A randomized controlled trial of the effect of an intensive 1-year care management program on measures of health status in independent, community-living old elderly: the Eldercare project.

BACKGROUND: Primary care practitioners are familiar with the frail elderly and commonly have to deal with their multi-morbidity and their functional decline, both physically and mentally. However, there are well elderly with high quality of life and very few co-morbidities who seldom seek medical care. OBJECTIVE: To determine if a nurse-based program of home-delivered care, linked directly with the primary care practitioner or primary care team, would improve quality of life, symptoms, satisfaction with care and utilization of community and medical services, in independent community living old elderly. DESIGN: Randomized controlled trial. SETTING: St. John's, Newfoundland, Canada. PARTICIPANTS: Two hundred and thirty-six independent, community-dwelling, cognitively functioning, people aged 80 years and older. INTERVENTION: A nurse-based program of care, carried out in the patients home, that involved a detailed assessment of needs, the development of a plan to meet the needs, and up to eight visits to the patients home during a 1-year period to facilitate the meeting of those needs. CONTROL GROUP: Usual care MAIN OUTCOME MEASUREMENTS: Quality of Life measured using the SF-36 and the CASP-19 scales; symptomology using the Comorbidity Symptom Scale; patient satisfaction using the PSQ-18; and assessment of health care services (community services, emergency room visits, hospitalizations, use of diagnostic services and family doctor visits) through patient recall, family physician chart review and assessment of hospitalization records. RESULTS: There were no statistical or meaningful differences between the intervention and control groups in any of the outcomes measured. CONCLUSION: The intensive, home-delivered, program of care for the well old elderly did not have an impact on the outcomes measured.

The healthy aged: Descriptive analysis by sex of cognitively functioning elderly patients 80 years and older living independently in the community.

OBJECTIVE: To describe a population of cognitively functioning seniors aged 80 years and older who are livingin dependently in the community. DESIGN: Descriptive cross-sectional study based on the enrolment cohort of a randomized controlled trial. SETTING: St John's, Nfld. PARTICIPANTS: A total of 236 cognitively functioning seniors aged 80 years and older living independently in the community. MAIN OUTCOME MEASURES: Demographic characteristics including age, sex, marital status, and education; health status and quality of life measured by the Short Form-36 and the CASP-19 (control, autonomy, self-realization,and pleasure); use of formal and informal community services;satisfaction with family physician care as measured by the Patient Satisfaction Questionnaire-18; and use of health care resources (family physician visits, emergency department visits,hospitalizations, and laboratory and diagnostic imaging tests). RESULTS: Overall, 66.5% of those in the group were women and the average age was 85.5 years. A quarter had postsecondary diplomas or degrees; 54.7% were widowed (69.4% of women and 25.3% of men). The cohort scored well in terms of health status and quality of life, with a range of scores on the Short Form­36 from 57.5 to 93.5 out of 100, and a score of 44 out of 57 on the CASP-19; they were satisfied with the care received from family physicians, with scores between 3.8 and 4.3 out of 5 on the Patient Satisfaction Questionnaire-18; and use of health services was low-70% had no emergency department visits in the previous year and 80% had not used any laboratory or diagnostic services. CONCLUSION: Seniors aged 80 years and older living in dependently are involved in the social fabric of society. They are generally well educated, slightly more than half are widowed,and two-thirds are female. They score well on scales that measure well-being and quality of life, and they use few health services. They are the healthy aged. TRIAL REGISTRATION NUMBER: NCT00452465 (ClinicalTrials.gov).

Psychiatric disorders presenting in the elderly with type 2 diabetes mellitus.

Diabetes mellitus (DM) is one of the major health problems of the elderly. Developed countries face an epidemic of Type 2 DM. Healthcare providers should be aware of the frequent coexistence of psychiatric conditions in elderly patients with DM. Dementia, depression, and anxiety are commonly seen in addition to other psychiatric conditions. The relationship between diabetes and psychiatric disorders is complex. Evidence suggests that common mechanisms may play a role in both the pathogenesis of DM and several psychiatric illnesses. Possible mechanisms, diagnosis, and management options are reviewed and discussed. Common mechanisms of psychiatric illness involving brain-derived neurotrophic factor, insulin resistance, and inflammatory cytokines are throwing new light that these psychiatric illnesses could be due to the complications of Type 2 DM. Periodic screening should be done in DM patients to identify the psychiatric complications. Healthcare professionals should routinely screen for psychiatric complications of DM in addition to the microvascular and macrovascular complications of DM. It is important to screen all diabetic elderly patients for mental health issues as these may interfere with self-care and the overall management of DM. Recognition and management of psychiatric disorders will help to optimize the diabetes management. Good diabetes control can also reduce the mental health complications in these patients.

Role of vascular factors in osteoporosis.

Osteoporosis is a silent epidemic in the world today. With the increase in the elderly population, there will be an increase in the prevalence of osteoporosis, and so the need for focused preventive strategies should become a public health priority. Prophylactic therapy and risk-factor reduction is important, as this is likely to be cost effective. There are scientific observations that point out that vascular dysfunction seen with aging may be related to the pathogenesis of osteoporosis. Here we review this relationship from a different angle. We think aggressive control of vascular risk factors in addition to the known existing osteoporosis risk factors may help to reduce the morbidity and mortality associated with this disease.

Continuity of care and health decline associated with a hip fracture.

OBJECTIVES: Identify determinants of health decline associated with hip fracture with the goal of designing interventions. METHOD: Prefracture and postfracture information was obtained from participants aged 65-plus years fracturing a hip between July 1996 and August 1997. Health utilization data were linked to the cohort data and to an age-gender matched cohort of nonfracture seniors. RESULTS: Fracture patients were likely to have been hospitalized and have low continuity of care. Patients making frequent physician visits were at increased risk of both prefracture hospitalization and postfracture health decline. Prefracture hospitalization was less likely for patients with high physical function; patients of high mental status were less likely to experience postfracture health decline. DISCUSSION: Health appears to be in decline prefracture. Patients may benefit from continuous physician care to prevent further health deterioration. Some hip fractures can be prevented by identifying high-risk seniors at an early stage and intervening to prevent falls.

Orthostatic hypotension. A primary care primer for assessment and treatment.

Orthostatic hypotension (OH), defined as a decline in blood pressure when a person moves from a supine to sitting or standing position, is a common physical finding in the primary care setting. It is associated with several medical conditions and its prevalence increases with age. Treatment is specific to cause. Drug-induced OH often can be alleviated by reducing dosage or completely changing medications. OH secondary to autonomic insufficiency or neurogenic causes remains a challenge to manage, and a combination of non-pharmacologic and pharmacologic measures are needed. Recommendations are made for preventive measures, patient and caregiver education, and nonpharmacologic and pharmacologic approaches to treatment. Approaches to managing OH in conjunction with hypertension are also discussed.

An investigation of videoconferenced geriatric medicine grand rounds in Alberta.

Geriatric medicine grand rounds (GMGR) from the University of Alberta are videoconferenced weekly to health-care providers at up to 9 urban and 14 rural sites across Alberta. A questionnaire was given to all participants attending 20 consecutive GMGR presentations from January 2002. The response rate was 85% (n = 625) for all participants and 99% (n = 123) for physicians alone. The audience was composed of registered nurses (42%), physicians (17%) and other health-care professionals. 'Interest in topic' was cited by 95% as the main reason for attendance. Doctors and nurses cited continuing medical education as an additional factor. The highest attendance was for the topics vascular dementia, behavioural problems in dementia, the genetics of dementia and falls prevention. Participants at the remote sites gave lower evaluations of quality of the GMGR presentations than those at the hub site. The measurement, care and treatment of dementia appeared to be the main concerns of health-care providers across the province. The videoconferencing of GMGR appears to be an effective method of meeting the demands of physicians and allied health professionals for education in geriatric medicine.

Specialist physicians in geriatrics-report of the canadian geriatrics society physician resource work group.

BACKGROUND: At the 2011 Annual Business Meeting of the Canadian Geriatrics Society (CGS), an ad hoc Work Group was struck to submit a report providing an estimate of the number of physicians and full-time equivalents (FTEs) currently working in the field of geriatrics, an estimate of the number required (if possible), and a clearer understanding of what has to be done to move physician resource planning in geriatrics forward in Canada. METHODS: It was decided to focus on specialist physicians in geriatrics (defined as those who have completed advanced clinical training or have equivalent work experience in geriatrics and who limit a significant portion of their work-related activities to the duties of a consultant). RESULTS: In 2012, there are 230-242 certified specialists in geriatric medicine and approximately 326.15 FTE functional specialists in geriatrics. While this is less than the number required, no precise estimate of present and future need could be provided, as no attempts at a national physician resource plan in geriatrics based on utilization and demand forecasting, needs-based planning, and/or benchmarking have taken place. CONCLUSIONS: This would be an opportune time for the CGS to become more involved in physician resource planning. In addition to this being critical for the future health of our field of practice, there is increasing interest in aligning specialty training with societal needs (n = 216).