Development of definitions for acute illness in nursing home residents based on chart-recorded physical exam findings.

OBJECTIVES: To develop and test simple, chart-based criteria for acute illness in nursing home residents for clinical and epidemiological study. DESIGN: Observational study. SETTING: A 409-bed not-for-profit nursing home. PARTICIPANTS: 102 custodial care residents. MEASUREMENTS: Physical exam findings commonly performed in nursing home residents were used to define 10 acute conditions. Residents were observed prospectively to test the clinical relevance of these definitions. Episodes of acute illness satisfying definition criteria were identified, as well as treatment changes, hospitalizations, and deaths. RESULTS: During a median follow-up of 60 days, 43 acute illnesses occurred, affecting 30 (29%) residents. Of these episodes, 77% were associated with treatment changes, hospitalization, or death. The new definitions captured 79% of all episodes of acute illness. The most common diagnoses were urinary tract infection, lower respiratory infection, and gastroenteritis/gastrointestinal upset. Independent risk factors for acute illness were gastrostomy feeding, depression, and history of fracture. CONCLUSIONS: Acute illness in the nursing home is common and frequently associated with treatment changes, hospitalization and death. It can be identified using a small number of chart-recorded physical exam-based findings as criteria.

Nursing assistants detect behavior changes in nursing home residents that precede acute illness: development and validation of an illness warning instrument.

BACKGROUND: Acute illness causes considerable morbidity and mortality in nursing home residents but is often difficult to recognize early. Nursing assistants often notice early signs of acute illness but do not methodically document or communicate their observations with medical staff. OBJECTIVE: To enhance nursing assistants' observation and documentation of signs of acute illness by developing a validated, standardized instrument for communication with medical staff. DESIGN: Observational cohort study. SETTING: Urban not-for-profit nursing home. SUBJECTS AND METHODS: Candidate instrument items were generated in focus group interviews with nursing home staff. Twenty-three nursing assistants completed the instrument on 74 nursing home residents over 4 weeks. Acute illness, the primary outcome, was identified by nurse report and chart review and determined according to preset criteria. MEASUREMENTS: Predictive validity was assessed by determining the relationship between instrument responses and development of acute illness within 7 days. Interobserver agreement was calculated between morning and afternoon nursing assistants' responses. Convergent validity was assessed by comparing instrument responses with three standard status indicators. RESULTS: The instrument consisted of 12 items that assessed behavioral and functional status changes. Residents with an instrument-recorded change were more likely to develop an acute illness within 7 days than those with no change (risk ratio 4.1, 95% confidence interval 2.6, 6.3). A final five-item instrument had a sensitivity of 53% and a specificity of 93% for acute illness. Nursing assistants' documentation of signs of illness preceded chart documentation by an average of 5 days. Interobserver agreement between morning and afternoon nursing assistants was 76%. Correlation of responses with standard indicators of functional, mental, and global status was high. CONCLUSIONS: A new instrument developed for nursing assistants to document behavioral and functional status changes in nursing home residents demonstrates fair sensitivity and high specificity for acute illness. Close monitoring of patients with a positive instrument might avert morbidity and mortality from acute illness by allowing earlier treatment.

What nursing home residents value in their doctors.

Patient satisfaction is influenced by multiple factors, and different populations are expected to define satisfaction in terms of their novel perspectives. Despite growing interest in patient satisfaction, an extensive literature search reveals no studies of nursing home residents' satisfaction with respect to medical care. In an initial qualitative study using transcripts of interviews conducted as part of a state quality control mandate, categories are identified that make up this population's construct of satisfaction and dissatisfaction. These categories serve as building blocks for designing future studies investigating these issues and allowing for comparison of nursing home residents' ideas of satisfaction and dissatisfaction to other older patients, including those in an outpatient geriatric setting.

The mortality of elder mistreatment.

CONTEXT: Although elder mistreatment is suspected to be life threatening in some instances, little is known about the survival of elderly persons who have been mistreated. OBJECTIVE: To estimate the independent contribution of reported elder abuse and neglect to all-cause mortality in an observational cohort of community-dwelling older adults. DESIGN: Prospective cohort study with at least 9 years of follow-up. SETTING AND PATIENTS: The New Haven Established Population for Epidemiologic Studies in the Elderly cohort, which included 2812 community-dwelling adults who were older than 65 years in 1982, a subset of whom were referred to protective services for the elderly. MAIN OUTCOME MEASURES: All-cause mortality among (1) elderly persons for whom protective services were used for corroborated elder mistreatment (elder abuse, neglect, and/or exploitation), or (2) elderly persons for whom protective services were used for self-neglect. RESULTS: In the first 9 years after cohort inception, 176 cohort members were seen by elderly protective services for verified allegations; 10 (5.7%) of these were for abuse, 30 (17.0%) for neglect, 8 (4.5%) for exploitation, and 128 (72.7%) for self-neglect. At the end of a 13-year follow-up period from cohort inception, cohort members seen for elder mistreatment at any time during the follow-up had poorer survival (9%) than either those seen for self-neglect (17%) or other noninvestigated cohort members (40%) (P<.001). In a pooled logistic regression that adjusted for demographic characteristics, chronic diseases, functional status, social networks, cognitive status, and depressive symptomatology, the risk of death remained elevated for cohort members experiencing either elder mistreatment (odds ratio, 3.1; 95% confidence interval, 1.4-6.7) or self-neglect (odds ratio, 1.7; 95% confidence interval, 1.2-2.5), when compared with other members of the cohort. CONCLUSIONS: Reported and corroborated elder mistreatment and self-neglect are associated with shorter survival after adjusting for other factors associated with increased mortality in older adults.

ED use by older victims of family violence.

STUDY OBJECTIVE: To determine the nature and frequency of ED use by victims of physical elder abuse. METHODS: Community-dwelling victims of abuse were identified through a state elderly protective service program independent of the health care system in a geographic area served by two EDs. ED records were reviewed and abstracted to determine if and how victims used emergency services. RESULTS: During a 7-year period, 182 elderly victims of physical abuse were identified in the catchment area of the study, and 114 (62.6%) had been seen in one or both EDs at least once during a 5-year "window" surrounding the initial identification of abuse. These 114 individuals accounted for 628 visits (median 3, range 1-46); 30.6% of visits resulted in a hospital admission. An ordinal system was used that assigned a probability of any single ED visit being referable to abuse; 37.8% of subjects had at least one visit categorized as being of high probability, and 66% of subjects had at least one visit that resulted in an injury-related chief symptom or ICD-9 discharge diagnosis. CONCLUSION: Elder abuse victims have substantial interactions with EDs and these visits frequently result in admission. Strategies that identify elder abuse in less acute settings and effectively address the needs of victims would improve quality of life and likely result in substantial savings in health care expenditures.

Is managed care good or bad for geriatric medicine?

This article uses clinical vignettes to examine the simultaneous dangers and opportunities that managed care brings to geriatric medicine. While the complex multifactorial syndromes prevalent in older adults might at first glance seem poorly handled under capitation, we argue that the incentives provided under existing delivery systems can be equally perverse. These improper incentives have arisen from (1) the fee-for-service payment mechanism itself, which has spawned a subspecialty culture ill-equipped to deal with the primary care needs of older adults and (2) the fragmentation of funding sources for geriatric care into two major payers (Medicare and Medicaid), encouraging providers to focus on cost shifting rather than the logical integration of services. The result has been a delivery system that provides little impetus to maximize functional status, the central goal of modern geriatric medicine. Because physicians may assume financial risk under global capitation, and because the cost of caring for a frail older adult is inversely related to functional status, managed care offers the potential to align the goals of cost containment with the goals of modern geriatric medicine. Physicians should have a substantive voice in the design and implementation of these systems.

Risk factors for reported elder abuse and neglect: a nine-year observational cohort study.

To determine longitudinal risk factors for elder abuse and neglect, an established cohort of community-dwelling older adults (n = 2,812) was linked with elderly protective service records over a 9-year follow-up period. Protective services saw 184 (6.5%) individuals in the cohort for any indication, and 47 cohort members were seen for corroborated elder abuse or neglect for a sampling adjusted 9-year prevalence of 1.6% (95% CI 1.0%, 2.1%). In pooled logistic regression, age, race, poverty, functional disability, and cognitive impairment were identified as risk factors for reported elder mistreatment. Additionally, the onset of new cognitive impairment was also associated with elder abuse and neglect. Because the mechanism of elder mistreatment case-finding in this study was a social welfare system (protective services), the influence of race and poverty as risk factors is likely to be overestimated due to reporting bias.

"Failure to thrive" in older adults.

The term "failure to thrive" is frequently used to describe older adults whose independence is declining. The term was exported from pediatrics in the 1970s and is used to describe older adults with various concurrent chronic diseases, functional impairments, or both. Despite this heterogeneity, failure to thrive has had its own international Classification of Diseases, Ninth Revision (ICD-9) code since 1979 and has been approached as a clinically meaningful diagnosis in many review articles. This conceptual framework, however, can create barriers to proper evaluation and management. The most worrisome of these barriers is the reinforcement of both fatalism and intellectual laziness, which need to be balanced with a deconstructionist approach, wherein the major areas of impairment are identified and quantified and have their interactions considered. Four syndromes known to be individually predictive of adverse outcomes in older adults are repeatedly cited as prevalent in patients with failure to thrive: impaired physical functioning, malnutrition, depression, and cognitive impairment. The differential diagnosis of contributors to each of these syndromes includes the other three syndromes, and multiple contributors often exist concurrently. Some of these contributors are unmodifiable, some are easily modifiable, and some are potentially modifiable but only with the use of resource-intensive strategies, initial interventions should be directed at easily remediable contributors in the hope of improving overall functional status, because a single contributor may simultaneously influence several other syndromes that conspire to create the phenotype of failure to thrive. How aggressively should more resource-intensive strategies for less easily modifiable contributors be pursued? This is a central clinical, ethical, and policy issue in geriatric medicine that cannot be settled without better process and outcome data. This paper examines the medical etymology of failure to thrive and proposes a rational approach to evaluation and management that is based on the limited medical literature.

Older adults. An 11-year longitudinal study of adult protective service use.

BACKGROUND: Little is known about the epidemiology of adult protective services agency (APS) utilization, the state entities charged with assessment and advocacy for disenfranchised older adults. OBJECTIVE: To determine the prevalence of utilization by older adults and risk factors for APS. METHODS: A longitudinal study using the New Haven Established Population for Epidemiologic Studies in the Elderly population, a cohort of 2812 community-dwelling adults who were older than 65 years in 1982. The main outcome measure was referral to the state ombudsman on aging for protective services. RESULTS: Over the 11-year follow-up period, 209 cohort members (7.4%) were referred to the ombudsman 302 times as protective service cases for a community prevalence of 6.4% after adjusting for the sampling strategy of the cohort. Self-neglect was the most common indication for referral (73% of the cases). While in bivariate analyses a variety of baseline sociodemographic features, functional impairments, medical conditions, and social network factors were associated with APS use, in multivariable analysis only sociodemographic variables remained independent risk factors including low income (odds ratio [OR], 2.6; 95% confidence interval [CI], 1.8 to 3.9), nonwhite race (OR, 2.2; 95% CI, 1.3 to 3.7), and age older than 75 years at cohort inception (OR, 1.9; 95% CI, 1.1 to 3.0). CONCLUSIONS: Prevalence of APS use by older adults is substantial, and sociodemographic features were the most compelling risk factors in our cohort. As the population ages, the number of older adults at risk for abuse, neglect, self-neglect, exploitation, and abandonment will increase; physicians will need to become familiar with APS referral pathways and mandatory reporting laws in their states.

Use of methodological standards in diagnostic test research. Getting better but still not good.

OBJECTIVE: To determine the frequency and temporal changes in application of seven accepted methodological standards for the evaluation of diagnostic tests. DATA SOURCES: A search of the MEDLINE database yielded 1302 articles about diagnostic test studies, during a 16-year secular interval, 1978 through 1993, in four prominent general medical journals. STUDY SELECTION: In the 112 eligible studies, the test was intended for clinical use, indexes of accuracy (sensitivity and specificity or likelihood ratios) were provided, and more than 10 patients were enrolled. DATA EXTRACTION: Although each study was critically reviewed by one primary observer, a subset was independently evaluated for interrater consistency. DATA SYNTHESIS: The percentage of studies that fulfilled criteria for each of the seven methodological standards are as follows: (1) specify spectrum of evaluated patients, 27%; (2) report test indexes for clinical subgroups, 8%; (3) avoid workup bias, 46%; (4) avoid review bias, 38%; (5) provide numerical precision for test indexes, 11%; (6) report frequency and management of indeterminate results when calculating test indexes, 22%; and (7) specify test reproducibility, 23%. Secular increases were found for six of the seven standards in ranges of use from 14% to 31% during 1978-1981 to 1990-1993. Nevertheless, only one standard, avoidance of workup bias, was fulfilled by more than 50% of studies in the most recent secular interval. CONCLUSIONS: These results indicate that most diagnostic tests are still inadequately appraised. The routine demand for methodological standards could raise the quality of diagnostic test information, and the careful predissemination evaluation of diagnostic tests could eliminate useless tests before they receive widespread application.

A prospective community-based pilot study of risk factors for the investigation of elder mistreatment.

PURPOSE: To identify risk factors for the investigation of elder abuse, neglect, self-neglect, exploitation, and abandonment in a population-based observational cohort of community living elders. STUDY POPULATION: Population-based sample of 2,812 community-living men and women in New Haven, Connecticut who were over age 65 in 1982. METHODS: Matching process whereby cohort members who were investigated by Connecticut's State Ombudsman on Aging in 1985 or 1986 were identified. ANALYSIS: Relative risks for ombudsman investigation in 1985 or 1986 were calculated based on risk factors status at baseline interview in 1982. RESULTS: Sixty-eight (2.4%) members of the cohort received investigation. Features at cohort entry significantly associated with investigation in multiple logistic regression included: requiring assistance with feeding (Adjusted OR 3.5, 95% CI 1.2, 11.7), being a minority elder (Adj. OR 2.3, 95% CI 1.4, 2.8), over age 75 at cohort inception (Adj. OR 1.9, 95% CI 1.1, 3.1), and having a poor social network as defined by a social network index (Adj. OR 1.7, 95% CI 1.0, 2.7). When stratified by race, requiring assistance with feeding was associated with ombudsman investigation in minority elders (Adj. OR 10.8, 95% CI 2.8, 40.5) but not non-minority elders (Adj. OR 1.1, 95% CI 0.5, 7.5). CONCLUSION: Functional disability, minority status, older age, and poor social networks were associated with investigation for elder mistreatment in this prospective, community-based population of men and women over the age of 65.

Recognizing elder abuse and neglect.

The signs and symptoms of elder abuse and neglect may mimic the signs and symptoms of many common chronic medical conditions in elderly persons. A complete assessment for elder abuse and neglect is time consuming and is best performed as a regimented evaluation that includes separate histories from the patient and suspected party and a clinical assessment that emphasizes function, cognition, and specific aspects of the physical examination. The management of elder abuse and neglect should be multidisciplinary with several key personnel participating. An elderly person in immediate danger should be removed from his or her environment. For less acute cases, a variety of interventions aimed at decreasing the stress of caregiving or ameliorating other family stressors may be appropriate. Most states require that clinicians who suspect elder abuse and neglect report their concerns to a designated authority. There are many gaps in our knowledge about elder abuse and neglect. It is hoped that with the future application of rigorous epidemiologic methodology as has been employed in the study of child abuse, this social ill can be better understood and prevented. Until then, clinicians must integrate their clinical experience and social skills to recognize the problem and provide thoughtful and compassionate intervention.

Bladder cancer and coffee drinking: a summary of case-control research.

An association between coffee drinking and cancer of the lower urinary tract (LUT) was first suggested 20 years ago and has been the subject of many epidemiological studies. We have undertaken a critical review and statistical summary of 35 case-control studies of this association published between 1971 and 1992. Predefined methodological criteria were applied to the available reports. Studies were classified as either meeting the criteria (core studies) or failing to satisfy at least one of the requirements for design or analysis (non-core studies). The summarised data from the 8 core studies showed no evidence of an increase in risk of LUT cancer with coffee drinking in men or women after adjustment for the effects of cigarette smoking (odds ratio 1.07 [95% CI 1.00-1.14] for men, 0.91 [0.81-1.03] for women). The measures of association from the non-core studies were higher on average than those from the core studies, although the inclusion of these data in an overall summarised estimate did not substantially change the findings from the core analysis. We conclude that the best available data do not suggest a clinically important association between the regular use of coffee and development of cancer of the LUT in men or women.

Diagnostic and treatment guidelines on elder abuse and neglect.

It is estimated that between 1.5 and 2 million older adults experience abuse or neglect each year in the United States. Elder mistreatment may be physical, psychological, or financial, and it may be perpetrated by family members or by other informal or formal caregivers. Physicians are encouraged to play an active role in assessment, intervention, and prevention.

Delusions and behavioral disturbances in cognitively impaired elderly persons.

OBJECTIVE: To compare cognitive function and the prevalence of selected behavioral problems in delusional and non-delusional dementia patients. DESIGN: Retrospective medical record review. SETTING: An outpatient geriatric assessment center. PARTICIPANTS: 114 consecutive patients with dementia. MAIN OUTCOME MEASURES: Delusions as recorded in a consultation report. RESULTS: Delusions were described in 25.5% of patients. A variety of behavioral disturbances were more common in delusional than non-delusional patients, including agitation, angry or hostile outbursts, urinary incontinence, wandering or pacing, and insomnia. While cognitive function as measured by the MMSE was similar in delusional and non-delusional patients (18.9 +/- 3.8 and 19.2 +/- 5.9, respectively), there was a statistically borderline tendency for delusions to occur more often in patients in the mid-range of cognitive impairment (17 less than or equal to MMSE less than or equal to 23) compared with patients with greater or lesser degrees of cognitive impairment (32% vs 17% respectively). CONCLUSION: Delusions in dementia are associated with a variety of behavioral problems. Further studies are needed to clarify the role of delusions in the development of disruptive behaviors in dementing illness.