[Can the screening of blood samples identify adverse drug reactions?]. / Kan screening av blodprøver avsløre legemiddelbivirkninger?

BACKGROUND: Analysis of blood samples may identify adverse drug reactions (ADRs) and risk situations. The study objective was to validate a method for in-hospital detection of ADRs based on screening of blood samples. MATERIAL AND METHODS: Routine blood samples from patients in a geriatric ward were screened according to simple decision criteria to identify ADRs. The method was compared to intensive clinical monitoring of ADRs. RESULTS: 61 ADRs were identified in 33 patients; 11 ADRs per 1,000 bed days by the screening method (14 totally) and 37 ADRs per 1,000 bed days by intensive monitoring. The positive predictive value for the screening method was 0.29 (95% CI (0.18-0.43). CONCLUSION: The screening method identified ADRs characterized by pathological laboratory values. The method should be further tested with modified decision criteria when electronic patient records, including electronic drug prescription, become routine practice in the hospital.

Concurrent and predictive validity of "getting up from lying on the floor".

BACKGROUND AND AIMS: Older age, higher morbidity and lower functional capacity are associated with fall injuries. Inability to get up from the floor is associated with older age, higher morbidity and lower functional capacity. The purpose of this study was to assess the concurrent and predictive validity of the ability of elderly women to get up from lying on the floor. METHODS: In a random sample of 307 women aged 75 years and over (mean 80.8 years, response rate 74.5%) living in the community, baseline registrations of ability to get up from lying on the floor, health and function were recorded. Serious fall injuries during the subsequent year served as the outcome. RESULTS: 240 (78.2%) managed to get up independently. The highest independent association was with items primarily related to mobility, e.g., ability to climb steps and performance on the Timed Up & Go test (TUG). However, arthrosis of the hip and difficulty with walking indoors were among the variables independently associated with the ability to get up from lying on the floor. During the follow-up year, 50.5% experienced falls, of which one in four resulted in serious injury and one in eight in a fracture. The ability to get up from lying on the floor was a significant predictor of serious fall-related injury (OR 2.1). Among those who experienced a fall, the risk of injury was markedly higher for those unable to rise (OR 3.7). The positive predictive value of being unable to rise for serious injury was 0.30, indicating that nearly one out of three of the elderly women with such problems are predicted to experience a serious fall-related injury during the following 12 months. CONCLUSIONS: The test "get up from lying on the floor" is a marker of failing health and function in the elderly and a significant predictor of serious fall injuries.

Oral hygiene and oral symptoms among the elderly in long-term care.

Dental teams examined 1910 elderly adults living in long-term care settings (1358 institutionalized, 552 homebound) from all 19 counties in Norway to document oral hygiene, oral symptoms and ability to receive dental treatment. The Mucosal-Plaque Score (MPS) was used to assess oral status. The MPS was significantly better in women than in men, in individuals with dentures than in those with any remaining teeth, and in people who were homebound rather than those who lived in institutions. The MPS did not differ between age groups or geographic regions. According to the Treatment Ability Index, nearly a quarter of the sample was able to receive comprehensive dental care. Reports of "any oral symptom" and "eating/chewing problems" decreased with age and were most prevalent for individuals who had dentures. The MPS had only slight impact on oral symptoms, chewing ability and dry mouth (p > 0.05). Dry mouth was found in 16.9% and was most prevalent in individuals with dentures.

Well-being and instrumental activities of daily living after stroke.

OBJECTIVE: To explore the relationship between subjective well-being and competence in instrumental activities of daily living after stroke. DESIGN: Cross-sectional with evaluation at six months post stroke. SUBJECTS: Eighty-two patients admitted to an acute stroke unit, of whom 64 were seen at six months. The mean age was 77.5 years, 55% were females and 55% were living alone. MAIN OUTCOME MEASURES: The General Health Questionnaire (GHQ-20 version), a well-being scale, was factor analysed and yielded three dimensions, named 'coping', 'anxiety' and 'satisfaction' that served as main outcomes. RESULTS: Explanatory variables were the four subscales of the Nottingham IADL scale, the Ullevaal Aphasia Screening test, urinary continence and demographics. Structural equation modelling showed that the GHQ dimension 'satisfaction' related significantly to the Nottingham subscale 'leisure activities' (beta = -0.38, p = 0.01), whereas 'coping' was indirectly associated with 'leisure activities' by its correlation with 'satisfaction' (R = 0.26, p = 0.01). None of the outcomes were statistically associated with aphasia, continence or the background variables. CONCLUSION: 'Leisure activities' demonstrated the strongest association to subjective well-being as expressed by the 'satisfaction' dimension. In stroke rehabilitation leisure activities should be addressed when assessing function and planning intervention.

Geriatric rehabilitation as an integral part of geriatric medicine in the Nordic countries.

OBJECTIVES: First, to outline the theoretical and practical framework for geriatric rehabilitation in the Nordic countries and second, to survey the scientific medical publications for evidence-based geriatric rehabilitation. METHODS: Brainstorming on geriatric rehabilitation in a working group of Nordic teachers in geriatric medicine. Papers on scientific programmes for geriatric rehabilitation from Internet sources were collected and analyzed. All articles describing randomized studies in geriatric rehabilitation were selected for meta-analyses. The papers were divided into four groups according to diseases, infirmity and resource settings: stroke, hip-fractures, acute admissions and programmes conducted in nursing homes, day hospitals and home services. RESULTS: The literature survey included 30 scientific studies (9496 patients) in randomized trials with valid endpoints. Geriatric rehabilitation programmes for stroke patients in geriatric settings (six papers, 1138 patients) reduced mortality and the need for nursing home placement, but the outcome for ADL function was not significantly changed. Function and length of stay varied between the studies. The outcome of geriatric rehabilitation was even more decisive in the randomized hip-fracture studies (seven articles, 2414 patients): the readmission rate and cost were significantly better. Ten studies were found, comparing the outcome of acute admissions of frail elderly patients (4683) with either geriatric (GEMU, GRU) or general medical wards. The effect of rehabilitation regarding mortality rate at one year, placement in a nursing home, physical function, contentment with services, readmission rate and cost was significant improvement in the geriatric settings. Internal comparisons of geriatric programmes in nursing homes, day hospitals and in-home services (seven studies, 1261 patient) revealed some differences in outcomes regarding function, contentment and costs. CONCLUSION: Specialized geriatric rehabilitation is complicated but effective when properly performed. Interdisciplinary teamwork, targeting of patients, comprehensive assessment and intensive and patient-targeted rehabilitation seem to characterize the most effective programmes. Rehabilitation of frail elderly people poses a major future challenge and has to be developed further for the sake of elderly people's quality of life as well as economic reasons.

Anxiety and well-being in older people after discharge from hospital.

BACKGROUND: A previous study using the State-Trait Anxiety Inventory (STAI) has documented a very high prevalence of anxiety symptoms among older inpatients. The STAI produced two main concepts on factor analysis -'Nervousness' and 'Well-being'- and high scores on both caused the high overall score in these patients. AIM: To investigate how the scorings on the STAI evolve after discharge in older patients in order to understand better the reasons for their high scorings while in hospital. METHODS: Sixty-three patients who had been scored on the STAI during their stay in an elder care department were followed up at 1-3 and 12 months after discharge. Data were analysed by ancova for unbalanced designs. RESULTS: The mean STAI sum score increased significantly (3.5 points adjusted for the baseline scoring, age and gender, P < 0.001) from the first follow-up while in hospital to 1-3 months after discharge, with no significant change between the second and the last follow-up. This increase resulted primarily from a significant worsening of the score on 'well-being'. The score on 'nervousness' remained unchanged. Age did not influence the scores, while females scored higher. No interaction effects were observed, indicating that the evolvement of nervousness and anxiety after discharge is independent of gender and age. Item analysis showed that the worsening of the score on 'well-being' in these patients during the first 1-3 months after discharge was primarily caused by a lower score on the item 'I feel secure'. CONCLUSION: The study does not support the hypothesis that a high level of nervousness and lack of well-being among hospitalized older patients results from acute illness and hospitalization. The worsening in the score on well-being after discharge of such patients is primarily caused by low levels of feelings of security. This represents a challenge to nurses providing home-based care.

Predictors of falls in the elderly by location.

BACKGROUND AND AIMS: In the elderly, balance and walking impairments are assumed to play an important role in causing falls. We have assessed prospectively the predictive ability of health, function and balance variables regarding falls and their location. METHODS: Falls which occurred during one year in a random sample of 307 women aged 75 years and over (mean 80.8 years, response rate 74.5%) living in the community were recorded and related to baseline registrations of health, medication and tests of walking and balance. RESULTS: In all, 155 women (50.5%) reported 308 falls. Outdoor falls were significantly more frequent than indoor falls (57.5 vs 42.5%). The variables having had a fall before the start of the study, osteoporosis, hypertension, feeling depressed, unable to climb 40 cm high steps and walking slowly, all independently predicted a higher number of falls overall. Regarding fall location, having experienced a fall before study start was associated with more falls indoors as well as outdoors. Vision impairment, symptoms of depression, a faster comfortable walking speed, and being able to cope with higher steps were all independent predictors of more outdoor falls also after adjustment for outdoor exposure. A slower comfortable walking speed, a higher amplitude of the center of pressure movements in the frontal plane, a poorer score on the Timed Up & Go test, multimorbidity, poor cognition and hypertension were independent risk factors for indoor falls. Neither number of drugs used nor any specific medication appeared as independent risk factors for falls in this study. CONCLUSIONS: The findings of this study suggest that risk factors for indoor and outdoor falls are different. Location of fall may be an important confounder in studies of predictors of falls in the elderly which should encompass this type of information.

Prevalence of teeth and dentures among elderly in Norway receiving social care.

The aim of this study was to estimate the prevalence of teeth and dentures in individuals aged 67 years and over receiving social care in Norway. A representative sample of 2893 individuals was selected from all 19 counties of Norway. In all, 1910 individuals (1358 living in institutions, 552 living at home) could be interviewed and examined by calibrated local dental teams in 1996-97. Overall response rate was 66%. Out of the examined, 1359 (71%) were women and 551 (29%) were men. The mean age was 85.1 years for women and 82.2 years for men. In all, 19.6% had 'own teeth only', 21.0% 'own teeth and dentures', 54.0% 'dentures only', and 5.3% 'neither teeth nor dentures'. Previous findings in a random sample of elderly Norwegians from three regions with markedly different dental health were confirmed by using polychotomous logistic regression. Three regions of Norway could be identified with respect to the occurrence of teeth and dentures: region A (South-East counties of Norway including the capital Oslo), region B (West-Central counties), and region C (Northern counties). Significant differences existed between them and non-significant differences within them. A mean number of 12.3 teeth were observed in 773 (40.5%) dentate individuals, 13.4 in region A, 11.4 in region B, and 9.0 in region C, respectively. In conclusion, there are large geographical disparities with respect to dental/denture status also in individuals receiving social care in Norway. When the data were collected (1996-97), the oral health goal for the year 2000 suggested by WHO/FDI aiming at 50% of people aged 65 years and above having a minimum of 20 remaining functional teeth was not fulfilled for individuals receiving social care in large parts of Norway.

Emotional well-being of close relatives to stroke survivors.

OBJECTIVE: To compare the well-being of stroke patients' relatives with that of a reference group, and to identify variables related to the well-being of the relatives. DESIGN: Cross-sectional study. SETTING: Outpatient hospital department and patients' and relatives' own homes. SUBJECTS: Fifty-four patients one year after a stroke and their closest relatives. A reference population consisted of 419 elderly people drawn at random from the census files. OUTCOME MEASURES: Emotional well-being was assessed with the General Health Questionnaire (GHQ-20), and the perceived burden attributed to the care of the patient with the Caregiver Strain Index (CSI). The personal and instrumental activities of daily life (PADL and IADL), motor and cognitive functions of the patients were assessed with standardized tests. RESULTS: The relatives rated their well-being lower than the reference group rated theirs, the odds ratio (OR) being 5.6 (95% confidence interval (CI) 3.1-10) adjusted for age and gender. No association was found between the relatives' well-being and the motor, cognitive, PADL, IADL or other characteristics of the patients. Strong relationships were found between the CSI and the GHQ scores of the relatives, the OR (95% CI) for a poor GHQ score being 2.4 (1.6-3.7) for each unit increase in CSI, adjusted for gender. CONCLUSIONS: Emotional well-being is influenced when a close relative gets a stroke. This seems to relate more strongly to the perceived burden of care than to objective characteristics of the patient.

Use of constraints and surveillance in Norwegian wards for the elderly.

OBJECTIVE: To describe the use of constraints and surveillance and their correlates in a nationwide sample of wards in institutions for the elderly in Norway. METHODS: Questionnaires were sent to 975 institutions and returned by 623 (64%) with 1398 wards. The wards' head nurses were asked whether any patient was currently subjected to physical restraints, electronic surveillance, force or pressure in medical examination or treatment, and force or pressure in ADL. The reporting of constraints was found reliable. RESULTS: In all, 79% of the head nurses reported daily or occasional use of constraints in their wards. Most frequently reported were force or pressure in the performing of activities of daily living (reported by 61%, 95% Confidence Intervals (CI) 59-64), use of force or pressure in medical treatment or examination (49%, 95% CI 47-53) and use of physical restraints (38%, 95% CI 36-41). Electronic surveillance was used less frequently (14%, 95% CI 13-16). All classes of constraints, except physical constraints, were used significantly more frequently in special care units for persons with dementia than in ordinary nursing home units. The methodology does not allow conclusions to be drawn regarding the role of ward size and person characteristics. The staffing was unrelated to the use of constraints which varied significantly across the counties. CONCLUSION: Constraints are widely used in Norwegian institutions for the elderly. A different pattern in use of constraints was found between special care units for demented patients and ordinary units in nursing homes.

Geographic differences in tooth loss and denture-wearing among the elderly in Norway.

OBJECTIVES: The purpose of this study was to estimate the prevalence of teeth and dentures in individuals aged 67 years and above. METHODS: A representative random sample of 1152 individuals was drawn from 11 of the 19 counties of Norway. In all, 582 subjects were interviewed and examined clinically by the same dentist (BMH) in 1996-99. Fifty-four had died before contact was established, and the response rate was 53%. The mean age of those examined was 76.4 +/- 5.9 years, range 67-99 years. RESULTS: In all, 40.0% had 'own teeth only', 27.9% 'own teeth and dentures' and 31.6% 'dentures only'. Three participants had neither teeth nor dentures. Interviews with 35 nonparticipants disclosed no statistically significant differences regarding dental/denture status compared to participants. By using stepwise polychotomous logistic regression, three regions of Norway could be identified with respect to the occurrence of teeth and dentures; significant differences existed between them and nonsignificant differences were found within them. In region A (South-East counties including the capital Oslo), region B (West-Central counties), and region C (Northern counties) the prevalence of 'own teeth only', 'own teeth and dentures' and 'dentures only' were 62.0, 26.5 and 11.1% in region A, 27.7, 28.9 and 43.1% in region B and 2.9, 28.6 and 65.7% in region C, respectively. Teeth were observed in 394 individuals, the mean number being 19,15 and 11 in regions A, B and C, respectively (over all mean 17 teeth). CONCLUSIONS: There are large geographical disparities with respect to dental/denture status in Norway. The oral health goals for the year 2000 suggested by WHO/FDI were far from met in large areas of the country at the time when the data were collected, (1996-99).

[Diagnostic imaging techniques in the investigation of dementia]. / Bildediagnostiske metoder ved demensutredning.

BACKGROUND: Neuroimaging can provide valuable information in the diagnostic work-up of patients presenting with suspected dementia. MATERIAL AND METHODS: Based on our experience from a memory clinic at Ullevål University Hospital in Oslo, Norway and on relevant literature identified on Medline, we give an overview of the use of neuroimaging methods in patients with suspected dementia. RESULTS AND INTERPRETATION: CT of the brain should be offered to all patients with suspected dementia as CT can provide essential diagnostic information regarding focal cerebral pathology (tumour, haemorrhage, normal pressure hydrocephalus). A CT scan is of no value in the diagnostic evaluation of patients with mild to moderate Alzheimer's disease as age-related atrophy may be a confounding factor. CT is necessary to reveal infarcts when vascular dementia is suspected, but lacks sensitivity in the detection of diffuse cerebrovascular disease. MRI is recommended in younger patients and may be used to diagnose subcortical lesions, e.g. leukoariosis. The accuracy of SPECT in the assessment of patients with cognitive impairment is not yet established though it seems to be a promising method for the detection of frontotemporal dementia. Functional MR may play a role in the work-up of dementia in the future.

Validity of the aphasia item from the Scandinavian Stroke Scale.

We studied the validity of the aphasia item of a widely used stroke scale - the Scandinavian Stroke Scale (SSS) - in discriminating between aphasia and normal language function in 33 stroke patients of an acute stroke unit. They were assessed by a nurse using the aphasia item from the SSS and by a speech and language therapist carrying out a full evaluation of the language function. The latter served as the 'gold standard'. The agreement between the nurses' and the speech and language therapist's scoring was good (weighted kappa = 0.74, 95% CI 0.51-0.97), and the sensitivity and specificity of the SSS aphasia item were also satisfactory. However, the predictive value of a positive test was as low as 0.55 (95% CI 0.23-0.83), indicating nearly every second of the positives being false positive. Using the aphasia score of the SSS as a diagnostic aid for aphasia after stroke results in a high rate of false positives and inflates the prevalence figures for aphasia in epidemiological studies of stroke.

The psychosocial burden on spouses of the elderly with stroke, dementia and Parkinson's disease.

OBJECTIVE: To characterize the psychosocial burden on spouses living with the elderly suffering from mild dementia, stroke and Parkinson's disease, and to identify patient characteristics associated with it. Materials and methods Data on patient-spouse couples came from three studies of patients with stroke (36 couples), mild dementia (92 couples) and Parkinson's disease (58 couples). The psychosocial burden was recorded by the 15-item Relatives' Stress Scale (RSS). A factor analysis of this instrument produced a one-factor solution (CFI = 0.98) consisting of eight items with good face validity and acceptable reliability within each diagnostic group (Cronbach's alpha range 0.66-0.69). Covariates of this factor were identified using structural equation modeling (SEM) by regression on patient's age, gender, cognitive function (MMSE), activities of daily living (ADL) and depressive symptoms (MADRS). RESULTS: Disorganization of household routines, difficulties with going away for holidays, restrictions on social life, and the disturbances of sleep were the most frequently reported problems in all three groups. According to the mean sumscore on the RSS, the perceived psychosocial burden was similar across the diagnostic groups. In the final SEM model, a lower cognitive function of the patient was associated with a higher psychosocial burden on the spouses of patients with stroke (beta = -1.3, p = 0.01) and Parkinson's disease (beta = -0.89, p < 0.01), while in the dementia group, only an insignificant trend was demonstrated. In the dementia group, a significantly higher burden was identified on female spouses (beta = -0.56, p = 0.04). A heavier burden of care was also associated with depressive symptoms in the patients with Parkinson's disease. In neither group did the final model disclose any effect of ADL function on the spouse's psychosocial burden. CONCLUSION: Spouses caring for patients with dementia, stroke and Parkinson's disease perceive a similar type and level of psychosocial burden, independent of the disease. The cognitive functioning of the patient is a particularly important factor in this, especially when caring for patients with stroke or Parkinson's disease.