The influence of clinical problems, age and social support on outcomes for elderly persons referred to regional aged care assessment teams

BACKGROUND

Aged Care Assessment Teams (ACATs) have been established throughout Australia during the past seven years. Early studies of their effect have concentrated on their impact on the rate of institutionalisation of disabled elderly, the clinical characteristics of referred cases and the relationship between disability and recommended care plan.

AIMS

The aim of this study was to explore the relationship between age, clinical features and social characteristics of ACAT subjects with outcomes at 12 months after assessment.

METHODS

The examination of an arbitrary sample of persons referred to ACATs over a year by one generalist geriatrician with follow-up of all cases by the three ACATs associated with the study was carried out. All analyses were performed on raw data presented as categorical variables in the form of contingency tables.

RESULTS

The sample included 324 subjects who suffered from 2030 clinical problems with a mean of 6.5 per person aged 75 or over and 5.5 for those under 75. Cardiovascular and neurological disease were the commonest source of problems. Study of accommodation outcome at 12 months, for those subjects who survived this period revealed that, in the older group, over 60% of subjects with neurological disease were resident in nursing homes while the majority of all other groups remained in the community, as did two-thirds of those aged under 75. Admission to a nursing home was independent of social support for older subjects with neurological disease, but it played a significant role in those with cardiopulmonary or musculoskeletal disease.

CONCLUSIONS

The study demonstrates that for one-year survivors there is an increased likelihood of admission to a nursing home of people aged 75 or over with neurological disease, while those under 75 were more likely to remain at home. The association was independent of whether spouse, family or friends were living with the subject.

Atrial and ventricular arrhythmias in asymptomatic active elderly subjects: correlation with left atrial size and left ventricular mass

Elderly normal subjects have an increased prevalence of cardiac arrhythmias compared with young and middle-aged subjects. The objective of this study was to test the hypothesis that the incidence and complexity of atrial and ventricular arrhythmias may be related to either left atrial enlargement or to increased left ventricular mass, respectively. From 146 asymptomatic volunteers older than 60 years, 86 subjects were considered to be free of cardiovascular abnormalities and had adequate M-mode echocardiograms and 24-hour ambulatory electrocardiograms. The mean age was 72 +/- 7 years, with a range of 60 to 96 years. There were 37 men and 49 women. During 1415 +/- 73 minutes of ambulatory electrocardiography, the average heart rate was 72 +/- 8 beats/min in men and 76 +/- 6 beats/min in women (p less than 0.05). Atrial arrhythmias were present in 64 subjects (74%); the frequency and complexity of these arrhythmias correlated with left atrial size (p less than 0.01). Ventricular arrhythmias were present in 55 subjects (64%); the frequency and complexity of ventricular arrhythmias did not correlate with left ventricular mass index. These results suggest that left atrial dilatation, a normal development in healthy elderly subjects, plays a significant role in the pathophysiology of the increased incidence of atrial arrhythmias. Increased left ventricular mass, which also occurs normally in the aging heart, is not, on the other hand, associated with an increased frequency and/or complexity of ventricular arrhythmias.

Acute effects of oral pyridostigmine on memory and cognitive function in SDAT

This study reports the effects of the anticholinesterase pyridostigmine on cognitive function in 15 elderly patients with senile dementia of the Alzheimer type (SDAT). Each patient was given placebo and pyridostigime 60 mg orally four times over 26 hours, with a seven day washout between, using a randomized double-blind cross-over design. There was no significant improvement in cognitive function following placebo or pyridostigmine. We did not perform any preliminary dose-finding trials to find the optimum dose of pyridostigmine, but gave the drug in a predetermined fixed dosage to each patient. We conclude that with this dosage, pyridostigmine did not significantly improve cognitive function more than placebo in this group of elderly patients.

Acute effects of exercise on neuropsychological function in elderly subjects

Fit elderly score higher on tests of fluid intelligence than aged-matched sedentary controls. Elderly patients who have taken part in exercise programs have shown improvement in mental function. We compared the effects of 45 minutes of exercise on memory, mood, and cognitive function in elderly subjects to a control intervention using a randomized control study design. Neuropsychological tests employed where the color slide test, digit symbol test, digit span test, logical memory test, word fluency test, and the Mini-Mental State Examination. We measured mood using a mood test and geriatric depression scale. Each subject was tested before, and immediately after, control and exercise sessions. Fifteen elderly subjects [ten men and five women; mean age, 66 years, (range, 60 to 85 years)] completed the study. There was a greater improvement in six of the eight scores of cognitive function following exercise, compared to control. These differences were significantly greater following exercise for the logical memory test score (P less than or equal to 0.02) and Mini-Mental State Examination (P less than or equal to 0.025) compared with the control intervention.

Integrated university training program in geriatric medicine accredited and evaluated by the Royal College of Physicians and Surgeons of Canada

The Federated Council for Internal Medicine recommended in 1981 "increased emphasis on geriatric medicine in the medical school curriculum, the medical residency, and continuing medical education." In the same year the first examination for a Certificate of Special Competence in Geriatric Medicine was held in Canada. This was the culmination of a process begun in 1974 to establish the subject as a subspecialty within Internal Medicine. The Royal College of Physicians and Surgeons of Canada set up a Specialty Committee which developed criteria for the accreditation of training programs. Candidates have to be eligible to sit for the certification examination in Internal Medicine before they can sit for the Certificate of Special Competence in Geriatric Medicine which is awarded only after passing both examinations. Thirty-nine individuals sat for the examination in its first five years of whom 26 were successful. These now form a nucleus of well-qualified internist-geriatricians who are developing academic programs in geriatric medicine in Canadian Medical Schools.

A clinical perspective on aging

Immobility, falls, incontinence, mental confusion and homeostatic disturbances are the major problems encountered in elderly patients. These occur with increasing frequency in the very old (age greater than 85) but studies have shown that the level of disability for those aged 65-84 remains no more than 15-20%. As at all ages, a small proportion of elderly experience most of the clinical problems. To improve our performance in managing these requires education of medical trainees, cooperation between acute and long-term care institutions and a concentrated program of biomedical research. Therapy designed to light up fading receptors or increase neurotransmitter function to maintain cerebral control mechanisms for posture, excretion and appetite control will achieve more than psychosocial or administrative attempts to solve such clinical problems.

A 12-month fever surveillance study in a veterans' long-stay institution

This report describes a 12-month fever surveillance survey in a 258-bed veterans long-term care institution. There were 128 episodes of fever (one episode per 24 patient-months); 114 were studied. Lower respiratory tract infections were most frequent, 36 (32%), with 26 (23%) urinary tract infections. Streptococcus pneumoniae was the most common pathogen in the chest infections and Proteus mirabilis the most common of the urinary tract infections. In 40 (35%) there was no evidence of a lower respiratory tract, urinary tract, or other bacterial infection. Most recovered rapidly, many with no specific treatment. There was a 16% mortality associated with the febrile episodes.

Preliminary observations of a form of coherence therapy for osteoporosis

Five patients suffering from osteoporosis were subjected to from three to eight cycles of a form of Coherence Therapy for Osteoporosis (1) used at this center. Assessment of the patients' trabecular bone remodeling activity as measured by histomorphometric analyses of trans-iliac crest bone biopsies showed a marked improvement.

Marathoners over sixty years of age: results of a survey

A survey of 32 marathon runners over the age of 60 years was undertaken. The group was predominantly male, well educated, and health conscious. While the injury rate was high, it was comparable to the expected rate in younger runners. Six of the 32 claimed to have an addiction to running.

Potassium-sparing diuretics: interaction with digoxin in elderly men

The effects of two potassium-sparing diuretic combination drugs, triamterene-hydrochlorothiazide and spironolactone-hydrochlorothiazide, were compared with those of two kaliuretic diuretics, hydrochlorothiazide and furosemide, in order to ascertain the effects of those diuretics on concentrations of serum digoxin, serum potassium, and erythrocyte potassium, and to determine whether any of these diuretics should be preferred for patients taking digoxin. It was concluded that in patients for whom potassium depletion may lead to digoxin toxicity, a potassium-sparing diuretic may safely be used in order to reduce potassium excretion and thereby reduce the risk of arrhythmias.

Myxedema megacolon after external neck irradiation

Myxedema megacolon is a rare manifestation of hypothyroidism. It may respond to appropriate treatment but is sometimes irreversible, resulting in fatal complications. Two possible mechanisms to explain the colonic atony include (1) myxomatous infiltration of the submucosa with separation of the muscular fibers from the ganglia of Auerbach's plexus, and (2) severe autonomic neuropathy affecting the extrinsic nerves to the colon and the myenteric plexus. Histology from our case supports the first proposed mechanism. Urecholine challenge and manometric measure response may help predict reversibility of colonic atony. Treatment should be individualized and should include factors such as age, duration of symptoms, and other medical illness. Low-dose oral or intravenous triiodothyronine is effective. Hypothyroidism following external radiation of the neck for lymphoma is not uncommon, and the risk increases following one or more lymphangiograms. Such patients should be followed up with regular TSH estimations for at least three years.

Vertebral-basilar insufficiency

Vertebral-basilar ischemia can result in giddiness, transient ischemic attacks, and drop attacks. Management involves controlling blood pressure, getting the patient to stop smoking, controlling diabetes and/or hyperlipidemia, and instituting antiplatelet therapy. Several facets of this problem remain unexplained.

Diuretics and the institutional elderly: a case against routine potassium prescribing

In 14 elderly male residents of a veterans' care complex who were receiving diuretic therapy for cardiac failure, oral potassium (K) supplements were withdrawn. Plasma and erythrocyte K levels were measured immediately before and six weeks after withdrawal of the supplements (38 mEq K daily). The controls comprised 19 elderly residents without disease and not taking drugs likely to influence K status. Study subjects and controls were receiving the same diet (average daily K content 100 mEq). After withdrawal of K supplements, the mean plasma K level fell significantly but the mean erythrocyte K level remained unchanged and did not differ from the control values. For a further six weeks after the withdrawal period, 7 subjects were treated with Aldactazide (diuretic hydrochlorothiazide plus K-sparing spironolactone). The plasma K level increased significantly but the erythrocyte K level remained unchanged. It was concluded that, in this setting, diuretic-induced hypokalemia is not necessarily accompanied by intracellular K depletion and that routine prophylaxis with K supplements or K-sparing agents is unnecessary and not without risk. Such therapy should be reserved for patients considered at special risk of K depletion because of known poor dietary intake, advanced liver disease, secondary hyperaldosteronism with renovascular hypertension, gastrointestinal losses, or nondiuretic medication known to affect K status adversely.

Acute confusional states and dementia in the elderly: the role of dehydration/volume depletion, physical illness and age

A prospective study was undertaken to investigate the incidence and aetiology of acute confusional states in physically ill old people. The subjects were 71 patients aged 70 years or over who were admitted as emergencies to a general medical unit. Mental testing revealed that: (a) one in six patients had an acute confusional state on admission; and (b) one in four patients had evidence of dementia. The presence of dehydration/volume depletion at the time of admission was estimated by various parameters which were brought together to form a new index called the 'dehydration score'. There was a definite statistical association between high degrees of dehydration/volume depletion and poor mental function. Advanced age, on the other hand, appeared to increase the risk of dehydration/volume depletion only slightly. It was also found that a patient's mental score was a much better guide to prognosis than age. The implications of these findings are discussed.

Perspective of health in old age

The elderly are often depicted as a deprived, disabled group of depressed people. A group of 385 elderly subjects drawn at random from those who lived in their own homes in the City of London, Ontario, or in Grey and Bruce Counties in Southwestern Ontario, were studied to assess their degree of disability, consumption of drugs, and need for health care. The method of sampling is described in detail. The proportion of cooperative subjects in the available chosen samples ranged from 80 to 92 percent. The results showed that disability, as assessed by lack of competence in five activities of daily living, ranged from about 6 percent at age 65 to over 35 percent at age 85. Within the previous year, only 15 percent of the subjects had not seen their family physician, and 36 percent had visited the doctor's office three or more times. Those living at home consumed an average of 1.6 drugs per person. In an institutional sample of 100 subjects, 12 percent were fully independent and had no obvious need to be in an institution; their consumption of drugs was more than twice that in the community sample. Old age is not necessarily a disabling period of life. On balance, it can offer more hope and fulfillment than despair.

Pseudohypertension in the elderly

1. Direct intra-arterial blood pressure (radial artery) has been compared with indirect blood pressures using a regular sized adult cuff and a thigh cuff, with a mercury sphygmomanometer, in 24 hypertensive patients aged 62--84 years, and in 16 hypertensive patients aged 29--59 years. 2. The patients were studied because they were suspected of having a false elevation of their indirect blood pressure, since they had diastolic pressures over 100 mmHg, without hypertensive retinopathy, cardiac hypertrophy, or nephropathy. 3. Indirect diastolic pressure was falsely elevated by 30 mmHg or more in 12 out of 24 of the subjects over age 60, and in four of the 16 of those under age 60. Pseudohypertension (indirect diastolic greater than 100 mmHg, direct diastolic greater than 90 mmHg) was present in 12 subjects over age 60 and 5 under age 60. 4. Errors in indirect measurement of blood pressure are a serious problem, particularly in the elderly. Direct intra-arterial measurement may be useful in the management of hypertension.

Alzheimer's disease and HLA

Thrity-four unrelated patients with Alzheimer's disease were typed for HLA-A, -B and -C serological determinants. HLA-Cw3 was increased over control antigen frequencies. This difference lost significance when corrected for the number of antigens tested.

Square pegs in round holes: a study of residents in long-term institutions in London, Ont

A large random sample of people in the long-term institutions (homes for the aged, nursing homes and continuing care hospitals) of London, Ont. was studied to assess the suitability of these people, according to physical and mental status, for the institution in which each resided. The results indicated a relative need for beds in homes for the aged and nursing homes. A high proportion (29% to 54%) of people in the three types of institutions were unsuitably placed. Greater flexibility is needed in institutional arrangements, and institutions should be examined for their potential to provide support in maintaining the elderly at home. The findings of this study add some weight to the arguments of those calling for more and better home care programs for the disabled.

Mean cerebral transit time in demented and normal elderly persons

The mean cerebral transit time (MCTT) was measured in 31 elderly subjects, approximately half of whom suffered from chronic dementing illness. The results indicated a significant correlation between the MCTT and arm-to-head circulation time. Both times increased significantly with age. There was no difference in MCTT between demented and non-demented patients.

Predicting mortality after elective abdominal aortic aneurysmectomy in the elderly

40 non-emergency cases of abdominal aortic aneurysmectomy were reviewed. Of the 20 cases who died during the follow-up period, a significant number had more evidence of pre-existing multiple diseases than had the survivors. The results of the study suggest that there is an association between the amount of coincident disease, length of survival, and mortality following elective abdominal aortic aneurysmectomy.

An immunological approach to dementia in the elderly

A study into the relationship of immune change in the serum and the presence of senile dementia is reported. Three groups were studied, senile dementia, cerebrovascular disease and subjects without evidence of brain disease. All were aged 65 years and over. The immunofluorescent studies showed an excess of antineuronal reactivity and a fall in antinuclear antibody in females with senile dementia. There was no significant difference between the groups in respect of immunoglobulins, slide latex and a complement fixation test, against a variety of tissues. The significance of the findings in relation to other published results is discussed.

Assessment of iron stores in old people

Iron deficiency is the commonest cause of anaemia in the old. Anaemia is a useful indicator of morbidity, occurring much more frequently in individuals referred to hospital. Isolated serum iron estimations are often misleading. A study of 34 cases in whom serum iron, iron-binding capacity and bone marrow were examined showed that the percentage saturation of the binding capacity remains a good method of assessing iron stores.