Frail Elderly Persons Research Articles

Respite care in a geriatric rehabilitation hospital: a support system for caregivers of disabled elderly.

Respite care is one of a wide range of services designed to help maintain the infirm elderly at home by reducing the burden on the caregiver. The availability and results of respite care may alter decisions to institutionalize an elderly relative. Fliman Hospital, a geriatric rehabilitation hospital in Haifa, provides short-term, inpatient care for bedridden frail or disabled elderly persons living in the community with the support of an informal network.

Physicians and Family Caregivers: A Model for Partnership

To the Editor. —The Council Report 1 on primary care physicians and family caregivers addressed two important aspects of the interaction between primary care physicians and caregivers: the detection of stress among caregivers and suggestions made by physicians to reduce stress. However, we were concerned that the proposed recommendations were more theoretical than practical. We offer several pragmatic applications of the model proposed in the report. The stability of the patient-caregiver unit is, indeed, critical to maintaining frail elderly persons in the community. However, the patient-caregiver unit might be difficult to identify. Some caregivers may be identified when they bring the elderly person to the physician's office, 2 but others may be overlooked. Physicians need to ask patients whether they have sole or shared responsibility for aging parents or other relatives, and what that responsibility entails. To evaluate the stability of the patient-caregiver unit, we have developed an instrument (the

Ethical Issues in Emergency Care

The ethical framework established for most health care decision making should apply to elderly patients in the ED, i.e., the authority to decide should rest either with the competent patient or, in case of incapacity, with the patient's surrogate. Whenever possible, ethical dilemmas in the ED should be prevented from occurring through the judicious use of advance directives crafted in the doctor's office. DNR orders should be based upon the wishes of a competent patient or upon a surrogate's estimation of the patient's values and best interests. Because advanced age is a predictor of poor outcome for most hospitalized elderly patients, physicians should educate themselves about the actual benefits and burdens of CPR in this population and share this information with patients and surrogates. In case physicians determine that CPR would be futile in a strict sense, they have no ethical or legal obligation to administer it, even if requested to do so; however, they have an ethical obligation to inform the patient or family of the reasons for the decision and should offer the family the option of dispute mediation in case of disagreement. If the patient arrives in the ED capable of making decisions but lacking an advance directive, it is the responsibility of physicians and nurses to educate the patient concerning the respective merits and drawbacks of the living will and health care proxy. Except for those elderly patients who lack family or friends or who do not wish to burden others with such decisions, the health care proxy, supplemented perhaps to some extent by oral or written specific directives, appears to be the best approach. Attention to these important problems bearing on the substance and procedures for life and death decision making in the ED should not obscure the manifest injustice of the context in which these decisions are often made. At many inner-city hospitals serving a largely poor and elderly clientele, the ED has become nothing short of a torture chamber for many critically ill elderly persons. An ethical framework for decision making, no matter how urgently needed, will not address the unnecessary pain and confusion of frail elderly patients subjected to an impersonal, overcrowded, and depersonalizing environment.

Project Safety Net: a health screening outreach and assessment program.

Although comprehensive geriatric assessment (CGA) has been conducted in many settings, its use in community-based outreach programs has been limited. We have developed Project Safety Net, a program that identifies low-income urban-dwelling frail elderly persons and provides CGA and appropriate referral. The program uses validated screening instruments and makes extensive use of a custom-designed computer program to provide information to the interdisciplinary team and for research purposes. During an 8 month period, 814 older persons were screened including high proportions who were widowed (51%) and who lived alone (66%). The effectiveness of this program remains to be determined in a randomized clinical trial.

Development and validation of a physical performance instrument for the functionally impaired elderly: the Physical Disability Index (PDI).

Article describes development of the Physical Disability Index (PDI), an observer-administered, performance-based instrument measuring physical disability in frail-elderly persons without severe cognitive impairment. Sixty-five items in four subscales encompassing Range of Motion (ROM), Strength (STR), Balance (BAL), and Mobility (MOB) were measured. Subjects were randomly selected frail nursing home residents (N = 103) with a Folstein Mini-Mental State Exam (MMSE) score of > or = 11. Using correlation matrices, cluster analysis, and regression techniques, the scale was reduced to 54 items. All individual item values were standardized and aggregated into subscale and summary PDI scores, each with a range of 0-100. Test-retest and interrater reliability were evaluated. Discriminant and convergent validity were established using MMSE, Physical Self-Maintenance Scale (PSMS), and Sickness Impact Profile-Physical Dimension (SIP-PD). PDI is a performance-based instrument that appears to discriminate among frail individuals with differing levels of physical function. Further testing is warranted in other populations of frail-elderly persons to ascertain its applicability and generalizability.

Historical perspective: the neurotrophic theory of skin ulceration.

Though nearly forgotten, the neurotrophic theory was very much a part of mainstream medical thinking during the mid-nineteenth century. This theory stated that all bodily organs are maintained by special nutritional factors secreted by the central nervous system. Development of skin ulceration in the face of neurologic injury became a model for the theory, and controversy involved two great neurologists of the time, Jean Martin Charcot and Edouard Brown-Séquard. As the neurotrophic theory fell into disfavor, interest in decubitus ulcers waned as well. Today, pressure sores remain a major epidemiologic problem for the growing population of frail elderly persons in both acute and long-term care settings. Because of the increased mortality, morbidity, and cost associated with these lesions, attention needs to be refocused on research and education concerning the decubitus ulcer.

Life-sustaining interventions in frail elderly persons. Talking about choices

Life-sustaining interventions in frail elderly persons. Talking about choices

Life-Sustaining Interventions in Frail Elderly Persons

Engaging older persons in consideration of use of life-sustaining measures, such as cardiopulmonary resuscitation, tube feeding, and urgent intubation, is widely recommended, yet uncommon. We studied the short-term impact of a physician-initiated discussion, geared toward guiding informed decision-making, with 20 frail elderly homebound patients. A battery of psychologic rating scales was administered in a pre-post design. Eighteen subjects completed the protocol. Fifteen of the mentally capable surviving subjects were reinterviewed 18 months following the initial discussion to evaluate durability of their decisions. Most welcomed the discussion and clear choices regarding future care usually emerged. Depression rating scales decreased slightly for the entire sample. For the subgroup having relatively internal locus of control, there was an increase in life satisfaction scores. No patient demonstrated signs of emotional trauma consequent to the discussion. On follow-up, several patients were indecisive about their choices. Involvement of these patients in decision-making appeared to have no adverse effects, and, for some, it was therapeutic, possibly through enhancement of personal control. Durability of their decisions was not a consistent finding, however.

Caregiver burden and nursing home admission of frail elderly persons.

The National Long-Term Care Survey, 1982-1984, and the Informal Caregivers Survey were used to test the importance of caregiver burden for risk of admission to a nursing home. This study was based on a subsample of 940 older persons with sole spouse or adult child caregivers in 1982. Using logistic regression, nursing home entrants (127) were compared to 624 continuous community residents. Characteristics of the older person included age, race (White), and number of instrumental activities of daily living limitations. Predictors related to the caregiving context included caregiver burden and use of formal services.

Randomized Trial of a Health Promotion Program For Frail Elders

AbstractThis study evaluates a local health promotion project that may be widely adaptable to assist frail elderly persons to live longer at home. Subjects, enrolled in New Westminster, B.C., were men and women aged 65 and over living in their own homes but assessed and newly admitted to “personal care at home” by the Long Term Care (LTC) program of the B.C. Ministry of Health. About 90 per cent of eligible clients consented to participate. Randomized to Treatment or Control, they were followed for three years. Controls (n = 86) received standard LTC services, which included screening and pre-admission assessment, arrangement/purchase of needed services and review at three months and at least yearly thereafter. The Treatment group (n = 81) received standard LTC services plus visits from the project nurse who helped each subject to devise a personal health plan based on his or her needs in the areas of health care, substance use, exercise, nutrition, stress management, emotional functioning, social support and participation, housing, finances and transportation. The visits concentrated on setting goals and developing personal health skills, with referral to appropriate community services. An additional group of LTC clients (n = 81) from the adjacent community of Coquitlam was also followed. Success or “survival” was defined as “alive and still assessed for care at home”. After three years the “survival rate” for the Treatment group was 75.3 per cent, compared with 59.3 per cent for the Control group and 58.0 per cent for the Coquitlam group. Standard Kaplan-Meier “survival” graphs show that Treatment subjects were more likely to be alive and living at home at every time point during the three years. Differences between the Treatment and Control groups were statistically significant (p ≤ 0.05) both for simple cross-tabulations of care status at 24 and 36 months and in tests comparing “survival” curves. The results are especially striking because Control subjects received LTC services in a geographic area that offers universal access to health care and community resources and because the Control data were concurrent, not historical.

Ethical Dilemmas in Family Caregiving for the Elderly: Implications for Occupational Therapy

An analysis of 60 ethnographic interviews with family caregivers for frail community-based elderly persons has suggested that ethical dilemmas are an important organizing framework for family caregiving. The present paper explores this conjecture as it relates to the practice of occupational therapy with older clients and their families. Major themes of ethical dilemmas in family caregiving, as derived from the ethnographic data, are described. Verbatim interview data are presented to illustrate the close ties between caregiving activity and the caregiver's ethical convictions. Occupational therapists are encouraged to seek understanding of their clients' ethical beliefs in order to maximize the potential for a therapeutic relationship built on mutual understanding and partnership.

Falls and Injuries in Frail and Vigorous Community Elderly Persons

Identification of different types of falls and fallers among elderly persons might aid in the targeting of preventive efforts. In a representative sample of 336 community elderly, subjects were assigned to Frail, Vigorous, or Transition groups based on observed patterns of clustering among demographic, physical, and psychological variables. The frequency and circumstances of falls in these three groups were then ascertained. As expected, the observed incidence of falling in one year of follow-up was highest in the Frail group (52%) and lowest in the Vigorous group (17%). However, 22% (5/23) of falls by vigorous subjects, but only 6% (5/89) of falls by frail subjects, resulted in a serious injury. Compared with frail subjects, vigorous fallers were somewhat more likely to fall during displacing activity (53% vs 31%), with an environmental hazard present (53% vs 29%), and on stairs (27% vs 6%). These findings suggest that fall-related injuries can be a serious health problem for vigorous as well as frail elderly persons. Injury prevention, therefore, should be directed at all elderly persons but tailored to expected differences in fall circumstances.

The Provision of Housing Related Services for Frail Elderly Persons

Data collected from 355 service providers were analyzed to discover 1) their involvement in providing services which assist elderly persons to remain in current homes, 2) their opinions as to the difficulty of frail elderly persons in obtaining such services, and 3) their attitudes regarding who should provide needed services. Analysis of variance was used to identify significant differences among service providers by type. Findings indicate that current services concentrate on areas that entail minimal costs yet have maximum benefits for providers and clients. To encourage the provision of higher cost services, attention needs to be focused on policies that effectively reduce costs in relation to benefits.

Social Network Characteristics and the Duration of Primary Relationships After Entry Into Long-term Care

This research extends the study of social network analysis into the context of long-term care. Network density, reciprocity, and intensity were hypothesized to explain duration of the ties between frail elderly persons and their networks after they enter a residential care home (RCH), which is a type of long-term care facility. Using longitudinal data from interviews with 81 new, elderly RCH residents and 75 of their closest others, multiple regression analyses showed that the density of frail elderly people's networks has the strongest effect on tie duration. Secondary direct effects were also shown for reciprocity, mental status, being state-financed, White, and having returned home. The intensity of elderly people's ties does not explain tie duration.

The Relationship between Caregiving and Employment

The need for persons to provide care on an informal basis to frail and dependent elderly persons has generated a "caregiving crisis" in this country. Middle age women, the traditional caregivers for most generations, are no longer readily available to provide informal care. Instead, they are likely to be struggling to cope with the dual demands of paid employment and family responsibilities. Significant differences exist between employed and unemployed caregivers in relation to age, marital status, gender, personal health status, and caregiver-care recipient relationships. However, no differences exist in relation to the amount of stress experienced as a consequence of caregiving responsibilities. Occupational health nurses have an ideal opportunity to help employed caregivers cope with their caregiving responsibilities both at the worksite and in their personal lives.

Learning from our Elders: Clinical Pastoral Education in A Geriatric Environment

Observes that the geriatric setting provides many learnings where frail elderly persons may teach a theology rooted in years of experience. Notes a variety of topics which Clincial Pastoral Education students may encounter in a geriatric environment, including issues of finitude, transcendent experiences, and creative coping strategies.

Day Care for Persons with Dementia: The Impact of the Physical Environment on Staff Stress and Quality of Care

This study considers the impact of the physical environment on work-related stress and quality of care in a day care center that integrates demented people and other frail elderly persons. The researcher examined positive and negative differences before and after the program moved to a new, improved facility. Implications for facility design and other program characteristics are discussed.

The Effect of a Support and Education Program on Stress and Burden Among Family Caregivers to Frail Elderly Persons

An eight-week professionally guided caregiver support group program was found to produce statistically significant reductions in anxiety, depression, and sense of burden among family caregivers to frail elderly persons living in the community. Effects were weaker four months after the intervention ended than immediately after, but reductions in anxiety and depression were still evident.

Establishing Interfaces Between Community- and Hospital-Based Service Systems for the Elderly

The gerontological service delivery system often fails to integrate the different types of services needed at different times by older clients. Social workers need to address the urgent and increasing need for communication among acute care hospitals that are diversifying into areas previously the domain of community-based providers of services for the aged. Coordinated care case management programs were developed in seven hospitals to determine whether hospitals could serve as a logical entry point of frail elderly persons into the system. Examination of the experiences of these hospitals illustrated the need for models of service integration and resulted in several approaches to comprehensive service delivery and coordination. Social work professionals in both acute and long-term care settings need to understand all aspects of the service delivery system to ensure that elderly clients receive appropriate levels and continuity of care in a complex and constantly changing system.

Use of psychoactive medication and the quality of care in rest homes. Findings and policy implications of a statewide study.

Rest homes have become a major component of the health care system for frail elderly persons and deinstitutionalized psychiatric patients. Although psychoactive medications are frequently used in rest homes, there is little detailed information about the extent of such use, its supervision, or its effects. In a survey of a random sample of 55 rest homes in Massachusetts, we found that 55 percent of the residents were taking at least one psychoactive medication. Antipsychotic medications were being administered to 39 percent; of these, 18 percent were receiving two or more such drugs. In a follow-up investigation, we studied 837 residents in 44 rest homes with particularly high levels of antipsychotic-drug use. About half the residents had no evidence of participation by a physician in decisions about their mental health during the year of the study. A third of the residents had performance deficits on mental-status testing that indicated serious cognitive impairment, although the causal relation of such impairment to medication use could not be determined. Six percent had evidence of moderate or severe tardive dyskinesia, probably as a side effect of medication. An assessment of staff competence revealed a low level of comprehension of the purpose and side effects of commonly used psychoactive drugs. We conclude that psychoactive drugs are widely used in rest homes, with little medical supervision or understanding by staff members of their possible side effects.