Home-care programmes for older adults with disabilities in Canada: how can we assess the adequacy of services provided compared with the needs of users?

The need for home care will probably continue to increase over the next decade as one response to innovative health practices designed to help people receive services at home instead of in institutions. However, there are no data for determining whether home-care programmes can meet user needs. The objectives of the present study were to describe the functional autonomy profile of the users of public home-care programmes in Québec, Canada, and to compare the level of adequacy between required and provided services in public home-care programmes for older adults with disabilities. This study was based on a cross-sectional design from September to December 2002. The population studied consisted of all users of public home-care services in one administrative region in the province of Québec over this 3-month period. Each user was assessed with the Functional Autonomy Measurement System (SMAF) and then classified into one of the 14 Iso-SMAF profiles. The total number of hours of care required was determined using the median number of hours of nursing care, personal care and support services associated with each profile. For the sake of comparison with the services required, the services provided were calculated from an administrative databank that included statistics of the time spent by health professionals on caring for home-care users. The ratio of hours of services provided to the number of hours of services required by home-care users highlights a discrepancy between the services provided and user needs. The results of this study show the feasibility of describing users of public home-care programmes and the adequacy of services provided in relation to user needs. Based on these results, public home-care programmes in the province of Québec appear to be under-funded.

Quality of life in type 2 diabetes patients under intensive multitherapy.

AIM: To assess the impact of an intensive multitherapy (IMT) on perceived quality of life (QOL), attitudes, knowledge and diabetes self-management in patients with poorly controlled type 2 diabetes. METHODS: A 12-month randomized trial was conducted in 72 patients with type 2 diabetes, HbA1c>or=8%, blood pressure (BP)>130/80 mmHg and dyslipidemia. Subjects were assigned to the IMT or control group, each n=36. IMT consisted in monthly visits including clinical and biochemical assessment, education sessions on diet, physical exercise, medical management of diabetes and associated diseases and adjustments in medication. Control patients were under the care of their physicians. We developed and validated a diabetes-specific questionnaire assessing QOL, attitudes, knowledge, diabetes self-management and socio-demographic data for this study. Outcomes were measured at 0, 6 and 12 months. RESULTS: Subjects were 54.8+/-8.1 years old (duration of diabetes: 10.3+/-7.2 years). At baseline, questionnaires showed no difference in QOL between groups. At 12 months, QOL improved significantly in the IMT group when compared to controls (+13.2+/-10.3/+5.6+/-13.2%, P=0.003), particularly with respect to the satisfaction scale (+25.3+/-13.9/+5.4+/-21.7%, P<0.001). QOL was not affected by complications or hypoglycaemic episodes. QOL scores improved in IMT subjects who began insulin therapy during the trial. Attitude scores, in the high normal range at baseline, did not change. Knowledge (+18.2+/-26.3/+8.9+/-30.4%, P=0.047) and diabetes self-management (+22.6+/-35.3/+6.8+/-20.1%, P<0.001) improved. CONCLUSIONS: In poorly controlled subjects, QOL improved statistically despite the inherent constraints imposed by IMT.

Functional autonomy measurement system: development of a social subscale.

The purpose of this study was to develop a subscale assessing social functioning for the functional autonomy measurement system (SMAF). The development of this new dimension was based on consultations (focus groups and nominal groups) of experts from different health care disciplines in Quebec, Canada, and France. Two interrater reliability studies were carried out with older people presenting a loss of functional autonomy and living either in an institution or at home. With the focus groups, the experts clarified the definition of social functioning and identified the factors involved. The nominal groups were used to construct a subscale composed of six items. The results of the first interrater reliability study showed a mean agreement percentage of 60% for the subscale and an intraclass correlation coefficient (ICC) of 0.70 (CI: 0.57-0.80). The results of the second interrater reliability study showed higher coefficients with an agreement percentage of 74% for the subscale and an ICC of 0.83 (CI: 0.61-0.93). These preliminary results demonstrate that the new social functioning subscale has good reliability, but more studies are needed to show its validity. The new SMAF, including the social functioning subscale, should help clinicians and researchers to obtain a comprehensive profile of functional autonomy. It could also contribute to the improvement of health care for older people.

Effects of aerobic physical exercise in the elderly with type 2 diabetes mellitus.

The objective of this study was to determine the impact of an aerobic physical exercise program in the treatment of a group of elderly patients with type 2 diabetes mellitus (DM) in relation to metabolic control, physical capacity, quality of life (QOL) and attitudes toward diabetes. Patients were randomly assigned to either an experimental (n=19) or a control (n=20) group. The following measurements were conducted at baseline and after week 16: glycosylated hemoglobin (hbA1c), fructosamine, 3 h oral glucose tolerance test, treadmill test (Balke-Naughton), and a questionnaire on QOL and attitudes toward DM. After the intervention, the experimental group showed a significant decrease of glucose excursion during the oral glucose tolerance test (OGTT) (area under the curve) (16.6+/-3.8 vs. 15.3+/-3.1, P<0.05) and an increase in total time on the treadmill (s) (423+/-207 vs. 471+/-230, P<0.05). An improvement in the attitudes toward DM was observed in the experimental group (P=0.01) but not in the control group. Female gender, higher body mass index and hbA1c were factors associated with a response to the intervention. This study suggests that physical exercise has significant effects on glucose excursion during an OGTT and exercise tolerance in elderly patients with type 2 DM.

Reliability of the revised functional autonomy measurement system (SMAF) for epidemiological research.

The Functional Autonomy Measurement System (SMAF) is an instrument designed to assess disabilities related to 29 functions with a four-point scale (from 0: independent to -3: dependent). For epidemiological studies, a total score and five sub-scores can be obtained. A revised version was developed adding a -0.5 level to many items to indicate an activity accomplished independently but with difficulty. The objective of the study was to verify the test-retest and inter-rater reliability of the total score and sub-scores of the SMAF. Ninety subjects were randomly recruited in nine different residential settings ranging from home to long-term-care hospitals. Half of the subjects were assessed by the same nurse within a 2-week interval (test-retest) and the other half were assessed twice by two different nurses within the same interval (inter-rater). Results show intra-class correlation coefficients (ICC) of 0.95 and 0.96 for the total scores on test-retest and inter-rater reliability, respectively. The ICC were over 0.74 for all sub-scores for both types of reliability. A small systematic bias was present for two SMAF subscores on the inter-rater reliability. The addition of a new level did not modify the reliability of the scale.

Cystic dilatation of intrahepatic bile ducts in primary sclerosing cholangitis.

A case of primary sclerosing cholangitis associated with cystic dilatations of intrahepatic bile ducts simulating Caroli's disease is described. The diagnosis of primary sclerosing cholangitis was based upon cholangiogram features, liver histologic examination and the association with chronic ulcerative colitis. It may be suggested that the cystic dilatation of intrahepatic bile duct represents an extreme form of the usual mild dilatations (cholangiectases) described in primary sclerosing cholangitis. We suggest that cystic dilatation of intrahepatic bile ducts could be included among the radiologic features of this disease.

Epstein-Barr virus infection and hepatic fibrin-ring granulomas.

Hepatic fibrin-ring granulomas were the main histological finding in the liver of a 38-year-old man with Epstein-Barr virus primary infection. The patient presented with fever, hepatomegaly, icterus, abnormal liver tests, autoimmune hemolytic anemia, and mononucleosis syndrome. There was neither enanthema nor lymphadenopathy or splenomegaly. Serologic tests disclosed an Epstein-Barr primary infection profile: anti-viral capsid antigen IgM antibodies and anti-early antigen antibodies were present, whereas anti-Epstein-Barr nuclear antigen antibodies were absent. There was no evidence for Q fever, Hodgkin's disease, or allopurinol-induced hepatitis, which are recognized causes of hepatic fibrin-ring granulomas. It is suggested that Epstein-Barr virus infection might be an additional cause of these peculiar hepatic granulomas.

[Pulmonary arterial hypertension and chronic obstructive bronchopneumopathy]. / Hypertension artérielle pulmonaire et bronchopneumopathie chronique obstructive.

Sooner or later, chronic obstructive lung disease becomes complicated with pulmonary arterial hypertension, largely responsible for chronic cor pulmonale. Its principal cause is an increase in pulmonary resistance due to chronic hypoxia. There is no non-invasive method that can be used to measure pulmonary arterial pressure (PAP) with accuracy. In the course of chronic obstructive lung disease PAP increases slowly, by about 0.5 to 0.6 mmHg per year. As mortality factor, it is the second major variable after FEV1. The usefulness of specific vasodilators has not yet been demonstrated.