Need For Institutional Care Research Articles

Falls and Fall-Related Injuries in Older Dialysis Patients

Dialysis patients are increasingly older and more disabled. In community-dwelling seniors without kidney disease, falls commonly predict hospitalization, the onset of frailty, and the need for institutional care. Effective fall prevention strategies are available. On the basis of retrospective data, it was hypothesized that the fall rates of older (> or =65 yr) chronic outpatient hemodialysis (HD) patients would be higher than published rates for community-dwelling seniors (0.6 to 0.8 falls/patient-year). It also was hypothesized that risk factors for falls in dialysis outpatients would include polypharmacy, dialysis-related hypotension, cognitive impairment, and decreased functional status. Using a prospective cohort study design, HD patients who were > or =65 yr of age at a large academic dialysis unit were recruited. All study participants underwent baseline screening for fall risk factors. Patients were followed prospectively for a minimum of 1 yr. Falls were identified through biweekly patient interviews in the HD unit. A total of 162 patients (mean age 74.7 yr) were recruited; 57% were male. A total of 305 falls occurred in 76 (47%) patients over 190.5 person-years of follow-up (fall-incidence 1.60 falls/person-year). Injuries occurred in 19% of falls; 41 patients had multiple falls. Associated risk factors included age, comorbidity, mean predialysis systolic BP, and a history of falls. In the HD population, the fall risk is higher than in the general community, and fall-related morbidity is high. Better identification of HD patients who are at risk for falls and targeted fall intervention strategies are required.

Stroke Unit : Does it make a difference ? Assessment of the early effectiveness of a Stroke Unit in improving functional state in Dr. Cipto Mangunkusumo Hospital

Abstact Stroke unit has been believed as the best institutional care for stroke patients. Recent researches in 1990s indicated that stroke units can produce increasing survival rate and improving the functional state of the patients which can reduce the need for institutional care after stroke. In Indonesia, stroke unit is still new. Because stroke unit has educational role beside its clinical importance, the research about stroke unit especially in its value in managing stroke patients in Indonesia is needed. This study was evaluated the effectiveness of stroke unit care in managing stroke patients especially in improving the functional state of the patients in compared with conventional care of stroke corner in general neurology ward. This study indicated that both stroke unit (SU) and stroke corner in general neurology ward (SC) shows reduction in NIHSS score. In Stoke Unit, the reduction of NIHSS was 17.35 to 5.31 while in Neurology ward from 13.83 to 8.87.Using independent t-test, the reduction of NIHSS in stroke unit is more significance compared with stroke corner in general neurology ward (p=0,000). (Med J Indones 2006; 15:30-3) Keywords: Stroke Unit, General Neurology Ward, NIHSS

A global clinical measure of fitness and frailty in elderly people

There is no single generally accepted clinical definition of frailty. Previously developed tools to assess frailty that have been shown to be predictive of death or need for entry into an institutional facility have not gained acceptance among practising clinicians. We aimed to develop a tool that would be both predictive and easy to use. We developed the 7-point Clinical Frailty Scale and applied it and other established tools that measure frailty to 2305 elderly patients who participated in the second stage of the Canadian Study of Health and Aging (CSHA). We followed this cohort prospectively; after 5 years, we determined the ability of the Clinical Frailty Scale to predict death or need for institutional care, and correlated the results with those obtained from other established tools. The CSHA Clinical Frailty Scale was highly correlated (r = 0.80) with the Frailty Index. Each 1-category increment of our scale significantly increased the medium-term risks of death (21.2% within about 70 mo, 95% confidence interval [CI] 12.5%-30.6%) and entry into an institution (23.9%, 95% CI 8.8%-41.2%) in multivariable models that adjusted for age, sex and education. Analyses of receiver operating characteristic curves showed that our Clinical Frailty Scale performed better than measures of cognition, function or comorbidity in assessing risk for death (area under the curve 0.77 for 18-month and 0.70 for 70-month mortality). Frailty is a valid and clinically important construct that is recognizable by physicians. Clinical judgments about frailty can yield useful predictive information.

Is stroke unit care portable? A systematic review of the clinical trials

It is not known if mobile stroke teams can achieve the good results seen in trials of geographically discrete stroke wards (stroke units). To establish the effectiveness of mobile stroke teams. Systematic review of controlled clinical trials that compared peripatetic systems of organised stroke care (stroke team care) with alternative hospital services. Systematic review and meta-analysis (using Cochrane Collaboration methodology and involving the primary trialists). Clinical outcomes included death, dependency, the need for institutional care and measures of the process of care such as the delivery of key investigations and treatments. Six clinical trials (1,085 patients) were identified; five (781 patients) compared some form of stroke team care with conventional care in general medical wards and one (304 patients) compared team care with a comprehensive stroke unit. Compared with care in general wards, stroke team care improved some aspects of the process of care, but clinical outcomes were similar. Compared with a comprehensive stroke unit, stroke team patients were significantly less likely to survive (P <0.001), return home (P < 0.001) or regain independence (P < 0.0001). Most aspects of the process of care were also poorer than in the stroke unit. Care from a mobile stroke team had no major impact on death, dependency or the need for institutional care.

Reassessing The Demographic Imperative

For many years gerontologists have discussed the consequences of advances that have lengthened lives but have been less successful at improving the quality of those lives. While this debate continues, the resulting demographic shift in the age profile of the United States threatens to overwhelm our ability to care for those who most need assistance. In the absence of major policy changes or dramatic medical discoveries, or both, the need for institutional care among the population 85 and older will soon exceed the available resources.

Loneliness among older people

Loneliness may be regarded as a ‘geriatric giant’, leading to impaired quality of life, greater need for institutional care and increased mortality. For the past 30 years, a growing number of studies have focused on loneliness. However, the majority of these have been descriptive and cross-sectional. Further longitudinal studies are needed to understand the causal relationship between life-events and loneliness, its prognostic significance and, in particular, whether negative consequences may be alleviated.

A Case for Community and Hospital-Based Long-Term Care Facilities in Saudi Arabia

A Case for Community and Hospital-Based Long-Term Care Facilities in Saudi Arabia

Telecare in practice: a telecare initiative focusing on carers of older people based on Action

There is a continual need to support and assist carers who play a central role in providing informal care for a relative. This approach to care provision must have a strong foundation based on liaison between the family carers, professional carers and the older or disabled person who is the focus of care. Services that enable effective communication using videoconferencing, interactive communication, tailored Web based programs and other specific resources configured for the needs of the individual can help carers carry out their role effectively. The initiative described in this paper uses a combination of telematic focused interventions to meet the needs of carers and provides an in-depth overview of the ACTION telecare project. The ACTION (Assisting Carers using Telematic Interventions to meet Older persons’ Needs) project was set up and funded because of the need to develop supportive methods for carers and older people. The initiative was designed to improve autonomy and maintain independence and quality of life for people in their own homes and therefore reduce the need for institutional care. This has an economic as well as a social dimension. The project has demonstrated that with the involvement of users at all levels it can fulfil this need. The role of the ACTION project was to develop a cost-effective telecare system for the provision of education, information and support and has been demonstrated with successful results.

Musculoskeletal fitness, health outcomes and quality of life.

The health benefits and quality-of-life outcomes of a fit musculoskeletal system (musculoskeletal fitness) are reviewed in this article. The World Health Organization suggests health is a state of complete physical, mental or social well-being and not merely the absence of disease or infirmity. Physical health includes such characteristics as body size and shape, sensory acuity, susceptibility to disease and disorders, body functioning, recuperative ability and the ability to perform certain tasks. One aspect of physical health is the musculoskeletal system, which consists of 3 components; muscular strength, endurance and flexibility. Muscular strength (dynamic) is defined as the maximum force a muscle or muscle group can generate at a specific velocity. Muscular endurance is the ability of a muscle or muscle group to perform repeated contractions against a load for an extended period of time. Flexibility has 2 components, dynamic or static, where dynamic flexibility is the opposition or resistance of a joint to motion, that is, the forces opposing movement rather than the range of movement itself. Static flexibility is the range of motion about ajoint, typically measured as the degree of arc at the end of joint movement. If strength, endurance and flexibility are not maintained, musculoskeletal fitness is then compromised which can significantly impact physical health and well-being. Many health benefits are associated with musculoskeletal fitness, such as reduced coronary risk factors, increased bone mineral density (reduced risk of osteoporosis), increased flexibility, improved glucose tolerance, and greater success in completion of activities of daily living (ADL). With aging, the performance of daily tasks can become a challenge. Additionally, falls, bone fractures and the need for institutional care indicate a musculoskeletal weakness as we age. The earlier in life an individual becomes physically active the greater the increase in positive health benefits; however, becoming physically active at any age will benefit overall health. Improved musculoskeletal fitness (for example, through resistance training combined with stretching) is associated with an enhanced health status. Thus, maintaining musculoskeletal fitness can increase overall quality of life.

What determines the need for nursing home admission in a universally insured population?

People in lower socio-economic groups are more likely to experience disability and cognitive impairments at earlier ages than those in higher status groups. As a result, the need for nursing home care would be expected to be greater among older people of lower socio-economic status. This study examines the effects of income and education on the probability of nursing home entry in a universally insured elderly population. Using a prospective observational study design, a range of predictors of nursing home admission was examined over a three-year period in a representative sample of 7220 residents, aged 60 years or older, in a Canadian province. Individual census records and computerized administrative records of health care utilization were linked to form a database for analysis. An increased risk of institutionalization was associated with older age, male gender, unmarried status and self-reported disability. In addition, lower household income and lower attained education were independently associated with a higher risk of nursing home admission. These results emphasize the independent role of socio-economic status in accentuating or accelerating the need for institutional care towards the end of life. It is important that these effects are recognized in policies that determine the finance of both nursing home care and formal community-based supportive care.

Effects of stroke on medical resource use and costs in acute myocardial infarction. GUSTO I Investigators. Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries Study.

Stroke occurs concurrently with myocardial infarction (MI) in approximately 30 000 US patients each year. This number is expected to rise with the increasing use of thrombolytic therapy for MI. However, no data exist for the economic effect of stroke in the setting of acute MI (AMI). The purpose of this prospective study was to assess the effect of stroke on medical resource use and costs in AMI patients in the United States. Medical resource use and cost data were prospectively collected for 2566 randomly selected US GUSTO I patients (from 23 105 patients) and for the 321 US GUSTO I patients who developed non-bypass surgery-related stroke during the baseline hospitalization. Follow-up was for 1 year. All costs are expressed in 1993 US dollars. During the baseline hospitalization, stroke was associated with a reduction in cardiac procedure rates and an increase in length of stay, despite a hospital mortality rate of 37%. Together with stroke-related procedural costs of $2220 per patient, the baseline medical costs increased by 44% ($29 242 versus $20 301, P<0.0001). Follow-up medical costs were substantially higher for stroke survivors ($22 400 versus $5282, P<0.0001), dominated by the cost of institutional care. The main determinant for institutional care was discharge disability status. The cumulative 1-year medical costs for stroke patients were $15 092 higher than for no-stroke patients. Hemorrhagic stroke patients had a much higher hospital mortality rate than non-hemorrhagic stroke patients (53% versus 15%, P<0.001), which was associated with approximately $7200 lower mean baseline hospitalization cost. At discharge, hemorrhagic stroke patients were more likely to be disabled (68% versus 46%, P=0.002). In this first large prospective economic study of stroke in AMI patients, we found that strokes were associated with a 60% ($15 092) increase in cumulative 1-year medical costs. Baseline hospitalization costs were 44% higher because of longer mean lengths of stay. Stroke type was a key determinant of baseline cost. Follow-up costs were more than quadrupled for stroke survivors because of the need for institutional care. Disability level was the main determinant of institutional care and thus of follow-up costs.

How do stroke units improve patient outcomes? A collaborative systematic review of the randomized trials. Stroke Unit Trialists Collaboration.

We sought to clarify the way in which organized inpatient (stroke unit) care can produce reductions in case fatality and in the need for institutional care after stroke. We performed a secondary analysis of a collaborative systematic review of all randomized trials that compared organized inpatient (stroke unit) care with contemporary conventional care. Nineteen trials were included, of which 18 (3246 patients) could provide outcome data on death, place of residence, and final functional outcome. Data were less complete (but always available for at least 12 trials; 1611 patients) for subgroup analyses examining timing and cause of death and outcomes in patients with different levels of severity of initial stroke. The reduction in case fatality of patients managed in a stroke unit setting developed between 1 and 4 weeks after the index stroke. The reduction in the odds of death was evident across all causes of death and most marked for those deaths considered to be secondary to immobility. However, data were insufficient to permit a firm conclusion. The relative increase in the number of patients discharged home from stroke units as opposed to conventional care was largely attributable to an increase in the number of patients returning home physically independent. Across the range of stroke severity, stroke unit care was associated with nonsignificant increases in the number of patients regaining independence. Within the limitations of the available data, we conclude that organized inpatient stroke unit care probably benefits a wide range of stroke patients in a variety of different ways, ie, reducing death from secondary complications of stroke and reducing the need for institutional care through a reduction in disability.

Institutionalization Following Diabetes-Related Lower Extremity Amputation

PURPOSE: We are unaware of any report in the medical literature that has discussed risk factors for both mortality and discharge disposition following lower extremity amputation (LEA). Our aim was to report risk factors associated with in-hospital mortality and the need for institutional care in diabetics with LEAs. PATIENTS AND METHODS: We abstracted data for every hospitalization for a LEA from January 1 to December 31, 1993 in six metropolitan statistical areas in South Texas. Amputation level was categorized as foot, leg, or thigh. Discharge status categories were: home, nursing home, rehabilitation facility, and death. We used the Kaplan scale of cogent comorbidities to determine the relationship of 12 disease categories and their association with discharge status. RESULTS: There were 1,043 LEAs in South Texas in 1993. Although only 2.3% of the population was admitted from an institutional care facility, over 25% were discharged to one. Of the total population, 18.5% were discharged to a nursing home and 7.0% to a rehabilitation facility, and 5.1% died within the period of hospitalization. We performed a univariate analysis. Factors with a P <0.25 were included in a stepwise logistic regression analysis with an α of 0.05. High level (leg or thigh) amputation, peripheral vascular disease, male gender, and absence of advanced locomotor impairment were associated with discharge to a rehabilitation facility. For discharge to a nursing home, significant associations were found with: female gender, advanced age (>65 years), single marital status, high level amputation, and advanced cerebrovascular disease and locomotor impairment. Death following LEA was strongly associated with female gender, high level amputation, advanced renal disease, anemia, and congestive heart failure. CONCLUSION: A significant number of patients either die or require long-term care following a diabetes-related LEA, thus further adding to the burden of this sequela. Several clinical parameters are significantly associated with discharge status after this procedure. More prospective clinical research is needed to verify the associations and to clarify their application in practice.

Prevalence and severity of cognitive impairment with and without dementia in an elderly population

Not all cognitively impaired people have dementia, but those who do not meet current criteria for dementia have received little study. We report a comprehensive estimate of the prevalence of "cognitive impairment, no dementia" (CIND) in an elderly population. The Canadian Study of Health and Aging gathered population representation information about elderly Canadians aged 65 and over from 36 cities and surrounding areas in five regions. In each region, the sample size was 1800 people in the community and 250 people in institutions. Patients in the community were screened for cognitive impairment by means of the modified mini-mental state examination. Those who scored below the cut-off point (n = 1106) and a randomly selected sample of those who scored above the cut-off point (n = 494) were referred for clinical examination. 59 individuals unable to take the screening test were also assessed clinically. We selected 17 long-term care institutions in each region, and then randomly selected consenting residents of these institutions for clinical assessment (n = 1255). The prevalence of CIND was 16.8%, which was more than all types of dementia combined (8.0%). The prevalence of all types of cognitive impairment, including dementias, increased with age. Patients with CIND were three times more likely to be living in institutions than were cognitively unimpaired patients (odds ratio 3-1 [95% CI 2.4-3.9]). Circumscribed memory loss has a prevalence of 5.3% in the elderly Canadian population, and was the most common category. CIND was related to some degree of functional impairment in elderly patients. CIND is commonly associated with functional disability and a need for institutional care. This diagnostic category includes a costly group of disorders that merit further study.

Collaborative systematic review of the randomised trials of organised inpatient (stroke unit) care after stroke

Objectives: To define the characteristics and determine the effectiveness of organised inpatient (stroke unit) care compared with conventional care in reducing death, dependency, and the requirement for long term institutional...

Psychogeriatric consultation services: effect and effectiveness.

To determine the nature of referrals to a psychogeriatric consultation/outreach service, the types of interventions provided, and the effects and effectiveness of the service. The study used a prospective approach in which 67 consecutive patients referred for psychogeriatric assessment were followed up 6 to 8 weeks after the initial assessment and then again 6 months after initial contact. Patients were rated at the time of referral and at follow-up on presence of psychiatric diagnosis, need for institutional care, and placement outcome. Of the 67 patients initially seen, 51 (76%) experienced memory problems and 46 (69%) had depressed mood. Consistent with this finding, 36 (54%) were diagnosed by consultants as having a dementia, and 15 (22%) received a diagnosis of depression. The most frequent recommendations included medication changes in 34 cases (50%) and further assessments in 37 cases (55%). Although information at 6-week follow-up was available for only 58% (n = 38) of the sample, 18 (46%) patients were generally improved. Interestingly, only 12 (31%) of referring physicians indicated that they had followed the advice of the consultants. Cognitive impairment and depressive symptoms were major concerns among referring physicians. The most common recommendation made involved pharmacotherapy. While compliance of family doctors to recommendations made was poor, patients improved over time. Patients requiring inpatient assessment were very old, living alone, experiencing behavioural problems, and not depressed. Psychogeriatric consultations appear most useful in cases where patients are more severely affected and/or are suffering from a greater range of symptoms.

Determining the appropriate level of care. An analysis of factors affecting the staff's overall needs assessments, using data collected through the ASIM monitoring system.

For the purpose of evaluating the validity of the staff's overall needs assessment in terms of the 'appropriate level of care' as a measurement of resource needs--with particular emphasis on the need for institutional resources--an analysis was made concerning the relation of the assessment to various other factors. In the analysis, we used data collected in a survey undertaken in Solna municipality on November 1, 1991 according to the ASIM monitoring system. It was found by multiple regression analysis, that the 'appropriate level of care' was closely related to the client's degree of disability, age, and actual level of care. On the other hand, variables describing the client's social situation--marital status, single-living, informal social support, standard and accessibility of housing--bore no relation to the assessment of need for institutional care. Chiefly because of the close relation to the actual level of care it was concluded that the staff's overall assessment of 'appropriate level of care' should be used with a degree of caution as measure of the need for institutional resources, since it would tend to overrate that need. A more systematic needs assessment procedure is required in order to provide the municipal authorities with unbiased estimates of institutional resource needs.

Acute cerebral infarction. Optimal management in older patients.

The optimal management of acute cerebral infarction requires consideration of the diagnosis, aetiology, identification of problems, general and specific aspects of care, and prevention of further vascular events. Stroke is a clinical diagnosis but cranial computed tomography (CT) scanning is invaluable to exclude the possibility of cerebral haemorrhage or where the diagnosis is uncertain. Good general care under a specialist multidisciplinary team can reduce mortality and the need for institutional care. Despite promising results from experimental studies, no routine drug therapies have yet shown clinical benefit in acute stroke. Several large trials are currently evaluating anticoagulant, antiplatelet, thrombolytic and neuroprotective agents. Many other proposed therapies have been subject to limited evaluation. Aspirin has a proven role in the prevention of further vascular events after a stroke or transient ischaemic attack. Warfarin, and to a lesser extent aspirin, can prevent recurrent events in patients with nonrheumatic atrial fibrillation. Concerns remain about the safety of warfarin in routine geriatric medical practice. The risk of recurrent stroke in patients with a symptomatic severe carotid artery stenosis is greatly reduced by endarterectomy.

The influence of dementia on the prevalence of urinary and faecal incontinence in 85-year-old men and women

The influence of dementia on the prevalence of urinary and faecal incontinence was investigated in a random sample ( n=485) of the total population of 85-year-olds from the city of Gothenburg, Sweden. The subjects were assessed by a psychiatric interview, physical examinations, computed tomography of the head and analysis of cerebrospinal fluid. Urinary and faecal incontinence were assessed by a urotherapist. Dementia, urinary and faecal incontinence were defined according to strict, internationally accepted criteria. The prevalences of urinary and faecal incontinence, and dementia were 38%, 17% and 29% respectively. Demented men (50%) and women (60%) were more often urinary incontinent than non-demented men (18%) and women (36%). Faecal incontinence was more prevalent in demented (34.8%) than non-demented subjects (6.7%). Both urinary and faecal incontinence were more prevalent in women (43% and 20% respectively) than men (27% and 11%, respectively). The prevalences of urinary and faecal incontinence, and dementia were higher in residents of a nursing home or hospital (74%, 51% and 92%, respectively) than in subjects living at home (32%, 9% and 18%, respectively). Of the demented subjects resident in an institution, 78% were incontinent compared with 37% living at home. Incontinence aids were used by 18% of the men and 33% of the women, and their use increased with increasing severity of dementia. Dementia influenced the prevalence of urinary incontinence, and both conditions independently of each other strongly influenced the need for institutional care.

Between Social Networks and Formal Social Services

ABSTRACTThis article reports a study of the social networks of recent applicants to the social welfare bureaux of Jerusalem. Beyond review of the relevant study variables as reflected in the literature, and an overview of Israeli social services for the aged, the article addresses why the social networks of the elderly claimants turned to formal assistance. The study revealed that networks were most likely to be the source of referral to social services when the applicant was frail, and the presenting problem was the need for institutional care. Multivariate analysis revealed that the degree of network-initiated contact with the social worker was significantly related to these same factors. Networks of the elderly seemed to turn to formal social services as a substitute for their own caregiving, rather than as a source for interweaving informal and formal care. The implications of the findings for social service policy are discussed.