Utilization of health and mental health services. Three Epidemiologic Catchment Area sites.

Utilization of health and mental health services by non-institutionalized persons aged 18 years and older is examined based on interviews with probability samples of 3,000 to 3,500 persons in each of three sites of the National Institute of Mental Health Epidemiologic Catchment Area (ECA) program: New Haven, Conn, Baltimore, and St Louis. In all three ECAs, 6% to 7% of the adults made a visit during the prior six months for mental health reasons; proportions were considerably higher among persons with recent DSM-III disorders covered by the Diagnostic Interview Schedule (DIS) or severe cognitive impairment. Between 24% and 38% of all ambulatory visits by persons with DIS disorders were to mental health specialists. In seeking mental health services, men were more likely to turn to the specialty sector than to the generalist; women used both sectors about equally. The aged infrequently received care from mental health specialists. Visits for mental health reasons varied considerably depending on specific types of DIS disorder.

Medication problems among outpatients. A study with emphasis on the elderly.

When patients ascribe adverse symptoms to their medications, the medical care process can be affected. To investigate how often medical outpatients link various adverse symptoms with their medications and to learn what actions they take in response, 299 randomly selected medical outpatients were interviewed. Thirty percent of the subjects identified at least one medication as causing an undesirable symptom. Subjects 65 years or older attributed a lower mean number of adverse symptoms to their medications than did younger subjects. Subjects rarely reported modifying their medication regimens due to adverse symptoms, a finding supported by multiple regression analysis. Approximately one in four subjects did not discuss their symptoms with their providers. These results have important implications for medical care in general, and for the elderly in particular.

Compliance and chronic disease.

The shifting demographics of the population and increasing skill in treatment of chronic disease in this country have combined to make compliance a topic of greater salience than ever before. General issues of compliance are a necessary background to specific issues of compliance with regimens for single diseases such as hypertension. The definition of compliance continues to be modified, and examination of past work reveals certain consistencies in studies of compliance. Non-compliance is higher in chronic conditions, in activities requiring change in life-style, and in clinician-initiated visits. Noncomprehension of instructions is held to be the most frequent cause of noncompliance. Noncompliance is a threat to the course of treatment, increases unnecessary diagnostic procedures, and confounds evaluation of effectiveness. Factors related to compliance have been identified with regard to certain patient and disease characteristics, amount of support in the immediate environment, and the nature of the doctor-patient relationship. Older patients are often at greater risk in understanding regimens because clinicians educate this group less often, because symptoms are misunderstood by both patient and provider, and because of greater complexity in both conditions that are being treated and number of drugs and other aspects of treatment required. Methods of improving the doctor-patient relationship have been urged most recently as a means through which compliance can be increased.

Delusions in newly admitted residents of nursing homes.

Two psychiatrists, using standardized clinical examinations, found that 21% of 125 patients newly admitted to nursing homes had delusions. The psychiatric disorders associated with these delusions are described. Delusional patients were more behaviorally disturbed before admission than nondelusional patients. These behavior problems were often the reason for admission, and they persisted after admission. Nursing home staff members infrequently identified and often inappropriately treated delusional patients. Since delusions are an important potentially treatable cause of behavior problems in nursing home residents, the authors suggest ways to improve the recognition and management of delusions.

Changing patient management: what influences the practicing pediatrician?

To explore some determinants of physicians' decisions to change practice habits, we posed three questions: To what extent are some particular innovations diffused among office-based primary care physicians? What characterizes the physicians who have adopted these innovations? And, what caused them to change their behavior and adopt the innovations? Three "markers," recent innovation in medical practice, were chosen using an expert consensus technique. A telephone survey of 200 office-based pediatricians was conducted, and the physicians were asked whether or not they used the following three innovations in medical practice: continuous rather than intermittent phenobarbital for the prevention of febrile seizures, glycosylated hemoglobin measurement in the management of diabetes, and slow release theophylline in the management of asthma. The questionnaire was completed by 156 pediatricians. Of the 110 pediatricians who cared for diabetics, 73% used glycosylated hemoglobin measurement; of the 145 who saw patients with febrile seizures, 77% prescribed the continuous use of phenobarbital (if they used it at all); and, of the 152 pediatricians who cared for asthmatics, 86% reported using slow-release theophylline. The characteristics significantly associated with using the innovations were board certification, group rather than solo practice, teaching, medically related publications, academic appointment, younger age, and caring for a greater number of patients per week. For two of the innovations, discussion with a colleague was the most important source of information leading to a change of practice. The subjects cited local specialists as the colleagues who most often sparked the adoption of an innovation.

Ascertaining dementia by expert panel in epidemiologic studies of nursing home residents.

A new method for ascertaining dementia in epidemiologic research and the results of a study to evaluate it are described. The method relies on an expert panel of clinicians reviewing clinically relevant information collected by lay evaluators to arrive at a diagnosis based on DSM-III-R criteria. The approach was developed to study dementia in a statewide sample of over 2400 new admissions to 59 nursing homes in Maryland. Expert panel ascertainment of dementia was compared to that obtained by direct clinical evaluation for 100 nursing home residents. Agreement between the panel and direct assessment was 76% (kappa = 0.59) using a three-category classification of dementia, no dementia, and indeterminate. This ascertainment strategy provides an alternative to methods currently in use and is particularly well-suited for populations with a high prevalence, in those dispersed over large geographic areas, and when timely, cost-effective evaluations are required.

Assessing the use of medications in the elderly: methods and initial experience in the Cardiovascular Health Study. The Cardiovascular Health Study Collaborative Research Group.

The Cardiovascular Health Study (CHS), a cohort study of risk factors for coronary heart disease and stroke, recruited 5201 community-dwelling adults aged 65 years or older. To assess the prevalence of medication use at baseline, we used the method of medication inventory and transcribed information about drug names and doses from prescription bottles. Using a specially-written computer program, persons without a knowledge of drug nomenclature coded 10,511 (89%) of the 11,846 medicines entered. We compared the results of the medication inventory and answers to questions on specific medications for reliability and validity. The use of beta-blockers and beta-agonists assessed by the method of medication inventory, but not by the method of directed recall, was associated with a significant effect on mean heart rate. Among 5197 participants with medication data, 76.1% were taking at least one medicine, and the mean number of drugs per person was 2.28. Among those with a reported history of high blood pressure, participants with cardiovascular disease (CVD) were more likely to be treated, and they were more likely to be taking beta-blockers and calcium-channel blockers than those without CVD. Daily aspirin use was also more common among those with CVD (30.5% of women and 43.2% of men) than among those without CVD (14.0% of women and 14.0% of men). The prevalence of post-menopausal estrogen use differed significantly among the four clinical centers (range = 5.5%-22.5% of women). We conclude that this method of assessing medications was easy to use and provided estimates of exposure to drugs that may affect risk of cardiovascular disease.

Mental health of the elderly: use of health and mental health services.

The utilization of services by older patients with mental morbidity is examined in this paper. The population is drawn from a large, multi-site study, the Epidemiological Catchment Area studies, and reports on the findings from the Baltimore, Maryland, site, The Eastern Baltimore Mental Health Survey. The fact that older individuals with mental disorders are less likely to be seen and treated for these disorders than are younger individuals was substantiated by data from this study. Of those under age 65, 8.7 per cent have made a visit to a specialty or primary care provider for mental health care; for those age 65 to 74, the rate is 4.2 per cent, and of those 75 and over, only 1.4 per cent have had such care. In this last group, 75 and over, not a single person saw a specialty mental health provider. The likeliest source of care for older individuals for emotional or psychiatric problems is their primary care providers within the context of a visit made for physical medical problems. Past work and these data suggest that the factors that influence this low level of care can be found in the characteristics of the population as well as in the characteristics of the health care system. The implications of these findings are discussed.

Adverse drug reactions among the elderly: a reassessment.

The elderly are widely believed to be predisposed to adverse drug reactions, chiefly because of the large quantities of drugs they consume, combined with the effects of aging on distribution, metabolism, and the patterns of drug usage. These beliefs affect the physician's prescribing behavior. To study the validity of these concepts, the supporting medical literature was reviewed. Existing studies of the rates of adverse drug reactions have several methodologic limitations, including inadequate control for disease severity, the use of calculation denominators which overestimate incidence, and dependence upon definitions of medication error rates which do not adequately reflect the potential for adverse outcome. Further studies are needed for clarification of drug-use patterns and problems among the elderly.

Knowledge of and compliance with drug regimens in the elderly.

In an interview study of 545 patients recently discharged from The Johns Hopkins Hospital, data were collected on the patients' knowledge of their diseases, knowledge of drug purpose, and compliance with the prescribed drug regimen. The interrelationships of these variables were compared in patients under age 65 and patients aged 65 or older. Age-related factors and trends were sufficiently important to warrant further investigation. Knowledge of and compliance with drug regimens may reflect doctor-patient relationships. Understanding the patterns of drug use offers a potential for appropriate strategies in clinical practice.

Patterns of mental disorders among the elderly residents of eastern Baltimore.

An extensive analysis of prevalence rates of cognitive impairment and other mental morbidities was carried out as part of a five-site national study on the health and mental health of an ambulatory population. This study reports on prevalence rates contrasted by age across the 18 and over population for cognitive impairment and other diagnoses in the Baltimore, Maryland, site of this study. Differences in prevalence rates by age are striking. Eight conditions have rates above 1 per cent among those 64 and younger: phobia (13.8 per cent), alcohol use disorder (6.5 per cent), obsessive compulsive disorder (2.2 per cent), schizophrenia (1.4 per cent), and panic disorder (1.2 per cent). For the older group, 65 to 74 years, five conditions have such prevalence rates: phobic disorder (12.1 per cent), severe cognitive impairment (3.0 per cent), alcohol use disorder (2.1 per cent), obsessive compulsive disorder (2.2 per cent), and dysthymia (1.0 per cent). For the oldest group, those 75 and over, only four conditions have rates of 1 per cent or more. These are: phobic disorders (10.1 per cent), severe cognitive impairment (9.3 per cent), major depression (1.3 per cent), and dysthymia (1.1 per cent). Rates of cognitive impairment increase markedly with age and high rates of this disorder were found among those never married, separated, divorced, or widowed. Implications of these findings for understanding mental morbidity among the elderly and issues for future planning are discussed.

Instruments for screening for depression and dementia in a long-term care facility.

The high prevalence of mental disorders such as depression and dementia in institutionalized elderly patients warrants screening for psychiatric diagnosis in patients newly admitted to long-term care facilities. The diagnostic accuracy of the Mini-Mental State Examination (MMSE) and the Geriatric Depression Scale (GDS) was evaluated against a standardized psychiatric interview. The MMSE was found to be 81% sensitive and 83% specific in screening for dementia using a previously established cutpoint of less than 24/30 points. Adjusting MMSE scores for physical disabilities precluding completion of specific tasks on the MMSE did not significantly change the diagnostic accuracy of the test. The GDS was 47% sensitive and 75% specific in screening for depression using the suggested cutpoint of greater than 13/30 points. The MMSE was significantly correlated with functional status (r = 0.48, P = .0001), but not with the scores on the GDS or the clinical diagnosis of depression. The GDS did not correlate with functional status. In summary, the MMSE is a good screening test for dementia in institutionalized elderly, but the GDS is not sensitive for depression in this population.

Urinary incontinence in nursing homes: incidence, remission and associated factors.

OBJECTIVE: To determine the incidence and remission rates of daytime urinary incontinence (UI) in a cohort of newly admitted nursing home (NH) residents. DESIGN: Prospective cohort study. SETTING: Eight proprietary NHs in Maryland. SUBJECTS: Four hundred thirty new admissions age 65 or older who were participants in a larger prospective study of mental morbidity and adjustment to the NH. MEASURES: Nurses aides' reports of continence status, psychiatric examinations, and nursing staff assessments of mobility at 2 weeks, 2 months, and 1 year after NH admission. RESULTS: The prevalence of daytime UI at admission was 39% in both females and males. Among the 293 members (68%) of the admission cohort remaining in the NHs 2 months after admission, the incidence of daytime UI was 27% (21% in females, 51% in males); daytime UI resolved in 23% (24% in females, 20% in males). Among the 178 members (41%) of the admission cohort remaining in the NHs 1 year after admission, the incidence of daytime UI between 2 months and 1 year after admission was 19% (16% in females, 46% in males); daytime UI resolved in 22% (23% in females, 14% in males). The continence status of about two-thirds of residents remaining in the NH at 1 year after admission was stable over time: 22% had daytime UI, and 42% were continent at all three data collection points. The development of daytime UI was associated with male sex, the diagnosis of dementia, fecal incontinence, and the inability to ambulate or transfer independently. Resolution of daytime UI was associated with the absence of these characteristics. CONCLUSIONS: Despite limitations attributable to the method of defining UI and potential biases related to the attrition of the admission cohort over time, this is the first large prospective study to examine the incidence and remission patterns of daytime UI among NH residents. The strong association between UI and dementia was validated for the first time by direct psychiatric examinations. Sex and mobility are also closely associated with the development and remission of UI in this setting. This study provides some valuable data that can be used to assess the impacts of the recently developed Resident Assessment Protocol for UI and Agency for Health Care Policy and Research Clinical Practice Guidelines.

Physical restraint use and cognitive decline among nursing home residents.

OBJECTIVE: This study investigated the association between physical restraint use and decline in cognition. DESIGN: Cohort analytic study describing changes in resident characteristics. SETTING: Eight nursing homes, both urban and suburban, operated by a proprietary corporation in a large metropolitan area. PARTICIPANTS: 437 nursing home admissions, with 201 remaining at 1 year. MAIN OUTCOME MEASURES: Cognitive status was measured by geropsychiatrists, using the Folstein Mini-Mental State Exam, during a psychiatric evaluation of the resident. Daily restraint use was documented from nursing orders. Observations were made at 2 weeks, 10 weeks, and 1 year. RESULTS: Restraint use alone and in combination with neuroleptic use was associated with poor cognition. Other variables associated with poor cognitive scores were: ADL impairment, poor adaptive behavior, and longer time in the nursing home. The use of neuroleptics alone was not significant. Variables which were associated with good cognitive status were: being non-ambulatory but without dementia and having strong social support. CONCLUSIONS: These findings raise the possibility that restraint use may contribute to cognitive impairment, specifically among residents who have moderate to no cognitive impairment at admission; however, the findings do not exclude an alternative explanation that residents undergoing cognitive decline are more likely to be put in restraints. Further research is needed to understand whether factors which can be manipulated contribute to cognitive decline.

Medical care for nursing home residents: differences by dementia status. Epidemiology of Dementia in Nursing Homes Research Group.

OBJECTIVE: To understand the use of medical services by nursing home residents. DESIGN: Descriptive, longitudinal study comparing medical service use of residents by dementia status and describing the use of medical services following detection of fever or infection. SETTING: Fifty-nine randomly selected nursing homes in Maryland from 1992 to 1995. PARTICIPANTS: 2,153 residents admitted to one of 59 randomly selected nursing homes. MEASUREMENT: A panel of psychiatrists and neurologists ascertained dementia based on review of medical records, interview data with significant others and nursing staff, and results of a cognitive exam. Medical service use was abstracted from medical records. BACKGROUND: Understanding the use of medical services by nursing home residents as distinct from services provided by the nursing home is important, particularly as new medical care models are tested. This study compares the medical service use of residents by dementia status and describes the use of medical services following detection of fever or infection. RESULTS: Residents with dementia compared with those without dementia had lower annual rates of physician visits (10.2 vs 12.7, P < .001) and hospitalizations (0.9 vs 1.2, P < .001), virtually the same rate of emergency department visits, and similar lengths of stay in the hospital. Subsequent to infection, a lower proportion of residents with dementia had either a physician visit, an emergency department visit, or a hospital admission compared with residents without dementia (27.2% vs 32.2%, P < .001). In 87% of infections, an antibiotic was used, implying meaningful contact with a physician. Residents with dementia compared with those without dementia had fewer physician visits subsequent to fevers (20.6% vs 29.9%, P < .001) and infections (21.8% vs 27.5%, P < .001). CONCLUSIONS: The association of less medical service use by individuals with dementia compared with those without dementia may reflect differences in health status or implicit end-of-life decision-making and a proclivity toward less-aggressive treatment for these individuals.

Episodes of illness and access to care in the inner city: a comparison of HMO and non-HMO populations.

Using data from a 1974 household survey, accessibility to ambulatory care is compared for residents of an inner-city area (East Baltimore) whose usual source of care is an HMO (the East Baltimore Medical Plan) and residents of the same area with other usual sources of care. Accessibility is measured by the probability of receiving care for an episode of illness. Results from multivariate linear and probit regressions indicate that children using the HMO are more likely to receive care than are children with other usual care sources, but no significant differences in the probability of receiving care are found among adults. Evidence of a substitution of telephone care for in-person care is also found among persons using the HMO. Data from a 1971 household survey of the same area suggest that selectivity is not an important confounding factor in the analysis.

Satisfaction with health care of dually eligible older beneficiaries.

Satisfaction with health care was compared for dually eligible older beneficiaries receiving care in three settings: a managed care organization (MCO) that is at risk for providing Medicare and Medicaid benefits (n = 200); the fee-for-service (FFS) sector in the same ZIP Code (n = 201); and respondents to the national Medicare Current Beneficiary Survey (MCBS) (n = 531). Patients in the MCO were more likely to be highly satisfied in three domains--global quality, access to care, and technical skills--compared with patients in the local and national FFS study groups but fewer were highly satisfied with the interpersonal manner of their providers.

Predictors of nursing home placement among elderly public housing residents.

This study examines risk factors for nursing home placement among elderly residents of public housing. Data on residents of six urban public housing developments for elderly persons (weighted n = 881) were analyzed by using logistic regression procedures to determine the predictors of nursing home placement during a 28-month period. Four baseline indicators of need were identified: greater impairment in instrumental activities of daily living, cognitive disorder, high scores on the General Health Questionnaire, and psychotic disorder. Thus, functional status and mental morbidity are major contributors to nursing home placement in this setting.

The role of mental morbidity in the nursing home experience.

The history of a newly admitted cohort to eight nursing homes (N = 454) was studied prospectively over the first year of residence. Data were gathered at admission, 2 months, and 1 year, and included full psychiatric examination and staff reports of behavior. Chart reviews collected additional data on preadmission and postdischarge information. At admission, 80% of the population had mental illnesses, 60% of which were dementia, and about half of demented patients had other complicating mental illnesses. Use of mixed-effects linear model analysis revealed significant associations of mental morbidity, restraints, and psychotropic medication with behaviors indicative of noncoping and nonadaptation to the nursing home settings.

Mental illness and the use of restraints in nursing homes.

Using data from 441 newly admitted nursing home residents, we examined whether the diagnoses of mental illnesses, as well as other resident characteristics, were associated with use of physical restraints in both high restraint and low restraint use homes. Predictors of restraint use during both the first month and the first year of admission were inability to transfer and having a combination of severe ADL and cognitive impairment. Other predictors were wandering, inability to dress, symptoms of depression, and severity of cognitive impairment.