Foster home characteristics and psychiatric patient outcome. The wisdom of Gheel confirmed.

Even with the emphasis on deinstitutionalization, mental health services are still skewed toward hospital and nursing home care. A relatively untapped resource that is likely to receive more attention is the foster home. We previously demonstrated, in a controlled study of psychiatric patients randomly assigned to foster care or continued hospitalization, that foster care produced better social adjustment within four months. From that study we examine characteristics of foster homes associated with the improvement in social functioning. Improved outcome was related to more children in the homes, fewer boarders, and smaller size. Too much stimulation in the environment, more supervision by foster care sponsors, and more intensive follow-up by social work staff was bad for schizophrenic patients but good for nonschizophrenic patients. Neither the sponsors' tolerance and expectation nor the cost of foster care was related to outcome. The size and composition of homes are important and attention needs to be given to finding an enriched environment that is neither too stimulating nor too sterile for schizophrenic patients.

Hospital vs community (foster) care for psychiatric patients.

The aim of this study was to determine the effectiveness of foster care preparation and placement. Five hundred seventy-two patients from five hospitals were randomly assigned to foster care preparation (experimentals) or continued hospitalization (controls). They were studied before assignment, at placement of experimental subjects, and four months later regarding social functioning, mood, activity, and overall adjustment. Hospitals averaged two months preparing experimental subjects, resulting in 73% placed in foster care. Little change was observed between referral and placement. However, four months after placement, experimental subjects were significantly improved over controls, particularly in social functioning and adjustment. After four months, 88% of the foster care subjects were in the community. Findings suggest that attention should be given to selection criteria, that lengthy preparation may be unnecessary, and that foster care is superior to hospitalization for patients who cannot return to their own homes.

Day treatment and psychotropic drugs in the aftercare of schizophrenic patients. A Veterans Administration cooperative study.

Schizophrenic patients referred for day treatment at the time of discharge from ten hospitals were randomly assigned to receive day treatment plus drugs or to receive drugs alone. They were tested before assignment and at 6, 12, 18, and 24 months on social functioning, symptoms, and attitudes. Community tenure and costs were also measured. The ten day centers were described on process variables every six months for the four years of the study. Some centers were found to be effective in treating chronic schizophrenic patients and others were not. All centers improved the patients' social functioning. Six of the centers were found to significantly delay relapse, reduce sumptoms, and change some attitudes. Costs for patients in these centers were not significantly different from the group receiving only drugs. More professional staff hours, group therapy, and a high patient turnover treatment philosophy were associated with poor-result centers. More occupational therapy and a sustained nonthreatening environment were more characteristic of successful outcome centers.

Nursing home care as an alternative to psychiatric hospitalization. A Veterans Administration cooperative study.

Nursing homes have played a major role in deinstitutionalization, and their increased use for the mentally ill has been questioned. We performed a controlled study of nursing homes as an alternative to continued psychiatric hospitalization. Men (N = 403) referred for nursing home placement from eight Veterans Administration medical centers were randomly assigned to community nursing homes (CNHs), Veterans Administration nursing care units, continued care on the same ward, or transfer to another psychiatric ward. Patients met defined criteria for schizophrenia or organic brain disease. Data were collected before random assignment and six and 12 months later, covering physical and mental function, psychopathology, mood, social adjustment, satisfaction with care, as well as drug use, characteristics of settings, and movement in and out of settings. Significant differences between settings were found in self-care, behavioral deterioration, mental confusion, depression, and satisfaction with care. Results were strikingly consistent, showing the group transferred to another ward doing better and the CNH group doing worse. Drug use did not differ from six months before entering the study or later between the settings. Cost showed a marked advantage for the CNH group. Thus, the less costly community nursing home alternative must be viewed in the context of the nonmonetary costs of less favorable patient outcome.

The importance of self-assessed health in patients with diabetes.

The role of self-assessment of health was compared in 150 diabetic and nondiabetic male outpatients matched for age and race. Data were collected (1) directly from the patient at intake into the study and then again in 2 mo, (2) from the medical record, and (3) from the physician. Variables included background information, symptomatology, satisfaction with care, attitudes, use of medical facilities, medications, diagnoses, compliance and physician's estimate of patient's compliance, current health, and whether improvement was expected. A 2 x 2 factorial design was used to compare diabetic and nondiabetic patients with good and poor perceptions of health. Diabetic patients who viewed their health as poor had significantly more clinic visits, greater symptomatology, and were less satisfied with the doctor-patient relationship. The physician's rating of health did not confirm that this group actually had poorer health than the diabetic patients who perceived their health as good, and there was no difference in number of diagnoses between these groups. Data suggest that self-health perception is an important variable in diabetic patients. For those who see their health as poor, there may be a lack of concordance between patient and physician, which may result from these patients being more negativistic and difficult to treat. This may represent a group for whom a different type of treatment approach is needed.

Relapse of psychiatric patients in foster care.

The authors examined factors related to relapse of psychiatric patients within 1 year of placement in a foster home. They collected data on 210 male patients who had been hospitalized in VA medical centers who were discharged to foster homes in five states. Slightly fewer schizophrenic than nonschizophrenic patients relapsed, but age, length of hospitalization, number of previous hospitalizations, marital status, education, and income did not predict relapse. There was a suggestion that relapsed schizophrenic patients may be characterized before hospital discharge by hyperactivity, undermedication or drug noncompliance, and fewer social skills.

The need to be held: state or trait variable.

The need to be held has been observed to be related to various moods and personality dimensions. It is unclear, however, whether this need functions as a state or trait variable. Data were collected from 85 pregnant subjects at 4 months, 9 months, and 6 weeks postpartum. Measures of the need to be held, neuroticism, relationship with parents, self-concept and maternal attachment were used to determine whether the need to be held is a trait or state variable, as well as to explore the etiology of the need to be held. Data were analyzed by a trend analysis of repeated measures and analysis of variance. Results showed that the need to be held is a trait variable in that it did not change throughout pregnancy and is related to the predisposition of depression. The etiology of the need to be held remains open for investigation.

Cultural and sex differences in dietary patterns of the urban elderly.

A group of 182 elderly subjects (91 females, 91 males; 94 blacks, 88 whites) were interviewed with respect to background data, dietary habits, and health variables. Analysis of variance showed race and sex differences with respect to meal patterns and quality of diet. In addition, correlational analyses revealed associations between quality of diet and social class, education, health status, and the smoking of cigarettes. Associations were strongest for the black subjects.

The rapid disability rating scale-2.

A revised version of the Rapid Disability Rating Scale (RDRS-2) is presented. Item definitions have been sharpened and directions expanded to indicate that ratings are based upon the patient's performance in regard to behavior, and that prosthesis normally used by the patient should be included in the assessment. Three items have been added to increase the breadth of the scale. Response items have been changed from three-point to four-point ratings in order to increase group discrimination amd make the scale more sensitive to changes in treatment. The new appraisals of reliability, factor structure, and validity are reported, along with the potential uses of the scale.

Dietary patterns and cancer of the digestive tract in older patients.

This study involved 97 male veterans (age range, 45-65) in four approximately equal groups, classified as follows: 1) colon or rectal cancer, 2) upper digestive-tract cancers, 3) other cancers, and 4) additional controls (no cancer). Dietary histories of these cancer and noncancer inpatients were recorded to see whether or not consumption of particular substances could be predictive of cancer. The interactions of substances in combination such as sugar x fat, and alcohol x smoking, proved to be important predictors of cancer of the upper digestive tract. The degree of coffee consumption was a predictor of nondigestive-tract cancer. However, colorectal cancer patients could not be distinguished from non-cancer patients by the dietary variables examined.

The relationship of self-help networks to physical and psychosocial functioning.

One hundred fifty-eight elderly persons living in retirement hotels and apartments were classified by being receivers or givers of help to their neighbors into four groups: givers, getters, both (GG), or neither (NGG). The aim was to determine whether the groups differed in personal characteristics, physical functioning, or psychologic adjustment at baseline and six months later. The groups did not differ in personal characteristics. The NGG group (N = 55) functioned significantly less well, both physically and psychosocially. At six months, with baseline scores adjusted, the givers had fewer illnesses and the GG group had better self-esteem. Thus, subjects did not change significantly in other variables. Efforts to enhance the ability of the NGG group to form social networks, if applied cautiously, may help to improve their overall adjustment.

Geriatric sweet tooth. A problem with tricyclics.

Ninety-three consecutive outpatients receiving tricyclic antidepressants for at least one month were asked about medication side effects, including excessive appetite and craving for sweets. Prevalence of these side effects and their relationship (Pearson r) to type of medication, dosage, patient characteristics, diagnoses, weight gain, and clinical improvement were examined. More than one-third (38%) reported excessive appetite, 34% had a craving for sweets, and about one-half (48%) had either one or the other of these reactions. These adverse side effects were related significantly to weight gain (P less than .001) and a higher dose of medication, but not to clinical improvement. Clinical improvement was in the moderate-to-good range but was not related to medication dose. Because increasing degrees of overweight can pose serious health risks, especially for the elderly, it is critical for future research to examine ways of maintaining therapeutic benefit while minimizing food craving side effects. Methods of dealing with these issues clinically are suggested.

Surgical stress in the healthy elderly.

Surgery has sometimes been studied as a stressful event. The aim here was to determine the relationship between degrees of anxiety before surgery and postoperative outcomes in healthy old and young men. Old and young men were selected if they had no illnesses or prior surgery and were scheduled for elective hernia repair. Levels of anxiety were measured preoperatively along with other physiologic, psychologic, and immunologic modalities. Operative data and follow-up data for 30 days were obtained. Old and young men did not differ significantly before surgery. When age groups were divided by preoperative anxiety and their postoperative outcomes compared, more anxiety was associated with more pain-relieving medications and more disability days in each age group. Furthermore, the old anxious had even more disability days and complications than did other groups. The study points to the need to prepare the old, even those essentially in very good health, for even a minor surgical stress in order to improve their overall health outcomes.

Future concerns and recent life events of elderly community residents.

Fifty-eight elderly community residents completed a 37-item inventory that measured their level of concern about potentially stressful events or emotions. Afterwards, they indicated whether selected life events had actually occurred in the last six months. All data were intercorrelated to determine if there were relationships between total scores, personal characteristics, and recent life events. Results showed elderly persons in this sample to be most worried about immediate economic survival and disability. Those in poorer health who had less education, were living with their children, and had less tenure in the neighborhood evidenced greater total concern.

Evaluation of continuing education for long-term care personnel: impact upon attitudes and knowledge.

Nursing assistants (aides) and licensed practical nurses (LPNs) from three proprietary nursing homes participated in a continuing education program designed to enhance knowledge and attitudes about the elderly in long-term care. The program covered six weeks for the initial 115 aides and one full-day seminar for the 83 LPNs. The content covered knowledge and human anatomy, the physiology of normal aging, physical and psychosocial problems of the elderly and, for the nurses, problems associated with cardiovascular accidents. The final participants (29 aides and 52 LPNs) consisted of those who were tested before and after their training with respect to knowledge, life satisfaction, and attitudes toward the elderly. Results indicated overall favorable changes for both aides and LPNs, particularly in the areas of increased knowledge and more positive attitudes. The data suggest that continuing education is an effective means of influencing the knowledge and attitudes of personnel in long-term care facilities, and it should be a first step toward improving the quality of care for elderly residents.

Effectiveness of a Service Workers' Action Team (SWAT) for the elderly.

The Service Workers Action Team (SWAT) is a three-year, community-based demonstration project for the elderly, with the primary goal of improving or maintaining psychosocial and physical functioning. With baseline scores and selected demography data os covariates, 243 experimental SWAT recipients were compared (MANOVA) with 158 controls after six months, with respect to: 1) Hopkin's Symptom Checklist, 2) Social Participation Scale, 3) Life Satisfaction Scale, 4) Self-Esteem Scale, 5) Activities of Daily Living, and 6) four selected health-related questions. The frequency of responses for the experimental elderly were computed for program satisfaction at the time of follow-up. In terms of psychosocial functioning, the experimental group fared significantly better at six months than did the control group. In terms of health, both groups declined in functional status, as evidenced by their scores on Activities of Daily Living, though the experimental subjects still were significantly better than the controls. The majority of the experimental group found the program to be helpful, with suggestions made for program expansion.

New patients versus revolving door patients.

The therapeutic expectation regarding the outcome of drug abusers entering a program for the first time as opposed to patients who have made previous rehabilitation attempts is controversial. Do new patients respond more positively to a therapeutic community than patients with previous treatment experience and is there an interaction between previous treatment/no treatment and heroin/non-heroin drug use? Data were collected from 89 male drug abusers as they entered treatment and also at discharge. Patients entering treatment for the first time were found to be more socially adjusted, but no differences were found between the two groups on attitudes, mood, or symptoms. Non-heroin patients with previous treatment scored significantly lower on the cheerfulness factor of the mood scale. At discharge, no differences were found between previously treated patients and new patients.

Patient symptoms and physician prescribing patterns in the elderly.

The aim was to determine if different doctors prescribed differently for older patients with the same diagnoses as patients who were younger. Five ambulatory-care physicians were selected randomly from a staff of 15. Over age 65 male patients (N = 329) were compared with 889 younger patients in regard to symptoms and medications. Patient-rated symptoms differed by age of patients but not by the five physicians. Comparison of 20 types of medications showed seven differed by patient age but none by physician. Analysis of data in an age x physician grouping, however, showed that certain physicians treated older patients differently in regard to use of digitalis, tranquilizers and pain medications. The findings suggest remarkable similarity in symptoms for older patients seen by different physicians. While use of the medications did not differ between physicians for patients as a total group, they did differ when age of the patient was taken into account. The inconsistent use of certain medications for the old without support of symptoms and diagnoses raises questions about how the old are viewed as a group by some physicians.

The influence of the family on control of diabetes.

The aim of this paper was to determine if the adult diabetic's perception of his family environment influenced control of his diabetes. Diabetic men (N = 97) living with their families completed a 10-factor Family Environment Scale. Family scores at baseline were then used to predict metabolic control 6 months later using stepwise multiple regression analysis. Diabetic control was derived from weighted scales for hemoglobin A1, fasting blood glucose, triglyceride and cholesterol. Three of the family factors were significant statistically. Those patients in better control of their disease perceived their families to be low in conflict and organization and oriented toward achievement. The high achievement environment activates responsibility towards success, which apparently carries into physical management of the disease. Lower conflict among family members as well as less organization creates a more relaxed atmosphere which perhaps encourages flexibility, less anxiety, less pressure and greater support associated with better metabolic control.

Beliefs about causes of cancer in cancer patients.

Beliefs about causes of cancer were studied in 120 patients with late-stage cancer and compared with beliefs of non-cancer patients matched for age, sex, and hospitalization. Cancer patients consistently had less strong beliefs about causes of cancer than did the other groups, even when causes such as smoking and having pulmonary cancer were probably associated with the development of their disease. Although some correlates of beliefs were found in cancer patients' personal and social background, these were generally of minimal levels of statistical significance. Those who had been diagnosed longer believed cancer was more often inherited. The non-cancer patients' beliefs were similar to those found in a large survey of the general population. It is likely that cancer patients need to defend themselves against self-blame as a means of coping with a terminal illness.