE

Understanding the contributors to physical disability in older adults is an important component of the national health objective of expanding disability-free life by the year 2000. The purpose of this study was to determine the frequency with which older adults attribute their difficulty performing a number of common daily tasks to "old age" and to identify specific conditions and diseases associated with this attribution. Finally we sought to determine the characteristics that might differentiate persons able to attribute their disability to specific conditions from those who cite old age as the etiology of their disability.

DESIGN

A cross-sectional, observational, study.

SETTING

The Johns Hopkins Functional Status Laboratory.

PARTICIPANTS

Two hundred thirty community-dwelling volunteers 60 years of age and older who could stand unassisted for > or = 1 minute and who were without cognitive impairment.

MEASUREMENTS

A 1-day evaluation included physical performance evaluations, both performance-based and self-reported function for 27 tasks, and self-report of physician-diagnosed diseases. Those with difficulty in a task and those who denied difficulty but had changed the method of task performance (modification) because of an underlying health or physical condition were identified and asked to name the cause of their difficulty or task modification; options were specific diseases/medical conditions or "old age." The prevalence of "old age" citation as a cause of functional limitation, as well as its associated characteristics and medical conditions, was determined.

MAIN RESULTS

Twenty percent of the 230 participants cited "old age" as the cause of their disability in two or more tasks. Tasks for which difficulty was most frequently attributed to "old age" were dressing oneself (31%), walking around the home (25%), walking 1/2 mile (5-6 blocks) (25%), cutting toenails (16%), getting in or out of a bed or chair or out a car (14% each), and ascending/descending stairs (13%). Significantly higher levels of arthritis, heart disease, and hearing loss were reported in persons attributing their disability to "old age" than in those not reporting "old age" as the cause of their disability. We found no differences in age, gender, race, education, or cognitive status for the two groups. However, individuals citing "old age" as the cause of functional decrements walked more slowly than those who cited a specific disease.

CONCLUSIONS

These data suggest that a significant proportion of functional decline attributed to "aging" in older adults may be associated with specific conditions. Identifying and reducing the impact of these conditions may prove to be a useful approach to preventing or minimizing functional loss.

Decreasing disability in the 21st century: the future effects of controlling six fatal and nonfatal conditions

OBJECTIVES

This study assessed the effects of reducing fatal and nonfatal health conditions on the number of functionally limited older Americans in the coming decades.

METHODS

Data from the 1990 census and the Longitudinal Study of Aging were used to project the number of functionally limited older Americans from 2001 to 2049, assuming 1% biennial reductions in five conditions that shorten life expectancy (coronary artery disease, stroke, cancer, diabetes, and confusion) and one condition that decreases functional ability (arthritis).

RESULTS

Decreasing the prevalence of arthritis by 1% every 2 years would lead to a much greater reduction in functional limitation between 2001 and 2049 (4 million person-years) than would decreasing any of the other conditions by the same amount. Decreases in two fatal conditions (cancer and coronary artery disease) would lead to increases in functional limitation (0.9 and 0.1 million person-years, respectively).

CONCLUSIONS

Advances against common nonfatal disabling conditions would be more effective than advances against fatal conditions in blunting the large increase in the functionally limited older population anticipated in the 21st century.