Fragilidade e risco de queda em idosos que vivem no domicílio / Fragilidad y riesgo de caída de ancianos que viven en su domicilio / Frailty and risk of falling in the older adult living at home

Resumo Objetivo Analisar a associação entre o risco de queda e a síndrome da fragilidade em idosos que vivem no domicílio. Métodos Estudo transversal com 261 idosos, de ambos os sexos, residentes em domicílios de um município paulista. A coleta ocorreu por meio dos instrumentos: Perfil Demográfico, Mini Exame do Estado Mental, Fall Risk Score, Edmonton Frail Scale , Indicador de Fragilidade de Tilburg e Indicador da fragilidade de Groningen. Para as análises bivariadas, utilizamos o teste de Qui-quadrado de Pearson e, para comparar as médias da escala numérica, o Teste não paramétrico de Mann-Whitney e a Regressão Logística Linear com p<0,05. Resultados Dos 261 idosos, a maioria era do sexo feminino, viúvas, com 1 a 4 anos de estudo e moravam com familiares. A prevalência do risco de queda foi de 51,7%. Em todas as escalas utilizadas, houve associação entre fragilidade com o risco de queda (p<0,001). Na análise de regressão logística linear, o idoso considerado frágil pela Escala de Tilburg apresentou 6,05 vezes mais chances de cair do que aquele não frágil. Na Escala de Groningen, as chances de o idoso frágil cair foram 5,55 vezes maiores e, na Escala de Edmonton, aqueles que apresentaram risco de queda obtiveram aumento de 1,53 na média do escore. Conclusão O risco de queda foi estimado com maior significância quando associado à fragilidade, nas três escalas utilizadas. Tais escalas são instrumentos de fácil acesso e aplicação por parte do enfermeiro e equipe multiprofissional e podem ser adotadas para favorecer um envelhecimento ativo.

Resumen Objetivo Analizar la relación entre el riesgo de caída y el síndrome de fragilidad de ancianos que viven en su domicilio. Métodos Estudio transversal con 261 ancianos, de ambos sexos, residentes en domicilios de un municipio de São Paulo. La recolección se realizó mediante los siguientes instrumentos: Perfil Demográfico, Mini Examen del Estado Mental, Fall Risk Score, Edmonton Frail Scale , Indicador de Fragilidad de Tilburg e Indicador de fragilidad de Groningen. Para el análisis bivariado, utilizamos la prueba χ2 de Pearson, y para comparar los promedios de la escala numérica, la Prueba no paramétrica de Mann-Whitney y la Regresión Logística Lineal con p<0,05. Resultados De los 261 ancianos, la mayoría era de sexo femenino, viudas, entre 1 y 4 años de estudio y vivían con familiares. La prevalencia del riesgo de caída fue del 51,7%. En todas las escalas utilizadas hubo relación entre la fragilidad y el riesgo de caída (p<0,001). En el análisis de regresión logística lineal, el anciano considerado frágil por la Escala de Tilburg presentó 6,05 veces más de probabilidad de caer que el no frágil. En la Escala de Groningen, la probabilidad de caída del anciano frágil fue 5,55 veces mayor. Y en la Escala de Edmonton, los que presentaron riesgo de caída obtuvieron un aumento de 1,53 en el promedio de la puntuación. Conclusión El riesgo de caída fue considerado de mayor significación cuando se lo relaciona con la fragilidad, en las tres escalas utilizadas. Estas escalas son instrumentos de fácil acceso y aplicación por parte de enfermeros y equipos multiprofesionales y pueden adoptarse para favorecer a un envejecimiento activo.

Abstract Objective To analyze the association between risk of falling and frailty syndrome in the older adult living at home. Methods Cross-sectional study with 261 older adult men and women living in households in a city of São Paulo. The collection took place through the instruments: Demographic Profile, Mini Mental State Examination, Fall Risk Score, Edmonton Frail Scale, Tilburg Frailty Indicator and Groningen Frailty Indicator. For the bivariate analyzes, we used Pearson's chi-square test and, to compare the means of the numerical scale, the nonparametric Mann-Whitney test and the linear logistic regression with p <0.05. Results Of the 261 older adults, most were female, widows, with 1 to 4 years of education and living with family members. The prevalence of fall risk was 51.7%. In all scales used, there was an association between frailty and risk of falling (p <0.001). In the linear logistic regression analysis, the older adult considered frail by the Tilburg Scale were 6.05 times more likely to fall than the non-frail. On the Groningen Scale, the chances of the frail older adult falling were 5.55 times higher and, on the Edmonton Scale, those at risk of falling had a 1.53 average increase in the score. Conclusion The risk of falling was most significantly estimated when associated with frailty, in the three scales used. Such scales are easily accessible and applicable instruments by nurses and multiprofessional staff and can be adopted to favor active aging.

The performance of three oncogeriatric screening tools - G8, optimised G8 and CARG - in predicting chemotherapy-related toxicity in older patients with cancer. A prospective clinical study.

BACKGROUND: Older patients are vulnerable to chemotherapy-related toxicity (CRT). Therefore we evaluated screening tools in their power to predict CRT. METHODS: Patients with cancer aged ≥65 years completed three screening questionnaires (G8, optimised G8 and Cancer and Ageing Research Group (CARG). Additionally, Comprehensive geriatric assessment (CGA) for verification of supportive care needs was undertaken on patients with impaired G8 scores. During chemotherapy treatment patients were assessed, capturing grade 0-5 CRT as defined by NCI CTCAE 4. RESULTS: 104 patients with non-haematological cancers were included at three study sites. Median age was 73 years (range 65-85). Onco-geriatric screening detected 74% as impaired using G8 and optimised G8 questionnaires and 86% using CARG screening. Grade 3-5 toxicity affected 64.4% of all patients. G8 (OR 0.3 95% CI [0.1;1.0]) and optimised G8 (OR 0.4 95% CI [0.1; 1.5]) did not reliably predict CRT, whereas screening with CARG demonstrated a strong prediction of severe CRT: OR 4.2, 95% CI [1.1, 15.9]. CGA was undertaken on 66 patients, revealing deficiencies in nutritional (83%) and functional-status (54%) and occurrence of relevant comorbidity (53%). CONCLUSION: The CARG tool could be useful for predicting CRT. CGA showed clinically relevant supportive care needs in patients with a positive G8 screening.

Performance of a brief geriatric evaluation compared to a comprehensive geriatric assessment for detection of geriatric syndromes in family medicine: a prospective diagnostic study.

BACKGROUND: Geriatric syndromes are rarely detected in family medicine. Within the AGE program (active geriatric evaluation), a brief assessment tool (BAT) designed for family physicians (FP) was developed and its diagnostic performance estimated by comparison to a comprehensive geriatric assessment. METHODS: This prospective diagnostic study was conducted in four primary care sites in Switzerland. Participants were aged at least 70 years and attending a routine appointment with their physician, without previous documented geriatric assessment. Participants were assessed by their family physicians using the BAT, and by a geriatriciant who performed a comprehensive geriatric assessment within the following two-month period (reference standard). Both the BAT and the full assessment targeted eight geriatric syndromes: cognitive impairment, mood impairment, urinary incontinence, visual impairment, hearing loss, undernutrition, osteoporosis and gait and balance impairment. Diagnostic accuracy of the BAT was estimated in terms of sensitivity, specificity, and predictive values; secondary outcomes were measures of feasibility, in terms of added consultation time and comprehensiveness in applying the BAT items. RESULTS: Prevalence of the geriatric syndromes in participants (N=85, 46 (54.1%) women, mean age 78 years (SD 6))ranged from 30.0% (malnutrition and cognitive impairment) to 71.0% (visual impairment), with a median number of 3 syndromes (IQR 2 to 4) per participant. Sensitivity of the BAT ranged from 25.0% for undernutrition (95%CI 9.8% - 46.7%) to 82.1% for hearing impairment (95%CI 66.5% - 92.5%), while specificity ranged from 45.8% for visual impairment (95%CI 25.6-67.2) to 87.7% for undernutrition (76.3% to 94.9%). Finally, most negative predictive values (NPV) were between 73.5% and 84.1%, excluding visual impairment with a NPV of 50.0%. Family physicians reported BAT use as per instructions for 76.7% of the syndromes assessed. CONCLUSIONS: Although the BAT does not replace a comprehensive geriatric assessment, it is a useful and appropriate tool for the FP to screen elderly patients for most geriatric syndromes. TRIAL REGISTRATION: The study was registered on ClinicalTrials.gov on February 20, 2013 ( NCT01816087 ).

What is Comprehensive Geriatric Assessment (CGA)? An umbrella review.

Background: Comprehensive Geriatric Assessment (CGA) is now the accepted gold standard for caring for frail older people in hospital. However, there is uncertainty about identifying and targeting suitable recipients and which patients benefit the most. Objectives: our objectives were to describe the key elements, principal measures of outcome and the characteristics of the main beneficiaries of inpatient CGA. Methods: we used the Joanna Briggs Institute umbrella review method. We searched for systematic reviews and meta-analyses describing CGA services for hospital inpatients in the Cochrane Database of Systematic Reviews, Database of Reviews of Effectiveness (DARE), MEDLINE and EMBASE and a range of other sources. Results: we screened 1,010 titles and evaluated 419 abstracts for eligibility, 143 full articles for relevance and included 24 in a final quality and relevance check. Thirteen reviews, reported in 15 papers, were selected for review. The most widely used definition of CGA was: 'a multidimensional, multidisciplinary process which identifies medical, social and functional needs, and the development of an integrated/co-ordinated care plan to meet those needs'. Key clinical outcomes included mortality, activities of daily living and dependency. The main beneficiaries were people ≥55 years in receipt of acute care. Frailty in CGA recipients and patient related outcomes were not usually reported. Conclusions: we confirm a widely used definition of CGA. Key outcomes are death, disability and institutionalisation. The main beneficiaries in hospital are older people with acute illness. The presence of frailty has not been widely examined as a determinant of CGA outcome.

Body Mass Index and Its Relationship with Disability, Chronic Diseases and Frailty in Older People: A Comparison of the Lipschitz and Who Classifications.

BACKGROUND: Anthropometric parameters are closely associated with the pathophysiology of frailty and with clinic and functional parameters assessed for its diagnosis. OBJECTIVE: To evaluate the possible association of the nutritional status of older people as assessed by Body Mass Index (BMI) and functional disability, self-reported chronic diseases and frailty, comparing the use of two different classifications of BMI. DESIGN: Cross-sectional study. SETTING: The sample was selected among community-dwelling older people from the city of Ribeirão Preto/ Brazil. PARTICIPANTS: 326 independent older people (mean age 73.8±6.4 years) who participated in the FIBRA (Frailty in Brazilian Older People) study. MEASUREMENTS: Weight and height were collected for BMI analysis and frailty criteria were applied according to Fried et al. Participants were also evaluated for self-reported activities of daily living (Katz Index and Lawton and Brody Scale), and the presence of chronic diseases. RESULTS: The prevalence of frailty was 12.3%. Regardless of the classification of BMI applied, most of the sample was classified as overweight (50.9% and 39.3% in the Lipschitz and WHO classifications, respectively). For both classifications, low weight was the only BMI classification associated with frailty status (OR Lipschitz: 4.12(1.53-11.14); OR WHO: 6.21 (1.26-30.58). Comorbidities and dependence in activities of daily living (ADLs) were associated with BMI ≥ 30kg.m2. CONCLUSION: Regardless of the classification adopted, low weight is associated with frailty. However, when the WHO stratification is employed, high BMI is also associated to increased functional disability and the presence of comorbidities, coexisting factors of frailty.

Classification of frailty using the Kihon checklist: A cluster analysis of older adults in urban areas.

AIM: Frailty is an important predictor of the need for long-term care and hospitalization. Our aim was to categorize frailty in community-dwelling older adults. METHODS: The present study was carried out in 2011-2013, and consisted of 1380 individuals over 65 years of age. Participants completed the Kihon checklist, which is widely used to assess frailty in Japan, and their physical, cognitive and social function was evaluated. Non-hierarchical cluster analysis was used to statistically categorize frailty. The optimum number of clusters was determined as the point at which the external reference values (instrumental activity of daily living score, grip power, 10-m walk time, body mass index, portable fall risk index, occlusal force and Mini-Mental State Examination score) differed. RESULTS: According to the Kihon checklist, 369 (26.7%) of the 1380 study participants were considered frail. When the cluster number was increased from two to six, the scores in each subdomain of the Kihon checklist significantly differed. The estimated minimum number of clusters was five, and each of the five cluster groups had distinct characteristics. The numbers of participants in cluster groups 1-5 were 105, 78, 62, 71 and 53, respectively. CONCLUSIONS: We identified five types of frailty in community-dwelling older adults in Japan: "experience of falling," "pre-frailty," "oral frailty," "housebound" and "severe frailty." Geriatr Gerontol Int 2017; 17: 69-77.

Instruments for assising person centered care in gerontology / Instrumentos para evaluar la Atención Centrada en la Persona en los servicios gerontológicos

ANTECEDENTS: The assessment of Person Centered Care (PCC) is internationally recognised as an approach of great interest for improving the quality of care of the elderly. The aim of this research is to review the procedures and instruments used in the assessment of services using this approach. METHOD:The measurement instruments designed to assess elderly care services from PCC were reviewed, particularly residential services, day centers and home help. The main databases, research articles, and specialized websites were consulted. RESULTS: Four observational instruments for the assessment of Person Centered Care are described; five for the assessment of physical space; six aimed at discovering users' opinions; one which records family opinions, and five aimed at professionals, as well as several qualitative tools for self-assessment of centers. CONCLUSIONS: Due to the diversity of instruments available for assessing PCC, and in order to avoid partial evaluations of attention, a combined strategy of assessment is recommended as well as integrating these measures into a broader service evaluation which includes the different strands related to care quality

ANTECEDENTES: la Atención Centrada en la Persona (ACP) es reconocida internacionalmente como un enfoque de gran interés para mejorar la calidad de los cuidados gerontológicos. El objetivo de este trabajo es describir detalladamente los principales instrumentos disponibles para la evaluación de servicios desde este enfoque. MÉTODO: se revisaron los instrumentos diseñados para evaluar servicios gerontológicos desde la ACP, concretamente servicios residenciales, centros de día y ayuda a domicilio. Se consultaron las principales bases de datos y webs especializadas. RESULTADOS: se describen cuatro instrumentos de observación de la atención centrada en la persona; cinco que evalúan el espacio físico; seis destinados a conocer la opinión de las personas usuarias, uno que registra la opinión de las familias y cinco la de los profesionales, así como distintas herramientas cualitativas para la autoevaluación de los centros. CONCLUSIONES: debido a la diversidad de instrumentos disponibles para evaluar la ACP, y con el objetivo de evitar una valoración parcial de la atención, se recomienda una estrategia combinada, así como integrar estas medidas en una evaluación del servicio más global que incluya los diferentes ejes relacionados con la calidad asistencial

Vulnerable Elderly Survey 13 as a screening method for frailty in Polish elderly surgical patient--prospective study.

UNLABELLED: The Vulnerable Elders Survey (VES-13) is a simple function based frailty screening tool that can be also administered by the nonclinical personnel within 5 minutes and has been validated in the out- and in patient clinic and acute medical care settings. The aim of the study was to validate the accuracy of the VES-13 screening method for predicting the frailty syndrome based on a CGA in polish surgical patients. MATERIAL AND METHODS: We included prospectively 106 consecutive patients ≥65, that qualify for abdominal surgery (both due to oncological and benign reasons), at the tertiary referral hospital.We evaluated the diagnostic performance of VES-13 score comparing to the results from the CGA, accepted as the gold standard for identifying at risk frail elderly patients. RESULTS: The prevalence of frailty as diagnosed by CGA was 59.4%. There was significantly higher number of frail patients in the oncological group (78% vs. 31%; p<0.01). According to the frailty screening methods, the frailty prevalence was 45.3%. The VES-13 score had a 60% sensitivity and 78% specificity in detecting frailty syndrome. The positive and negative predictive value was 81% and 57%, respectively. The overall predictive capacity was intermediate (AUC=0.69) CONCLUSIONS: At present, the VES-13 screening tool for older patients cannot replace the comprehensive geriatric assessment; this is due to the insufficient discriminative power to select patients for further assessment. It might be helpful in a busy clinical practice and in facilities that do not have trained personal for geriatric assessment.

Neglect and abuse of older people in Nepal: a commentary on "A baseline study on reported cases of elder abuse in Nepali press".

Little is known about elder abuse in Nepal. To gain further insights, the National Human Rights Commission in association with the Geriatric Center in Nepal published a report that analyzes all cases of older people's abuse published in two daily newspapers in Nepal over a 2-year period. This commentary discusses the main findings of the report, as well as future directions.

Screening for elderly patients admitted to the emergency department requiring specialized geriatric care.

BACKGROUND: There is a need for a brief geriatric assessment (BGA) tool to screen elderly patients admitted to the Emergency Department (ED) for their risk of a long hospital stay. OBJECTIVE: To examine whether a BGA administered to elderly patients admitted to the ED may predict the risk of a long hospital stay in the geriatric acute care unit. METHODS: This study had a prospective cohort study design, enrolling 424 elderly patients (mean age 84.0 ± 6.5 years, 31.6% male) who were evaluated in the ED using a BGA composed of the following items: age, gender, number of medications taken daily, history of falls during the past 6 months, Mini-Mental State Examination (MMSE) score, and non-use of home-help services (i.e., living alone without using any formal or informal home services or social help). The length of stay (LOS) was calculated in days. Patients were separated into three groups based on LOS: low (<8 days), intermediate (8-13 days), and high (>13 days). RESULTS: The prevalence of male gender was higher among patients with the longest LOS compared to those with intermediate LOS (p = 0.002). There were more patients with a history of falls in the high LOS group compared to the intermediate LOS group (p = 0.001) and the low LOS group (p < 0.001). The classification tree showed that male patients with an MMSE score <20 who fell with age under 85 years formed the end node with the greatest relative risk (RR) of a long hospital stay (RR = 14.3 with p < 0.001). CONCLUSIONS: The combination of a history of falls, male gender, cognitive impairment, and age under 85 years identified elderly ED patients at high risk of a long hospital stay.

Trajectories of combined laboratory- and real world-based speed of processing in community-dwelling older adults.

OBJECTIVES: To characterize the trajectories of laboratory- and real world-based speed of processing (SOP) over 5 years using finite latent growth mixture modeling, and to explore associated baseline individual-level predictors and functional outcomes in 2,802 community-dwelling older adults from the Advanced Cognitive Training for Independent and Vital Elderly cohort. METHOD: Laboratory- and real world-based SOP and functional outcomes were assessed over 5 years, and candidate individual-level predictors were collected at baseline. RESULTS: After controlling for intervention assignment and demographic information, 4 distinct trajectories were identified: 4.6% of older adults had poor laboratory-based SOP and very poor real world-based SOP that both declined substantially over time; 17.9% had poor laboratory- and real world-based SOP that declined moderately; 38.7% had neutral laboratory- and real world-based SOP that maintained stable; and 37.9% had good laboratory- and real world-based SOP that declined slightly. Non-White, depression, subjective memory complaints, and vascular factors predicted the trajectories. The trajectories significantly differed in the rate of decline in basic activities of daily living, instrumental activities of daily living, and grip strength over time. DISCUSSION: Heterogeneous trajectories of SOP exist in old age. Future interventions addressing SOP should target the vulnerable group with poor SOP over time.

A reduced scoring system for the Clock Drawing Test using a population-based sample.

BACKGROUND: Many scoring systems exist for clock drawing task variants, which are common dementia screening measures, but all have been derived from clinical samples. This study evaluates and combines errors from two published scoring systems for the Clock Drawing Test (CDT), the Lessig and Tuokko methods, in order to create a simple yet optimal scoring procedure to screen for dementia using a Canadian population-based sample. METHODS: Clock-drawings from 356 participants (80 with dementia, 276 healthy controls) from the Canadian Study on Health and Aging were analyzed using logistic regression and Receiver Operating Characteristic curves to determine a new, simplified, population-based CDT scoring system. The new Jouk scoring method was then compared to other commonly used systems (e.g. Shulman, Tuokko, Watson, Wolf-Klein). RESULTS: The Jouk scoring system reduced the Lessig system even further to include five critical errors: missing numbers, repeated numbers, number orientation, extra marks, and number distance, and produced a sensitivity of 81% and a specificity of 68% with a cut-off score of one error. With regard to other traditionally used scoring methods, the Jouk procedure had one of the most balanced sensitivities/specificities when using a population-based sample. CONCLUSIONS: The results from this study improve our current state of knowledge concerning the CDT by validating the simplified scoring system proposed by Lessig and her colleagues in a more representative sample to mimic conditions a general clinician or researcher will encounter when working among a wide-ranging population and not a dementia/memory clinic. The Jouk CDT scoring system provides further evidence in support of a simple and reliable dementia-screening tool that can be used by clinicians and researchers alike.

Práctica de Tai Chi en ancianos, alternativa para mejorar su longevidad / Practice of Tai Chi in the elderly, an alternative to better longevity

El Tai Chi Chuan es un arte marcial efectivo como ejercicio para prolongar la vida. Con el objetivo de demostrar la eficacia de la práctica del Tai Chi en los ancianos para mejorar la longevidad, se realizó una investigación de intervención-acción, durante el año 2009-2010. El universo y la muestra de estudio lo constituyeron 60 ancianos que practican Tai Chi en el Círculo Viento de Otoño del Municipio Pinar del Río. Los datos fueron recogidos a través de las historias clínicas individuales y una encuesta elaborada por el autor; se obtuvieron datos generales de los pacientes, así como las variables para su estudio: la edad, sexo, polifarmacia, evaluación geriátrica: psicológica, social, biomédica y funcional. Los datos cualitativos se resumieron en frecuencias absolutas y relativas porcentuales. Se realizaron pruebas de comparación de proporciones para probar la existencia o no de diferencias significativas en algunos indicadores, antes y después de la práctica del Tai Chi. Se pudo apreciar que la edad más frecuente fue de 60-64 años del sexo femenino. Después del ejercicio de Tai Chi: disminuyó la polifarmacia, se evidenció una convalecencia psicológica, en la evaluación biomédica y social hubo una ligera rehabilitación. La evaluación social fue la única prueba que no presentó diferencias significativas en las proporciones de ancianos con ligero riesgo social antes y después de la práctica. La mayoría de los ancianos se tornaron independientes para realizar las actividades instrumentadas de la vida diaria(AU)

Tai Chi Chuan is a martial art which is very effective to prolong life. A study aimed at showing the effectiveness of Tai Chi in the elderly was carried out by means of an intervention-action research during 2009-2010. The target group and the sample of the study were comprised of 60 old people who practice Tai Chi at Viento de Otoño Circle, Pinar del Rio municipality. Data were collected from the individual clinical histories and from a survey prepared by the author; obtaining the general data of patients, together with the variables: age, sex, polypharmacy, geriatric assessment (psychological, social, biomedical and functional view points). Qualitative data were summed up in absolute frequencies and relative percentages. Comparison of proportion tests to prove the existence or not of significant differences in some indicators, before and after the practice of Tai Chi. The most frequent group of ages was 60-64 where female sex prevailed. After the practice of Tai Chi: polypharmacy decreased, evidencing psychological convalescence, and observing a mild rehabilitation in the biomedical plus social assessment. Social appraisal was the only that did not present significant differences regarding the proportion of old people with mild social risks before and after Tai Chi practice. The majority of the old people became independent to perform instrumented daily-life activities(AU)

Time trends and predictors of mortality from ill-defined causes in old age: 9 year follow-up of the Bambuí cohort study (Brazil).

The study objective was to examine differentials in time trends and predictors of deaths assigned to symptoms, signs and ill-defined conditions in comparison with other ill-defined conditions (ill-defined cardiovascular diseases, cancer and injury) in a population-based cohort study. Of 1,606 baseline participants aged 60 years and over, 524 died during 9-year follow-up and were included in this study. Deaths coded to "symptoms" declined by 77% in the period from 1997-1999 to 2003-2005. Deaths coded to other ill-defined conditions remained unchanged. The calendar period 2003-2005 (RR = 0.25; 95%CI: 0.09-0.70) and in-hospital deaths (RR = 0.16; 95%CI: 0.08-0.34) were independently associated with "symptoms", but not with other ill-defined conditions. Baseline socio-demographic characteristics and chronic diseases were not predictors of these outcomes. International and national agencies have focused on the reduction of deaths assigned to "symptoms" to improve the registration of vital statistics, while other ill-defined conditions have received little attention. Our data provide evidence supporting the need to redress this situation.

Time trends and predictors of mortality from ill-defined causes in old age: 9 year folllow-up of the Bambuí cohort study (Brazil) / Tendências e fatores associados aos óbitos por causas mal definidas em idosos: nove anos de seguimento da coorte de Bambuí (Brasil)

The study objective was to examine differentials in time trends and predictors of deaths assigned to symptoms, signs and ill-defined conditions in comparison with other ill-defined conditions (ill-defined cardiovascular diseases, cancer and injury) in a population-based cohort study. Of 1,606 baseline participants aged 60 years and over, 524 died during 9-year follow-up and were included in this study. Deaths coded to "symptoms" declined by 77 percent in the period from 1997-1999 to 2003-2005. Deaths coded to other ill-defined conditions remained unchanged. The calendar period 2003-2005 (RR = 0.25; 95 percentCI: 0.09-0.70) and in-hospital deaths (RR = 0.16; 95 percentCI: 0.08-0.34) were independently associated with "symptoms", but not with other ill-defined conditions. Baseline socio-demographic characteristics and chronic diseases were not predictors of these outcomes. International and national agencies have focused on the reduction of deaths assigned to "symptoms" to improve the registration of vital statistics, while other ill-defined conditions have received little attention. Our data provide evidence supporting the need to redress this situation.

As tendências e os determinantes dos óbitos codificados como sinais, sintomas e afecções mal definidas ("sintomas") foram comparados a outras causas mal definidas (algumas doenças cardiovasculares, neoplasias e causas externas). De 1.606 participantes da coorte de base populacional de idosos de Bambuí, Minas Gerais, Brasil, 524 faleceram em nove anos de seguimento e foram incluídos no estudo. As mortes por "sintomas" diminuíram 77 por cento entre 1997-1999 e 2003-2005. Os óbitos por outras causas mal definidas permaneceram inalterados. O período de 2003-2005 (RR = 0,25; IC95 por cento: 0,09-0,70) e os óbitos hospitalares (RR = 0,16; IC95 por cento: 0,08-0,34) associaram-se independentemente com "sintomas", e não com as outras causas mal definidas. Características sócio-demográficas e doenças crônicas na linha de base não apresentaram associações com esses eventos. Estratégias para a redução dos óbitos por "sintomas" têm sido priorizadas por agências internacionais e nacionais, enquanto os óbitos por outras causas mal definidas têm recebido pouca atenção. Os resultados reforçam a necessidade de estratégias para mudar essa situação.

Public policy and the dependency of nursing home residents in Australia: 1968-69 to 2006-07.

OBJECTIVE: The purpose of this paper is to derive annual estimates of the aggregate dependency of the nursing home population in Australia, and to use these data to consider the impact of Government policies to target nursing home services to those with high care-needs/dependency. Two related tools, the 'Aggregate Dependency Value' and 'Aggregate Dependency Index', have been constructed using the principles of case-mixed based systems, to quantify the aggregate dependency of residents. Data on all residents 1968-1969 to 2006-2007, and on newly admitted residents 1992-1993 to 2006-2007 have been derived and analysed. METHODS: To construct the tools, the percent of residents classified into various dependency categories were weighted by proxy measures of their dependency. These were summed, and converted into index numbers to estimate rates of change in the aggregate dependency of residents. The derived data were used to consider possible impacts of the policies. RESULTS: The data indicate that the dependency of residents has, for the most part, increased over recent decades but that the rate of the increase has varied. An increase in the dependency of residents corresponds with the policies' objectives. CONCLUSIONS: The tools extend the ways the dependency of nursing home residents in Australia can be assessed. The estimates support the effectiveness of the Government's targeting policies but causal relationships have not been estimated.