Effectiveness of care for older people: a review

Iatrogenic disease in the elderly: risk factors, consequences, and prevention

The epidemiology of iatrogenic disease in the elderly has not been extensively reported. Risk factors of iatrogenic disease in the elderly are drug-induced iatrogenic disease, multiple chronic diseases, multiple physicians, hospitalization, and medical or surgical procedures. Iatrogenic disease can have a great psychomotor impact and important social consequences. To identify patients at high risk is the first step in prevention as most of the iatrogenic diseases are preventable. Interventions that can prevent iatrogenic complications include specific interventions, the use of a geriatric interdisciplinary team, pharmacist consultation and acute care for the elderly units.

Socioeconomic status and hospitalization in the very old: a retrospective study

Background

Socioeconomic status could affect the demand for hospital care. The aim of the present study was to assess the role of age, socioeconomic status and comorbidity on acute hospital admissions among elderly.

Methods

We retrospectively examined the discharge abstracts data of acute care hospital admissions of residents in Rome aged 75 or more years in the period 1997–2000. We used the Hospital Information System of Rome, the Tax Register, and the Population Register of Rome for socio-economic data. The rate of hospitalization, modified Charlson's index of comorbidity, and level of income in the census tract of residence were obtained. Rate ratios and 95% confidence limits were computed to assess the relationship between income deciles and rate of hospitalization. Cross-tabulation was used to explore the distribution of the index of comorbidity by deciles of income. Analyses were repeated for patients grouped according to selected diseases.

Results

Age was associated with a marginal increase in the rate of hospitalization. However, the hospitalization rate was inversely related to income in both sexes. Higher income was associated with lower comorbidity. The same associations were observed in patients admitted with a principal diagnosis of chronic condition (diabetes mellitus, heart failure, chron obstructive pulmonary disease) or stroke, but not hip fracture.

Conclusion

Lower social status and associated comorbidity, more than age per se, are associated with a higher rate of hospitalization in very old patients.

Oral hygiene care for adults with dementia in residential aged care facilities

OBJECTIVE

The objective of this systematic review was to report on the best available evidence relating to oral hygiene for adults with dementia in residential aged care facilities, including: INCLUSION CRITERIA: This review considered any randomised or non-randomised controlled studies, cohort studies, case-control studies, multiple time series studies, uncontrolled studies, descriptive studies and opinions of respected authorities (including theses and other publications) related to residents with dementia living in residential aged care facilities in Australia and overseas; community-dwelling adults with dementia; and special needs adult populations (for preventive oral hygiene care strategies and interventions).The review considered studies and publications designed to:1 quantify the oral health status of older adults living in residential aged care facilities;2 quantify the oral health status of adults with dementia living in the community and in residential aged care facilities;3 evaluate tools used to assess the oral health of residents by staff and carers working in residential aged care facilities;4 evaluate preventive oral hygiene care strategies and interventions used in special needs adult populations (including adults with dementia); and5 evaluate oral health care training and oral hygiene care provision, staff and carers working in residential aged care facilities.Dental outcome measures of interest were those relating to the prevalence, incidence, experiences and increments of oral diseases and conditions including: denture problems, coronal and root caries, periodontal diseases (plaque accumulation, gingivitis, loss-of-attachment), oral mucosal conditions, xerostomia and salivary gland hypofunction, tooth loss, difficulty chewing, behavioural problems and pain/discomfort. Related characteristics and outcomes of interest included: medical conditions, medications, cognitive status, functional status, nutritional status and sociodemographics.

SEARCH STRATEGY

The aim of the search was to locate relevant English-language studies and publications appearing between 1980 and 2002. The search utilised a two-step approach, involving an initial search of electronic databases using combinations of key words followed by a second extensive search carried out using the identified key words. This was supplemented with a secondary search of the references cited in the identified studies. Electronic database searched were: Cinahl, Embase, Psycinfo, Medline and Current Contents.

METHODOLOGICAL QUALITY

All selected studies were critically appraised by two reviewers prior to inclusion in the review.

RESULTS

In regards to relevance, incidence, experiences, and increments of oral diseases and conditions, possible risk factors identified included: saliva dysfunction, polypharmacy, comorbid medical conditions, swallowing and dietary problems, increased functional dependence, need for assistance with oral hygiene care, and poor access and utilisation of dental care.Evidence on the use of assessment tools by carers to evaluate residents' oral health showed that successful assessment of residents with and without dementia by nursing staff requires appropriate staff training by a dental professional. Coupled with appropriate training, an oral assessment screening tool designed for residents with dementia has been successfully used by nursing and care staff to identify residents requiring further review by dental professionals. Expert opinion in the field indicates that oral assessment screenings by a staff member and then by a dentist would ideally be undertaken upon admission to a facility, and regularly thereafter by staff and/or dentists as required.Clinicians and researchers suggested that oral hygiene care strategies to prevent oral diseases and conditions were found to be effective in preventing oral diseases, and thus are relevant for use in the resident with dementia.In regards to the provision of dental treatment and ongoing management of oral diseases and conditions, the use of adjunctive and preventive aids were found to be effective when introduced in conjunction with a staff training program:Expert opinion suggests that behaviour management techniques will increase the potential of performing oral hygiene care interventions.

CONCLUSIONS

This review suggests that the training of staff in the form of a comprehensive practically oriented program addressing areas such as oral diseases, oral screening assessment, and hands-on demonstration of oral hygiene techniques and products is likely to have a positive impact on the management of oral hygiene care within residential aged care facilities. The review also identified that regular brushing with fluoride toothpaste, use of therapeutic fluoride products and application of therapeutic chlorhexidine gluconate products are validated by research as effective for the general population and some populations with special needs.

Improving the health of older people: what do we do?

This article, based on a paper given at the International Network for Studies Concerning Older Adults conference in Brazil, considers the health of older people. It argues that greater efforts must be made both to improve preventive healthcare interventions and enhance quality of life. It is suggested that nurses have a significant but, as yet, largely unrealized role to play and that action is needed if older people are to get maximum benefit from health care.

An inner city GP unit versus conventional care for elderly patients: prospective comparison of health functioning, use of services and patient satisfaction

BACKGROUND

GP units are generally nurse-led wards, where GPs have direct admitting rights and retain clinical responsibility for their patients. While GP-led wards are not new, they are relatively uncommon in urban areas. In addition, there has been little comparative evaluation of this type of service.

OBJECTIVES

The aim of the present study was to compare patients admitted to an inner city GP unit with comparable patients in conventional care (e.g. district nursing, nursing/residential homes, acute care of the elderly wards) in terms of mental and physical functioning, use of health and social services and patient satisfaction.

METHODS

Study group patients were those admitted to the GP unit; comparison group patients were identified by GP practices or conventional services who had agreed to participate in the study. Suitable patients were aged 65 years or over and fitted the eligibility criteria for the GP unit. Patients were interviewed at three time points: admission to either the GP unit or conventional care, and at 1 and 3 months after admission. Baseline comparability was assessed by demographic and medical data, cognitive function, mental state, social support, use of health and social services, and mental and physical functioning (SF-12). Mental and physical functioning and use of health and social services were compared between the groups over time. Patient satisfaction with their care was also compared between groups.

RESULTS

Change in the mental and physical functioning between patients on the GP unit (n = 67) and those in conventional care (n = 60) did not differ when the groups were compared at any of the three time points. However, the mental function of patients in the GP unit significantly improved between admission and 1 month after admission (P: < 0.05). This effect was not sustained at 3 months after admission. GP unit patients were consistently more positive about the care they received than patients receiving conventional care; this included communication and information, staff, care and the facilities. Both groups of patients were high users of health and social services, with similar patterns of use in both groups, which did not alter over time.

CONCLUSIONS

Patients who received care on the GP unit experienced a similar physical outcome to patients in conventional settings; however, they appeared to enjoy a short-term improvement in mental functioning and were consistently more positive about the quality of their care. This study has important policy implications with regard to planning future intermediate care services and will be of particular interest to health service planners and those responsible for clinical governance.

Oral health care needs of dependent older people: responsibilities of nurses and care staff

The population of older people as well as the number of dependent older people is steadily increasing. Those unable to live independently at home are being cared for in a range of settings and varying degrees of dependency means that many are unable to attend fully to their needs, one aspect of which is oral care. The fact that the oral and dental health of the UK population is generally improving, makes more emphatic the responsibilities of nurses and care staff in this area. This review of the literature reveals that oral health of older people in continuing care settings is generally inadequate and that nurses' and care staff's knowledge and practice of oral care for older people is variable. Inadequate oral care is identified as multifactorial, with implications for educators, policy makers, practitioners and researchers. The need to address oral care for nurses pre- and post-registration as well as adequate preparation for support workers is highlighted. Development of a robust oral assessment tool, as well as empirical investigation of the effectiveness of oral cleaning agents, equipment and techniques to inform standard setting is indicated, with monitoring of standards being imperative.