Survival rate and pressure ulcer prevalence in patients with and without dementia: a retrospective study.

OBJECTIVE: This retrospective study aimed to investigate the prevalence of pressure ulcers (PUs) in older patients with advanced dementia versus older patients without dementia but with other comorbidities, such as diabetes, ischaemic heart disease and chronic renal failure. PUs were thought to be more prevalent and to present a higher risk of mortality in patients with dementia. METHOD: PUs were assessed on admission using the European Pressure Ulcer Advisory Panel (EPUAP) staging system. Patients were classified as either with or without dementia according to Reisberg's functional assessment staging test (FAST). The prevalence of PUs and the survival rates were analysed and compared in both groups. The combined effect of PUs and dementia on survival was assessed using the Cox proportional hazard model. RESULTS: The median survival rate of patients with PUs and dementia was 63 days, significantly lower than in patients with PUs without dementia 117 days. Both groups had similar other comorbidities. CONCLUSION: These findings underscore the requirement for geriatricians and health professionals to be more vigilant in examining PUs as dementia progresses.

Setting up a dedicated pressure ulcer unit in a geriatric ward.

A geriatric hospital in Israel set up a unit for older patients with pressure ulcers who had other serious, sometimes terminal, conditions. A one-year follow-up study showed overall improvements in their condition and number of ulcers.

[Pressure sores unit--a one year study].

The phenomenon of pressure sores in the elderly patient often requires an alternative management policy to that of the standard treatment. In general, the therapeutic approach to pressure sores in the elderly should be different to that in younger patients. This modification is due to the accompanying comorbidity so often associated with aging. Due to accompanying illnesses, the aging population is at high risk and more predisposed to the development of pressure sores. The importance of the establishment of a unit for pressure sores arises from the specific geriatric team approach to the patient and the need to focus carefully on the pressure sores. The management of this special Pressure Sores Unit with a permanent capable staff requires skilled treatment, both localized and systemic, since pressure sores are very often a result of systemic failure or an indication of a terminal condition in the elderly patient. Over six months we followed-up on the number and location of the pressure sores in 47 patients in addition to other functional and nutritional parameters, in order to investigate any connection between the pressure sores and nutritional parameters. The results of the study indicate that the nutritional state of the patients admitted for pressure sores was very poor. Two thirds of the patients suffered from either dementia or stroke, and 90 percent were bedridden, incontinent and enterally fed. Despite the poor general condition of the patient, the study shows improvement in the pressure sores with a reduction from an average of 2.8 to 1.8 pressure sores per patient. The improvement in the pressure sore located on the legs was three times greater than those located in the pelvic area. By the end of the study, 50% of the patients had died, 33% of the original patients who were still in the unit showed improvement in the pressure sores and 15% were discharged showing complete recovery from the sores. No significant correlation was found between changes in the pressure sores and the parameters relating to nutritional status (albumin, cholesterol, body weight and total lymphocyte count) except for the level of hemoglobin. Since there was no control group, the results of the study, naturally, did not show any advantage in treatment of pressure sores in a specific unit as opposed to such treatment in a general ward. Nevertheless, the need for a Pressure Sores Unit is justified and important. It is possible that the patients observed in this study arrived for treatment in the unit at very late, irreversible and terminal stages. The presence of a Pressure Sores Unit would heighten awareness and early referral of these patients.

A prospective comparison of the use of nasogastric and percutaneous endoscopic gastrostomy tubes for long-term enteral feeding in older people.

OBJECTIVE: To compare the indications for and the outcome of long-term enteral feeding by nasogastric tube (NGT) with that of percutaneous endoscopic gastrostomy (PEG) tube. DESIGN: A prospective, multicenter cohort study. SETTING: Acute geriatric units and long-term care (LTC) hospitals in Jerusalem, Israel. PARTICIPANTS: 122 chronic patients aged 65 years and older for whom long-term enteral feeding was indicated as determined by the treating physician. Patients with acute medical conditions at the time of tube placement were excluded. MEASUREMENTS: We examined the indications for enteral feeding, nutritional status, outcome and complications in all subjects. Subjects were followed for a minimum period of six months. RESULTS: Although the PEG patients were older and had a higher incidence of dementia, there was an improved survival in those patients with PEG as compared to NGT (hazard ratio (HR)=0.41; 95% confidence interval (CI) 0.22-0.76; P=0.01). Also, the patients with PEG had a lower rate of aspiration (HR=0.48; 95% CI 0.26-0.89) and self-extubation (HR=0.17; 95% CI 0.05-0.58) than those with NGT. Apart from a significant improvement in the serum albumin level at the 4-week follow-up assessment in the patients with PEG compared to those with NGT (adjusted mean 3.35 compared to 3.08; F=4.982), nutritional status was otherwise similar in both groups. CONCLUSION: In long-term enteral feeding, in a selected group of non-acute patients, the use of PEG was associated with improved survival, was better tolerated by the patient and was associated with a lower incidence of aspiration. A randomized controlled study is needed to determine whether PEG is truly superior to NGT.

Association between high concentration of antibodies to insulin and some diseases common in the elderly.

Antibodies to insulin (IA) were measured by graded hemagglutination in 164 patients and in 90 control subjects aged 18-65 years. The greatest prevalence of these antibodies was found in patients with the organic mental syndrome, of whom 70% (n = 110) had an antibody concentration above the normal 95th percentile. Among patients with diabetes, hypertension and cerebrovascular accidents, 42% had a high concentration of IA, while in all other geriatric patients (n = 21) the concentration of these antibodies was within the normal range.

[Locating and monitoring of the elderly by family physicians].

A program to locate and monitor the elderly population registered at the East Talpiot Clinic in Jerusalem was set up. 93% of the 372 registered elderly were located, of whom 6.2% were not previously known to their assigned family physician at the clinic. The program established risk groups based on medical, social and psychological factors. These factors were elevated blood pressure, diabetes, psychiatric illness, tumors, confinement to home, isolation and recent bereavement. 68% of the elderly fell into at least one of these risk groups. There was positive response to the monitoring program in 2/3 of the cases. This method of locating and monitoring the elderly within the on-going work of the family physician in the clinic was practical and effective. It also indicates an appropriate role for the neighborhood clinic in its own setting.

[Interagency coordination between family physicians, psychiatrists and social workers].

Family physicians care for large populations suffering from illnesses which are influenced by social, emotional and family factors. We present a program based on the application of a comprehensive care model in the Kupat Holim clinic and the integration of an interdisciplinary, interagency treatment team in which the focus of intervention is the clinical responsibility of the family physician. The social worker from the neighborhood social service agency and the psychiatrist from the regional mental health clinic participate as integral members of the staff. A broad patient assessment, including identification of clinical psychosocial components and interagency coordination, permits the family physician to involve the other staff members. This article is based on a survey of approximately 100 cases, 70 of which were referred to the clinic social worker for assessment and treatment, while 30 were discussed at bi-monthly consultations in which the clinic staff (family physicians and nurse), psychiatrist and psychiatric social worker, participated. It should be noted that most patients referred to the interdisciplinary forum remained the responsibility of the family physician, which supports the validity of the interagency coordination program.