Costs of potentially inappropriate medication use in residential aged care facilities

Background

The potential harms of some medications may outweigh their potential benefits (inappropriate medication use). Despite recommendations to avoid the use of potentially inappropriate medications (PIMs) in older adults, the prevalence of PIM use is high in different settings including residential aged care. However, it remains unclear what the costs of these medications are in this setting. The main objective of this study was to determine the costs of PIMs in older adults living in residential care. A secondary objective was to examine if there was a difference in costs of PIMs in a home-like model of residential care compared to an Australian standard model of care.

Methods

Participants included 541 participants from the Investigation Services Provided in the Residential Environment for Dementia (INSPIRED) Study. The INSPIRED study is a cross-sectional study of 17 residential aged care facilities in Australia. 12 month medication costs were determined for the participants and PIMs were identified using the 2015 updated Beers Criteria for older adults.

Results

Of all of the medications dispensed in 1 year, 15.9% were PIMs and 81.4% of the participants had been exposed to a PIM. Log-linear models showed exposure to a PIM was associated with higher total medication costs (Adjusted β = 0.307, 95% CI 0.235 to 0.379, p < 0.001). The mean proportion (±SD) of medication costs that were spent on PIMs in 1 year was 17.5% (±17.8) (AUD$410.89 ± 479.45 per participant exposed to a PIM). The largest PIM costs arose from proton-pump inhibitors (34.4%), antipsychotics (21.0%) and benzodiazepines (18.7%). The odds of incurring costs from PIMs were 52% lower for those residing in a home-like model of care compared to a standard model of care.

Conclusions

The use of PIMs for older adults in residential care facilities is high and these medications represent a substantial cost which has the potential to be lowered. Further research should investigate whether medication reviews in this population could lead to potential cost savings and improvement in clinical outcomes. Adopting a home-like model of residential care may be associated with reduced prevalence and costs of PIMs.

Electronic supplementary material

The online version of this article (10.1186/s12877-018-0704-8) contains supplementary material, which is available to authorized users.

Visual Field Dependence Is Associated with Reduced Postural Sway, Dizziness and Falls in Older People Attending a Falls Clinic

Moving visual fields can have strong destabilising effects on balance, particularly when visually perceived motion does not correspond to postural movements. This study investigated relationships between visual field dependence (VFD), as assessed using the roll vection test, and reported dizziness, falls and sway under eyes open, eyes closed and optokinetic conditions. Ninety five falls clinic attendees undertook the roll vection test (i.e. attempted to align a rod to the vertical while exposed to a rotating visual field). Sway was assessed under different visual conditions by centre of pressure movement. Participants also completed questionnaires on space and motion discomfort, fear of falling, depression and anxiety. Thirty four (35.8%) participants exhibited VFD, i.e. had an error > 6.5º in the roll vection test. Compared to participants without VFD, participants with VFD demonstrated less movement of the centre of pressure across all visual conditions, were more likely to report space and motion discomfort and to have suffered more multiple falls in the past year. VFD was independent of fear of falling, anxiety and depression. VFD in a falls clinic population is associated with reduced sway possibly due to a stiffening strategy to maintain stance, dizziness symptoms and an increased risk of falls.

Virtual reality for stroke rehabilitation: an abridged version of a Cochrane review

Virtual reality and interactive video gaming have emerged as new treatment approaches in stroke rehabilitation settings over the last ten years. The primary objective of this review was to determine the effectiveness of virtual reality on upper limb function and activity after stroke. The impact on secondary outcomes including gait, cognitive function and activities of daily living was also assessed. Randomized and quasi-randomized controlled trials comparing virtual reality with an alternative intervention or no intervention were eligible to be included in the review. The authors searched a number of electronic databases including: the Cochrane Stroke Group Trials Register, the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, AMED, CINAHL, PsycINFO, clinical trial registers, reference lists, Dissertation Abstracts and contacted key researchers in the field. Search results were independently examined by two review authors to identify studies meeting the inclusion criteria. A total of 37 randomized or quasi randomized controlled trials with a total of 1019 participants were included in the review. Virtual reality was found to be significantly more effective than conventional therapy in improving upper limb function (standardized mean difference [SMD] 0.28, 95% confidence intervals [CI] 0.08 to 0.49) based on 12 studies and significantly more effective than no therapy in improving upper limber function (SMD 0.44 [95% CI 0.15 to 0.73]) based on nine studies. The use of virtual reality also significantly improved activities of daily living function when compared to more conventional therapy approaches (SMD 0.43 [95% CI 0.18 to 0.69]) based on eight studies. While there are a large number of studies assessing the efficacy of virtual reality they tend to be small and many are at risk of bias. While there is evidence to support the use of virtual reality intervention as part of upper limb training programs, more research is required to determine whether it is beneficial in terms of improving lower limb function and gait and cognitive function.

Six minutes of walking leads to reduced lower limb strength and increased postural sway in people with Multiple Sclerosis

BACKGROUND

Fatigue, lower limb weakness and poor balance can significantly limit safe mobility in people with Multiple Sclerosis (MS). Further research is required to elucidate relationships among these factors.

OBJECTIVE

To investigate the effect of walking-induced fatigue on lower limb strength and postural sway in people with moderately disabling MS.

METHODS

Thirty-four people (26 female) with moderate MS (mean Expanded Disability Status Scale of 3.7 ± 0.7) underwent assessments of acute fatigue, postural sway and lower limb strength before and after six-minute conditions of seated rest and walking. A matched sample of 10 healthy controls also undertook identical assessments before and after a six-minute walk.

RESULTS

Significant time by condition effects for all assessment measures indicated the six-minute walk induced fatigue with associated increases in postural sway and reductions in lower limb strength in people with MS. Increases in sway with eyes closed correlated with increases in acute fatigue and self-reported impact of fatigue on physical and psychological functioning. No changes were observed in healthy controls.

CONCLUSION

People with MS show signs of fatigue after 6 minutes of walking, including strength and balance deficits. These findings have implications for both mobility and fall risk in this group.

Cochrane review: virtual reality for stroke rehabilitation

AIM

Virtual reality and interactive video gaming are innovative therapy approaches in the field of stroke rehabilitation. The primary objective of this review was to determine the effectiveness of virtual reality on motor function after stroke. The impact on secondary outcomes including activities of daily living was also assessed.

METHODS

Randomised and quasi-randomised controlled trials that compared virtual reality with an alternative or no intervention were included in the review. The authors searched the Cochrane Stroke Group Trials Register, the Cochrane Central Register of Controlled Trials, electronic databases, trial registers, reference lists, Dissertation Abstracts, conference proceedings and contacted key researchers and virtual reality manufacturers. Search results were independently examined by two review authors to identify studies meeting the inclusion criteria.

RESULTS

Nineteen studies with a total of 565 participants were included in the review. Variation in intervention approaches and outcome data collected limited the extent to which studies could be compared. Virtual reality was found to be significantly more effective than conventional therapy in improving upper limb function (standardised mean difference, SMD) 0.53, 95% confidence intervals [CI] 0.25 to 0.81)) based on seven studies, and activities of daily living (ADL) function (SMD 0.81, 95% CI 0.39 to 1.22) based on three studies. No statistically significant effects were found for grip strength (based on two studies) or gait speed (based on three studies).

CONCLUSION

Virtual reality appears to be a promising approach however, further studies are required to confirm these findings.

Not just about costs: the role of health economics in facilitating decision making in aged care

This commentary discusses how health economic techniques can usefully be applied to inform clinical and policy decision making in the aged care sector from two perspectives: firstly, in relation to the measurement and valuation of the costs and benefits of new and existing health care technologies and modes of aged care service delivery and secondly, in relation to the facilitation of autonomy and patient choice.

Self-management and peer support among people with arthritis on a hospital joint replacement waiting list: a randomised controlled trial

INTRODUCTION

To evaluate the efficacy of a self-management support program including a 6 week self-management course, individualised phone support and goal setting in osteoarthritis patients on a waiting list for arthroplasty surgery.

METHOD

Randomised controlled trial of 152 public hospital outpatients awaiting hip or knee replacement surgery who were not classified as requiring urgent surgery. Participants were randomised to a self-management program or to usual care. The primary outcome was change in the Health Education Intervention Questionnaire (HeiQ) from randomisation to 6 month follow-up. Quality of life and depressive symptoms were also measured. Changes in pain and function were assessed using the Western Ontario and McMaster Universities (WOMAC) Arthritis Index.

RESULTS

At 6 month follow-up, health-directed behaviour was significantly greater in the intervention [mean 4.29, 95% confidence interval (CI) 3.99-4.58] than the control (mean 3.81, 95% CI 3.52-4.09; P=0.017). There was also a significant effect on skill and technique acquisition for the intervention (mean 4.37, 95% CI 4.19-4.55) in comparison to control (mean 4.11, 95% CI 3.93-4.29; P=0.036). There was no significant effect of the intervention on the remaining HeiQ subscales, WOMAC pain or disability, quality of life or depressive symptoms.

DISCUSSION

The arthritis self-management program improved health-directed behaviours, skill acquisition and stiffness in patients on a joint replacement waiting list, although the observed effects were of modest size (Cohen's d between 0.36 and 0.42). There was no significant effect on pain, function or quality of life in the short term. Self-management programs can assist in maintaining health behaviours (particularly walking) in this patient group. Further research is needed to assess their impact on quality of life and over longer periods.

Stroke rehab down under: can Rupert Murdoch, Crocodile Dundee, and an Aboriginal elder expect the same services and care?

Australia is the world's sixth largest country, has a relatively small population of 21.5 million, and a blended (public and private) health system. In this article, we explain the stroke rehabilitation infrastructure including consumer organisations, research networks, data collection systems, and registries. This represents a complex but fledgling set of organisations showing great promise for coordination of care and research. The article goes on to expose the inequalities in service provision by describing the paths of stroke survivors in three settings - in the city, in the country, and in remote settings. The complexities and difficulties in treating indigenous stroke survivors are described in a culturally sensitive narrative. The article then discusses the outcomes of the first Australian audit of post acute stroke services completed in December 2008, which describes the journeys of 2,119 stroke survivors at 68 rehabilitation units throughout Australia's 6 states and 2 territories. It demonstrates an average length of stay of 26 days, with 18% of survivors requiring nursing home or other supported accommodation. The article concludes with future directions for stroke rehabilitation in Australia, which include hyperacute rehabilitation trials, studies in 7-days-a-week rehabilitation, and the potential use of robotics.

Activities of daily living in children with hemiplegic cerebral palsy: a cross-sectional evaluation using the Assessment of Motor and Process Skills

Upper limb impairment can affect the ability to perform and participate in activities of daily living. The level of activity and participation limitation in the home environment for children with hemiplegic cerebral palsy (CP) is poorly understood. A greater understanding of these limitations could be used to provide targeted and appropriate intervention programmes. Level of activity and participation limitation were investigated, with the use of the Assessment of Motor and Process Skills (AMPS) in a representative sample of 54 South Australian children (31 males, 23 females) with hemiplegic CP, aged 3 to 12 years (mean age 7y 4mo [SD 2y 5mo]). Two AMPS tasks that were familiar to the child were performed in the home under the supervision of a trained occupational therapist. Findings suggested that younger children (3-8y) performed significantly better than older children (9-12y) for motor skill ability (0.46 vs 0.09, p=0.041) but not for process skill ability (-0.25 vs -0.28, p=0.885). Functional performance for the sample was below that of age-matched normative data. Motor performance in activities of daily living as detected by the AMPS seemed to worsen with age in children with hemiplegic CP. Further investigation into what can influence this outcome is required.

Lower limb fracture, cognitive impairment and risk of subsequent malnutrition: a prospective evaluation of dietary energy and protein intake on an orthopaedic ward

OBJECTIVE

To report the dietary energy and protein intake of undernourished older adults (with and without cognitive impairment) admitted to hospital following a lower limb fracture and to determine whether dietary intakes met estimated requirements.

DESIGN

An observational study of a sequential sample.

SETTING

The orthopaedic ward of a South Australian metropolitan teaching hospital.

SUBJECTS

Sixty-eight patients aged > or =70 years screened as undernourished and admitted to hospital following lower limb fracture (50% cognitively impaired) provided 3 to 5 days of dietary data. MAJOR OUTCOME METHODS: Dietary energy and protein intake.

METHODS

Dietary assessment using plate waste methodology and snack record charts commenced within 6 days postinjury and continued for up to five consecutive days or until discharge. Estimated resting energy requirements were calculated and adjusted for activity equivalent to bed rest and physiological stress. Protein requirements were calculated as 1 g/kg/day. Cognition was assessed using the Short Portable Mental Status Questionnaire.

RESULTS

Cognitively impaired participants and those without cognitive impairment consumed, mean (95% CI) respectively, 3661 kJ/day (3201, 4121) versus 4208 kJ/day (3798, 4619) and 38 g (33, 44) versus 47 g (41, 52) protein/day. Cognitively impaired participants consumed mean (95% CI) 48% (43, 53) of estimated total energy expenditure and 78% (69, 87) of estimated protein requirements.

CONCLUSIONS

Orthopaedic fracture patients at greatest nutritional risk, including those with cognitive impairment, do not achieve estimated energy or protein requirements from diet alone. Effective methods of achieving requirements in this vulnerable group are needed before improvements in outcomes will be observed.

Establishment of and first 20 months of operating an outreach geriatric clinic in a regional centre

INTRODUCTION

Providing geriatric assessments to older people residing in rural or remote areas is a challenge due to the complexities of distance and a declining medical workforce. This study aimed to develop a feasible model of service delivery in a rural area, delivering specialised falls and memory clinics similar to those available in the metropolitan area. At the end of the first 20 months we evaluated the service in terms of patient access and the satisfaction of the local health care providers.

METHODS

A meeting was held with key stakeholders to identify existing service provision in the region, and to determine which services were needed. Clinic attendance and information on services provided by the clinic were collected. Questionnaires regarding clinic performance were sent to health-care providers in the region.

RESULTS

The stakeholder meeting identified communication, collaboration and continuing education as the main services required of the clinic. The clinic model included a specialist geriatrician and an extended practice nurse specialising in aged care. Between May 2003 and Dec 2004, 115 people were assessed by the extended practice nurse. Interventions relating to falls and cognition were accessed by clients. Time from referral to seeing a specialist and failure to attend rates were comparable to rates seen in the metropolitan clinics. All heath-care providers who responded to the survey found the service useful.

CONCLUSION

Our clinic model is a possible mechanism for delivering ambulatory aged care services to rural and remote regions. This model of care did not improve access or shorten waiting times for attendees. Future models of specialised rural care need to explore innovative workforce strategies to improve access.

Nutritional status and clinical outcomes of older patients in rehabilitation

BACKGROUND

Malnutrition is associated with poor outcomes in older adults and those admitted to rehabilitation may be particularly at risk. Objective To assess the nutritional status and outcomes of older adults in rehabilitation.

SUBJECTS AND METHODS

We recruited 133 adults > or = 65 years from consecutive rehabilitation admissions. Nutritional status was assessed using the mini nutritional assessment, body mass index (BMI) and corrected arm muscle area (CAMA). Outcomes measured included length of stay, admission to higher level care, function and quality of life (QOL).

RESULTS

Sixty-two (47%) subjects were well nourished, 63 (47%) at risk of malnutrition and eight (6%) malnourished. Twenty-two (17%) and 27 (20%) were below the desirable reference values for BMI and CAMA respectively. Subjects at risk of malnutrition/malnourished had longer length of stay (P = 0.023) and were more likely to be admitted to higher level care (P < 0.05). These subjects also had poorer function on admission (P < 0.001) and 90 days (P = 0.002) and QOL on admission (P < 0.008) and 90 days (P = 0.001). Those with low CAMA were twice as likely to be admitted to higher level care (P < 0.05) and had poorer function at 90 days (P = 0.017).

CONCLUSIONS

Over half our sample was identified as at risk of malnutrition or malnourished and this was associated with poorer clinical outcomes.

The addition of computer simulated noise to investigate radiation dose and image quality in images with spatial correlation of statistical noise: an example application to X-ray CT of the brain

This study validates a method to add spatially correlated statistical noise to an image, applied to transaxial X-ray CT images of the head to simulate exposure reduction by up to 50%. 23 patients undergoing routine head CT had three additional slices acquired for validation purposes, two at the same clinical 420 mAs exposure and one at 300 mAs. Images at the level of the cerebrospinal fluid filled ventricles gave readings of noise from a single image, with subtraction of image pairs to obtain noise readings from non-uniform tissue regions. The spatial correlation of the noise was determined and added to the acquired 420 mAs image to simulate images at 340 mAs, 300 mAs, 260 mAs and 210 mAs. Two radiologists assessed the images, finding little difference between the 300 mAs simulated and acquired images. The presence of periventricular low density lesions (PVLD) was used as an example of the effect of simulated dose reduction on diagnostic accuracy, and visualization of the internal capsule was used as a measure of image quality. Diagnostic accuracy for the diagnosis of PVLD did not fall significantly even down to 210 mAs, though visualization of the internal capsule was poorer at lower exposure. Further work is needed to investigate means of measuring statistical noise without the need for uniform tissue areas, or image pairs. This technique has been shown to allow sufficiently accurate simulation of dose reduction and image quality degradation, even when the statistical noise is spatially correlated.

Does hydrotherapy improve strength and physical function in patients with osteoarthritis--a randomised controlled trial comparing a gym based and a hydrotherapy based strengthening programme

OBJECTIVE

To compare the effects of a hydrotherapy resistance exercise programme with a gym based resistance exercise programme on strength and function in the treatment of osteoarthritis (OA).

DESIGN

Single blind, three arm, randomised controlled trial.

SUBJECTS

105 community living participants aged 50 years and over with clinical OA of the hip or knee.

METHODS

Participants were randomised into one of three groups: hydrotherapy (n = 35), gym (n = 35), or control (n = 35). The two exercising groups had three exercise sessions a week for six weeks. At six weeks an independent physiotherapist unaware of the treatment allocation performed all outcome assessments (muscle strength dynamometry, six minute walk test, WOMAC OA Index, total drugs, SF-12 quality of life, Adelaide Activities Profile, and the Arthritis Self-Efficacy Scale).

RESULTS

In the gym group both left and right quadriceps significantly increased in strength compared with the control group, and right quadriceps strength was also significantly better than in the hydrotherapy group. The hydrotherapy group increased left quadriceps strength only at follow up, and this was significantly different from the control group. The hydrotherapy group was significantly different from the control group for distance walked and the physical component of the SF-12. The gym group was significantly different from the control group for walk speed and self efficacy satisfaction. Compliance rates were similar for both exercise groups, with 84% of hydrotherapy and 75% of gym sessions attended. There were no differences in drug use between groups over the study period.

CONCLUSION

Functional gains were achieved with both exercise programmes compared with the control group.

The effect of treatment on radiological progression in rheumatoid arthritis: a systematic review of randomized placebo-controlled trials

OBJECTIVE

To undertake a systematic review of randomized placebo-controlled trials to assess and rank the efficacy of pharmacological interventions in preventing radiological progression of rheumatoid arthritis.

METHODS

The two outcome measures were the weighted standardized mean difference and the odds of progression of X-ray scores pooled as close to 12 months as possible to minimize heterogeneity.

RESULTS

A total of 38 trials were identified. Of these, 13 were excluded, leaving data on 3907 subjects. Infliximab, cyclosporin, sulphasalazine, leflunomide, methotrexate, parenteral gold, corticosteroids, auranofin and interleukin 1 receptor antagonist were statistically better than placebo in terms of change in erosion scores. All agents were equivalent statistically, with the exception of infliximab (which was superior to the last five agents). There were similar findings for the odds of progression, with the exception of auranofin (P=0.06) and the infliximab-methotrexate comparison (P=0.07). Other agents did not reach statistical significance in either outcome measure. With the exception of the antimalarials, the magnitude of the effect was consistent with the effect seen in short-term disease activity trials.

CONCLUSION

There is published evidence which supports the efficacy of nine agents in decreasing radiological progression in rheumatoid arthritis.

Australian Longitudinal Study of Ageing: prospective evaluation of anthropometric indices in terms of four year mortality in community-living older adults

The Australian Longitudinal Study of Ageing (ALSA) aims to identify factors that contribute to & predict the health & social well-being of older Australians. Analyses were performed to determine the predictive value of anthropometric measurements in older Australians for four-year mortality. Weight, height, skinfolds (triceps, abdominal, supra-spinale, sub-scapular, medial calf, and front thigh) & girth (arm, waist, hip, calf) measurements were performed on a randomly selected community-living sample of 772 men & 624 women aged>70 years. Waist: Hip, % weight loss, corrected-arm-muscle area (CAMA) & BMI were calculated. These measures were categorised into quartiles & also according to commonly adopted definitions of nutritional status. Cox regression analysis was undertaken to assess the predictive value of the independent anthropometric variables for four-year mortality, adjusting for potential confounders (age, gender, marital status, smoking, alcohol status, self-rated health, basic activities of daily living & co-morbidity). Risk of four-year mortality increased with weight loss >10% over two years (HR=2.53, CI=1.37-4.67) & CAMA <21.4cm2(M) & <21.6cm2(F) (HR=1.93, CI=1.03-3.60) independent of confounding variables. These results confirm that selected anthropometric indices (weight loss, CAMA) independently increase the risk of four-year mortality & highlights their potential use in the nutrition screening and assessment of community-living older adults.

Primary care-based physical activity programs: effectiveness in sedentary older patients with osteoarthritis symptoms

OBJECTIVE

This study examined, in a group of older patients, (a) the effectiveness of an invitation to participate in a program providing individualized physical activity advice in a primary care setting and (b) the changes in self-reported physical activity and symptoms in patients with osteoarthritis (OA).

METHODS

Healthy, sedentary community-dwelling men and women aged 60 years or more were invited to participate. Following random allocation, the intervention group received individualized physical activity advice at baseline and at 3, 6, and 12 months followup.

RESULTS

Of the 299 people who satisfied the study's inclusion criteria, a subgroup of 69 people reported pain and stiffness of the hip or knee at baseline. These patients reported increases in frequency and time of walking and vigorous exercise (all P < 0.001), with no change to OA symptom scores (pain and stiffness), and a small decline in physical functioning was reported at 12 months followup in the control group only (P = 0.027). At the 12-month followup more intervention participants than control participants (P = 0.013) reported a greater intention to exercise.

CONCLUSIONS

An offer of primary care-based physical activity advice, with an emphasis on the benefits for general health (rather than "treatment" for OA), will attract individuals with OA symptoms. Although the present study was unable to demonstrate intervention-control group differences for the majority of outcomes, intention to exercise did appear to be positively influenced.

Hip fracture treatments--what happens to patients from residential care?

Hip fractures are a growing problem and new models of care have been called for. However, patients from residential care are rarely considered in these discussions. Hip fracture is a common serious problem for older people in residential care with profound effects on subsequent mobility and quality-of-life. There are no Australian data documenting differences in hospital treatments offered to patients from the community and residential care to inform discussions. In a prospective audit we describe the treatment and 4 month outcomes of patients with fractured hips who were admitted to Flinders Medical Centre in South Australia from the community and residential care between August 1998 and June 1999. Information was collected on prefracture health, types of surgical and rehabilitation treatments and dependency. Of the 215 older adults who were admitted during this time, 183 agreed to participate (119 from community and 64 from residential care). Surgical management of the fracture was not affected by admission accommodation. Those from residential care had short hospital stays, less rehabilitation and access to physiotherapy. Although 61% of those from residential care were classified as independently mobile prefracture, by 4 months this had declined to 32% of survivors. Strategies to improve outcomes in those from residential care include: early identification of those walking independently prefracture with assessment by rehabilitation teams. Inclusion of liaison with community therapists in the clinical pathway and in selected cases use of 'rehabilitation at home' services to provide physiotherapy services should be considered.

Teaching medical students about disability and rehabilitation: methods and student feedback

The predicted increase in the prevalence of chronic and disabling diseases in the population over the next 30 years calls for a more effective approach to educating medical students about the assessment and management of disability. The introduction of a new postgraduate medical course at Flinders University of South Australia in 1996 allowed the development of a new topic on disability and rehabilitation. Over a 4-week period, students undertake four activities. First, they follow a particular patient in an inpatient rehabilitation setting and learn about the multidisciplinary approach to rehabilitation. Secondly, they each visit two people with a disability living in the community and assess their physical, mental, functional and social status. Thirdly, they each visit a service which supports those people in the community. Finally, they simulate having a disability which is randomly allocated to them. During these 4 weeks, students also participate in problem-based learning (PBL) and have 27 h of associated sessions or lectures. The PBL cases and associated sessions have a 'chronic disease' theme. We developed a questionnaire to obtain student feedback on this new topic in the first 2 years of its delivery. A 69% response rate has been obtained. Overall, the topic was well-received, and as a result most students felt more comfortable in dealing with disabled people. They were enthusiastic about ward work, and enjoyed learning about aspects of multidisciplinary team care. Exercises involving simulation of disability were largely acceptable. We believe that this topic helps our students to deal better with the problems of disabled people.

Home rehabilitation for older adults with fractured hips: how many will take part?

Rehabilitation at home is a new 'technology' which has been promoted as an efficient alternative to hospital rehabilitation for older patients with conditions such as fractured hip. In Australia, no formal description of elderly patients with fractured hips likely to be eligible for home rehabilitation has been made and the acceptability of such services is unclear. Using information obtained prospectively from a consecutive sample of 188 patients with a fractured hip we describe the characteristics of older adults who were eligible for a trial examining home versus hospital rehabilitation. While staff assessed 36% of patients as eligible, only 20% were both eligible and agreeable. Reasons for refusal to participate included a preference for inpatient rehabilitation (26%), family reluctance (26%) and anxiety regarding the ability to manage at home (16%). Our results suggest that home rehabilitation is suitable for the least disabled group but is still unacceptable to many elderly patients and their families. As the population ages and hip fractures increase, home rehabilitation in its current form will have little impact on future bed needs.

Interventions for psoriatic arthritis

OBJECTIVES

To assess the effects of salazopyrin, auranofin, etretinate, fumaric acid, IMI gold, azathioprine, and methotrexate, in psoriatic arthritis.

SEARCH STRATEGY

We searched Medline up to 1995, and Excerpta Medica (June 1974-95). Search terms were psoriasis, arthritis, therapy and/or controlled trial. This was supplemented by manually searching bibliographies of previously published reviews, conference proceedings and contacting drug companies. All languages were included in the initial search.

SELECTION CRITERIA

All randomized trials comparing salazopyrin, auranofin, etretinate, fumaric acid, IMI gold, azathioprine, and methotrexate, in psoriatic arthritis. The main outcome measures included individual component variables derived from Outcome Measures in Rheumatology Clinical Trials (OMERACT). These include Acute Phase Reactants, Disability, Pain, Patient Global Assessment, Physician Global Assessment, Swollen joint count, Tender joint count and radiographic changes of joints in any trial of 1 year or longer [Tugwell 1993], and the change in pooled disease index. Only English trials were included in the review.

DATA COLLECTION AND ANALYSIS

Data were independently extracted from the published reports by two of the reviewers. An independent blinded quality assessment was also performed.

MAIN RESULTS

Nineteen randomized trials were identified of which eleven were included in the quantitative analysis with data from 777 subjects. Although all agents were better than placebo, parenteral high dose methotrexate (not included), salazopyrin, azathioprine and etretinate were the agents that achieved statistical significance in a global index of disease activity (although it should be noted that only one component variable was available for azathioprine and only one trial was available for etretinate suggesting some caution is necessary in interpreting these results). Analysis of response in individual disease activity markers was more variable with considerable differences between different medications and responses. In all trials the placebo group improved over baseline (pooled improvement 0.43 DI units, 95% CI 0. 28-0.59). There was insufficient data to examine toxicity.

REVIEWER'S CONCLUSIONS

Parenteral high dose methotrexate and salazopyrin are the only two agents with well demonstrated published efficacy in psoriatic arthritis. The magnitude of the effect seen with azathioprine, etretinate, oral low dose methotrexate and perhaps colchicine suggests that they may be effective but that further multicentre clinical trials are required to establish their efficacy. Furthermore, the magnitude of the improvement observed in the placebo group strongly suggests that uncontrolled trials should not be used to guide management decisions in this condition.

Tradition and culture in Heidegger's Being and Time

In nursing literature, Heideggerian hermeneutics, as expounded in Being and Time, is taken well near unanimously to be an invitation to explore tradition and culture. Understanding, we are told in the name of Heidegger, is to be found in the realm of common meanings and shared practices. This interpretation of what Heidegger is about in Being and Time is neither unchallengeable nor unchallenged. While a number of scholars can be found to agree with it, there are many others who see it as an utter misreading of Heidegger. In their judgement, it is an interpretation diametrically opposed to what Heidegger sets forth in his treatise. For researchers interested in invoking Heidegger or following a Heideggerian approach, this is a frustrating impasse. The only valid starting point for resolving it, this article suggests, is a close reading of what Heidegger actually says in the pages of Being and Time.

Are rheumatoid arthritis patients more willing to accept non-steroidal anti-inflammatory drug treatment risks than osteoarthritis patients?

One hundred and thirty-four patients with either osteoarthritis or rheumatoid arthritis, and with a history of current or past non-steroidal anti-inflammatory drug (NSAID) treatment, were interviewed regarding the benefits, expectations and side-effects of NSAID therapy. Their willingness to accept risks in medical treatment was also evaluated. Both groups experienced positive effects of the NSAID treatment corresponding to their expectations. However, rheumatoid arthritis patients were significantly more willing to accept gastrointestinal side-effects when given an effective NSAID than the osteoarthritis patients, and they were also more willing to take risks in trying a hypothetical new NSAID that had been shown to be effective in clinical trials.

Anti-rheumatic drug-prescribing behaviour of Australasian rheumatologists 1984-1994

The prescribing behaviour of Australian and New Zealand rheumatologists was studied in 1994 using a questionnaire, and the results compared with a similar questionnaire administered in 1984. Perceived differences in efficacy and toxicity for disease-modifying anti-rheumatic drugs (DMARDs) and cytotoxics were reported. Over the decade, methotrexate and sulphasalazine have become the most commonly used anti-rheumatic agents, and methotrexate is clearly seen as the most effective drug. Wide variations in monitoring practices for DMARDs were reported, highlighting the need for cost-effectiveness studies on monitoring. There was low usage of functional outcome measurements in assessing patients.

Psoriatic arthritis: a quantitative overview of therapeutic options. The Psoriatic Arthritis Meta-Analysis Study Group

The objective of this study was to use the technique of meta-analysis to undertake a systematic review of published and unpublished randomized controlled trials of pharmacological agents to determine their relative efficacy and toxicity in the treatment of psoriatic arthritis. The main outcome measure was the change in pooled disease index with component variables derived from OMERACT. Nineteen randomized trials were identified, of which 12 were included in the quantitative analysis with data from 792 subjects. Although all agents were better than placebo, parenteral high-dose methotrexate, salazopyrin, azathioprine and etretinate were the agents that achieved statistical significance (although it should be noted that only one component variable was available for azathioprine and only one trial with a high dropout rate was available for etretinate suggesting some caution is necessary in interpreting these results). In all trials, the placebo group improved over baseline (pooled improvement 0.43 disease index (DI) units, 95% CI 0.28-0.59). There were insufficient data to examine toxicity. In conclusion, parenteral high-dose methotrexate and salazopyrin are the only two agents with well-demonstrated published efficacy in psoriatic arthritis. The magnitude of the effect seen with etretinate, oral low-dose methotrexate, azathioprine and perhaps colchicine suggests that they may be effective, but that further multicentre clinical trials are required to establish their efficacy. Furthermore, the magnitude of the improvement observed in the placebo group strongly suggests that uncontrolled trials should not be used to guide management decisions in this condition.

An international comparison of the estimated effect of the aging of the population on the major cause of disablement, musculoskeletal disorders

OBJECTIVE

To illustrate quantitatively the effect of the aging of the population on the prevalence of chronic disorders by comparing the projected frequency of musculoskeletal (MSK) disorders in 3 comparatively "young" countries, Australia, Canada, and the United States, and 3 comparatively "old" countries, France, the United Kingdom, and Sweden.

METHODS

Age specific rates for MSK disability in Canada were applied to World Bank population estimates and projects to estimate prevalence rates and numbers of persons with MSK disability in the years 1985, 2000, 2010, and 2020.

RESULTS

The age structure of the populations affected baseline rates for MSK disability. Increases in both prevalence and numbers affected are expected for all countries between 1985 and 2020, up to a 34% increase in prevalence in Canada, and an 88% increase in numbers in Australia.

CONCLUSION

The aging of the population is likely to result in a disproportionate increase in the number of people with chronic disabling disorders, which will be taking place against a background of a decreasing or static number of young adults, with implications for meeting needs for health care and community support.

The psychosocial and clinical status of younger women with early rheumatoid arthritis: a longitudinal study with frequent measures

A longitudinal study of 75 young women (median age 43 yr) with early RA was performed with psychological, clinical and functional status measured every 4 months for up to 44 months. The aim was to describe functional changes, and to estimate the association between psychosocial variables and function in the early years after diagnosis. Function was measured by the Stanford Health Assessment Questionnaire (HAQ) and improved on average by about 10% per year with most improvement occurring over the first year. Pain and psychosocial variables also improved over time. There was still a residual improvement in HAQ with time of about 4% per year not accounted for by changes in these measured variables. When examined over time, psychosocial variables were as important as disease and pain in determining function. The results suggest interventions based on the importance of maintaining social relationships could impact on function.

The changing role of the nurse teacher

This paper concludes a series on the findings from a study on the emerging role of nurse teachers in Project 2000 programmes. The various aspects of the study, including the literature review and methodology, have been previously discussed (Crotty & Butterworth 1992, Crotty 1992, Crotty 1993a,b,c,d). This paper highlights the main findings and suggests recommendations regarding the key issues to be addressed in the future role and preparation of the nurse teacher. The study revealed two major changes which are contrary to the expectations of Project 2000. These are firstly, the teaching of academic subjects by nurse teachers, and secondly, the rejection of clinical teaching involving 'hands on care' by nurse teachers.