Tuberculosis in Somalia.

This is a description of a tuberculosis treatment programme in a country at war where security and the absence of order pose problems to health care delivery. It is also a description of an epidemic of tuberculosis where treatment and diagnosis are difficult and the methods used have changed little in many years. More international pressure is needed.

Health status assessment of the elderly.

The elderly are a heterogeneous population group who range from well and completely independent individuals to a smaller proportion who are frail, require help and are high users of the healthcare system. Since health is a state of well-being which includes the domains of social, spiritual, psychological and physical function, each of these domains must be evaluated when we are measuring the health of older adults. In this article, we discuss some of the more important aspects of these domains. If we focus exclusively on the diseases which occur in older adults we will miss important aspects of their health status. We may miss the interactions of several different disease processes occurring in 1 individual, and the impact of those diseases on the individual's ability to live independently and his or her quality of life. In this article, we not only justify the measurement of function, cognition, affect and quality of life in the elderly but we also describe the necessary measurement qualities of instruments used to measure health-related quality of life in the elderly. We provide some examples of measurement approaches with which we as researchers and health workers are familiar.

Measuring quality of life in the frail elderly.

This study was carried out to develop and test the Geriatric Quality of Life Questionnaire (GQLQ), a health-related qualify of life (HRQL) questionnaire designed for the frail elderly. One hundred patients were asked to identify areas of their daily lives affected by their health. The GQLQ, developed on the basis of the results, the Rand Physical and Emotional Function Questionnaires, and the Barthel Index, were administered serially to a group of 76 patients participating in a randomized trial of a Geriatric Day Hospital. Participants in all phases of the study were over 65 years of age, living in their own home but with sufficient functional status impairment to compromise their ability to live independently. The GQLQ includes 25 questions focusing on activities of daily living (ADL), symptoms, and emotional function. In the ADL and Symptom domains respondents define personal problem areas. The responsiveness coefficients of the GQLQ ADL and Symptom domains (0.26 and 0.30 respectively) were similar to those of the Rand Physical Function instrument and the Barthel Index (0.29 and 0.20). The responsiveness coefficient of the GQLQ Emotional Function domain (0.50) was similar to that of the Rand Emotional Function instrument (0.63). Correlations between the GQLQ ADL domain and the Barthel Index (0.41), and between GQLQ and the Rand Physical Function instrument (0.30), were similar to the correlation between the Barthel Index and Rand Physical Function (0.40). While the GQLQ captures important areas of health-related quality of life impairment for the frail elderly, we failed to show any advantages in either responsiveness or validity to existing, simpler measures. New, specific instruments should be tested in head-to-head comparisons with existing measures, particularly generic instruments, before dissemination.

Effectiveness of a geriatric day hospital.

OBJECTIVE: To determine whether there is a difference in the quality of life between elderly patients managed in a day hospital and those receiving conventional care. DESIGN: Randomized controlled trial; assessment upon entry to study and at 3, 6 and 12 months afterward. SETTING: Geriatrician referral-based secondary care. PATIENTS: A total of 113 consecutively referred elderly patients with deteriorating functional status believed to have rehabilitation potential; 55 were assessed and treated by an interdisciplinary team in a day hospital (treatment group), and 58 were assessed in an inpatient unit or an outpatient clinic or were discharged early with appropriate community services (control group). OUTCOME MEASURES: Barthel Index, Rand Questionnaire, Global Health Question and Geriatric Quality of Life Questionnaire (GQLQ). MAIN RESULTS: Eight study subjects and four control subjects died; the difference was insignificant. Functional status deteriorated over time in the two groups; although the difference was not significant there was less deterioration in the control group. The GQLQ scores indicated no significant difference between the two groups in the ability to perform daily living activities and in the alleviation of symptoms over time but did show a trend favouring the control group. The GQLQ scores did indicate a significant difference in favour of the control group in the effect of treatment on emotions (p = 0.009). CONCLUSION: The care received at the day hospital did not improve functional status or quality of life of elderly patients as compared with the otherwise excellent geriatric outpatient care.

Iron deficiency anemia in the elderly: the diagnostic process.

OBJECTIVE: To determine the effectiveness of physician probability estimates calculated on the basis of findings from history-taking and physical examination in the diagnosis of iron deficiency anemia in elderly patients. DESIGN: Prospective study. SETTING: Two community hospitals offering secondary and tertiary care. PATIENTS: A total of 259 patients over 65 years of age found to have previously undiagnosed anemia. MEASURES: Physician estimates of the likelihood of iron deficiency before (pretest probability) and after (post-test probability) the laboratory test results were available. The hemogram was available to the physicians when they made their pretest probability estimates. Because the serum ferritin level proved to be the most powerful of the laboratory test results studied, the likelihood ratios associated with the post-test estimates were compared with the ratios associated with the serum ferritin level. MAIN RESULTS: The post-test probability estimates were influenced by the serum ferritin level and the pretest estimates. The post-test estimates derived from the findings obtained through history-taking and physical examination and the laboratory test results (including the serum ferritin level) were slightly less accurate in predicting iron deficiency than the serum ferritin level alone. Nevertheless, a model in which the pretest estimates were used in addition to the serum ferritin level to predict iron deficiency proved to be more powerful than the serum ferritin level alone (p = 0.006). This indicated that the limitations of the post-test estimates were due to a misinterpretation of the serum ferritin level and that the findings from history-taking and physical examination added important diagnostic information. CONCLUSIONS: Physicians must be aware of test properties to provide optimal care to their patients. If test results are properly interpreted, pretest probabilities derived from findings obtained through history-taking and physical examination can add useful information that will lead to more accurate diagnoses.

Diagnosis of iron-deficiency anemia in the elderly.

PURPOSE: To determine the value of serum ferritin, mean cell volume, transferrin saturation, and free erythrocyte protoporphyrin in the diagnosis of iron-deficiency anemia in the elderly. PATIENTS AND METHODS: We prospectively studied consecutive eligible and consenting anemic patients over the age of 65 years, who underwent blood tests and bone marrow aspiration. The study consisted of 259 inpatients and outpatients at two community hospitals in whom a complete blood count processed by the hospital laboratory demonstrated previously undiagnosed anemia (men: hemoglobin level less than 12 g/dL; women: hemoglobin level less than 11.0 g/dL). RESULTS: Thirty-six percent of our patients had no demonstrable marrow iron and were classified as being iron-deficient. The serum ferritin was the best test for distinguishing those with iron deficiency from those who were not iron-deficient. No other test added clinically important information. The likelihood ratios associated with the serum ferritin level were as follows: greater than 100 micrograms/L, 0.13; greater than 45 micrograms/L but less than or equal to 100 micrograms/L, 0.46; greater than 18 micrograms/L but less than or equal to 45 micrograms/L, 3.12; and less than or equal to 18 micrograms/L, 41.47. These results indicate that values up to 45 micrograms/L increase the likelihood of iron deficiency, whereas values over 45 micrograms/L decrease the likelihood of iron deficiency. Seventy-two percent of those who were not iron-deficient had serum ferritin values greater than 100 micrograms/L, and in populations with a prevalence of iron deficiency of less than 40%, values of greater than 100 micrograms/L reduce the probability of iron deficiency to under 10%. Fifty-five percent of the iron-deficient patients had serum ferritin values of less than 18 micrograms/L, and in populations with a prevalence of iron deficiency of greater than 20%, values of less than 18 micrograms/L increase the probability of iron deficiency to over 95%.

Urinary incontinence: current overview of a prevalent problem.

Urinary incontinence is a prevalent problem affecting elders of both sexes in community and institutional settings. Much of this problem is reversible. Detailed history, physical, and a residual urine test can provide sufficient information to begin treatment. There are three main types of incontinence: (1) stress, which may be alleviated by strengthening the pelvic floor muscles or by surgical intervention; (2) overflow; and (3) urge. These different types may co-exist. If the initial treatment is ineffective, it is recommended that referral be made for expert evaluation and urodynamic investigation.

Concordance of occupational and environmental exposure information elicited from patients with Alzheimer's disease and surrogate respondents.

Identification of risk factors for Alzheimer's disease through the use of well designed case-control studies has been described as a research priority. Increasing recognition of the neurotoxic potential of many industrial chemicals such as organic solvents raises the question of the occupational and environmental contribution to the etiology of this high-priority health problem. The intention of this study was to develop and evaluate a methodology that could be used in a large scale case-control study of the occupational and environmental risk factors for dementia or a population-based surveillance system for neurotoxic disorders. The specific objectives of this study were to investigate: 1) the reliability of exposure-eliciting, interviewer-administered questionnaires given to patients with Alzheimer's disease (SDAT); 2) the reliability of exposure-eliciting interviewer-administered questionnaires given to the family of patients with SDAT and the agreement with the responses of the patient or surrogate respondents; 3) the reliability and agreement of responses of age- and sex-matched control patients and their families selected from geriatric care institutions and the community, with respect to the same exposure-eliciting and interviewer-administered questionnaire; and 4) the reliability of agent-based exposure ascertainment by a single, trained rater. The results of the study demonstrate that occupational and environmental histories from which exposure information can be derived is most reliably elicited from job descriptions of cases and control subjects rather than job titles alone or detailed probes for potential neurotoxic exposures. This will necessitate the use of standardized interviewer-administered instruments to derive this information in case-control studies of Alzheimer's disease or population-based surveillance systems for occupational and environmental neurotoxicity.

Are geriatric units needed for elderly patients with hip fractures?

To assess the need for a multidisciplinary geriatric unit in the treatment of elderly patients with hip fractures, we reviewed the charts of all patients aged 60 years or older who were treated for hip fractures in five hospitals in Hamilton, Ont., between August 1982 and September 1983. We hypothesized that discharge to a different location from that before admission would indicate reduced functional status and classified the reasons for a change in residence as poor patient motivation, need for rehabilitation, compromised ambulation, postoperative complications and inevitable deterioration. We believed that geriatric care would be most beneficial to those in the first three groups. Of the 327 patients with hip fractures 40 (12%) died before discharge. Of the 287 surviving patients 149 (52%) had been discharged by 4 weeks, and only 29 (10%) remained in hospital by 12 weeks. Of the 287, 44 (15%) were discharged to a different location from that before admission: in 75% the cause appeared to be inevitable deterioration (57%) or postoperative complications (18%). The remaining 25% needed rehabilitation and were all sent to appropriate facilities. None of the patients with ambulation problems or poor motivation required an increased level of care. We could not show a need for geriatric care in our population; possible explanations are discussed.

Assessment of iron stores in anemic geriatric patients.

Of patients referred to a geriatric service, 66 were identified who were clearly anemic (hemoglobin less than 12 g in men, less than 11 g in women) but whose cause of anemia was not readily identifiable by noninvasive measures. The difficulty in distinguishing iron deficiency from chronic disease as a cause of anemia by noninvasive means (serum iron, total iron binding capacity, transferrin saturation ratio, and serum ferritin), is highlighted by the poor power of these investigations when compared with bone marrow iron stores. A transferrin saturation ratio of less than 11% and a serum ferritin of less than 45 pg/L serve better than currently accepted values to identify iron deficiency in this population.