Information needs in terminal illness.

Despite evidence that doctor-patient communication affects important patient outcomes, patient expectations are often not met. Communication is especially important in terminal illness, when the appropriate course of action may depend more on patient values than on medical dogma. We sought to describe the issues important to terminally ill patients receiving palliative care and to determine whether patient characteristics influence the needs of these patients. We utilized a multimethod approach, first conducting interviews with 22 terminally ill individuals, then using these data to develop a more structured instrument which was administered to a second population of 56 terminally ill patients. Patient needs and concerns were described and associations between patient characteristics and issues of importance were evaluated. Seven key issues were identified in the initial interviews: change in functional status or activity level; role change; symptoms, especially pain; stress of the illness on family members; loss of control; financial burden and conflict between wanting to know what is going on and fearing bad news. Overall, respondent needs were both disease- and illness-oriented. Few easily identifiable patient characteristics were associated with expressed concerns or needs, suggesting that physicians need to individually assess patient needs. Terminally ill patients receiving palliative care had needs that were broad in scope. Given that few patient characteristics predicted responses, and that the majority opinion may not accurately reflect that of an individual patient, health care providers must be aware of the diverse concerns among this population and individualize assessment of each patient's needs and expectations.

Medical history and risk assessment.

The "graying" of America has resulted in dentists treating increased numbers of elderly patients, 60% of whom are dentate. Since the majority of elderly persons has at least one chronic disease, this chapter addresses critical aspects of history taking and risk assessment for the geriatric dental patient. Self-administered questionnaires have limitations in the geriatric population and the medical history must emphasize functional status, medication use, social support, and financial considerations. Common chronic diseases which potentially increase the risk of adverse events for the geriatric patient undergoing dental care are discussed. Effective dentist-physician communication is pivotal to the successful management of the elderly dental patient.

Measures of paraspinal muscle performance do not predict initial trunk kinematics after tripping.

The ability to limit the trunk flexion associated with an anteriorly directed trip is a determinant of successful recovery of recovering postural stability and is subservient to rapidly detecting and correcting the imposed trunk flexion in the available time. This experiment tested the hypothesis that subjects demonstrating greater eccentric trunk/hip extension strength, faster voluntary reaction times, shorter automatic response latencies, and larger automatic activation amplitudes of the paraspinal muscles, would demonstrate less trunk flexion following a trip. An isokinetic protocol was used to obtain measures of trunk extension strength, response latencies, and activation amplitudes. Motion analysis methods were used to quantify trunk kinematics during the positioning phase of recovery following an induced trip. Statistically significant and functionally meaningful relationships between eccentric strength of the trunk/hip extensors, voluntary-reaction time, automatic reaction time, activation amplitudes and trunk kinematics failed to emerge. Thus, although automatic and voluntary paraspinal muscle responses have the potential to limit trunk flexion during the positioning phase of recovery, the task may be achieved through intersegmental factors or other muscular sources such as the gluteus maximus and hamstrings.

Training of care givers for our aging population.

We cannot rely on geriatricians, internists, and family practitioners alone in the medical community to provide all of the geriatric care. Even though there are alternatives to the use of specialists, we cannot afford to ignore the largest group of current physician trainees who will provide a great deal of geriatric medical care in the future. We need to help make the basic principles of geriatric care part of every training program for every resident, whether in general or specialty programs.

On the assumption of bilateral lower extremity joint moment symmetry during the sit-to-stand task.

This study examined the validity of the assumption of bilateral lower extremity joint moment symmetry during the sit-to-stand motion for a group of young (n = 7) and a group of elderly (n = 7) female subjects. Two force plates and a motion analysis system were used to determine peak joint moments at the ankles, knees, and hips following liftoff from a chair. Statistically, bilateral asymmetries in peak joint moments were found at the knee joint in the young group [a right to left difference of 0.43% BW x BH (body weight x body height)] and at the hip joint in both subject groups (differences of 0.20% BW x BH and 1.09% BW x BH for the young and elderly subjects, respectively). Subsequent data analysis, using an algorithm that assumed bilateral ground reaction force (GRF) symmetry, was performed to determine whether the bilateral differences were a result of kinematic or GRF asymmetry. It was concluded from these results that both the kinematic and GRF data account for the bilateral asymmetry. The results of the subsequent analysis also showed that the method which assumed bilateral GRF symmetry underestimated the peak joint moments at the ankles, knees, and hips, with the greatest difference between methods being 0.10% BW x BH for the ankle joint. The results of this study suggest that the assumption of bilateral symmetry of lower extremity joint moments during the sit-to-stand is not valid. However, the biomechanical significance of the errors associated with assuming symmetry must also be taken into account.(ABSTRACT TRUNCATED AT 250 WORDS)

Factors influencing physicians in recommending in-hospital cardiopulmonary resuscitation.

BACKGROUND: Cardiopulmonary resuscitation (CPR) is a dramatic, costly, and often futile intervention whose appropriate use is under scrutiny. Physicians often ask patients and families to make decisions about resuscitation for themselves or loved ones. Clinical variables and personal beliefs may influence physician recommendations about CPR. METHODS: Physicians (N = 451) at a tertiary care hospital were surveyed to determine the following: (1) the factors they consider when recommending in-hospital CPR, (2) the conditions under which they discuss CPR with patients, (3) their recent participation in CPR attempts, (4) their perceptions of its effectiveness, (5) their personal wishes regarding their own resuscitation, and (6) their personal and professional characteristics. RESULTS: The patient's self-reported wishes about resuscitation and physician judgment of medical utility were the most important influences on physician recommendations. Most physicians believe that patients with metastatic cancer or late Alzheimer's disease should not be resuscitated. Age alone was not viewed as an important clinical consideration. Guidance from hospital policies and ethics committees had the least influence on physicians. Physicians overestimated the likelihood of survival to hospital discharge after in-hospital CPR by as much as 300% for some clinical situations and predicted an overall success rate of 30%. CONCLUSION: These findings suggest that most physicians are thoughtful and discriminating in their recommendations to patients about CPR. Patient's wishes are of paramount importance, followed by physician judgment of medical utility. However, physicians do overestimate the efficacy of CPR and may thus misrepresent the potential utility of this therapy to patients and their families.

Do not resuscitate orders and the cost of death.

BACKGROUND: The appropriate role of cardiopulmonary resuscitation in the hospital continues to be a topic of interest to physicians and patients alike. The use of do not resuscitate (DNR) orders reflects a growing expression of autonomy by patients to refuse medical treatment, and also a growing recognition of its futility in many circumstances by physicians. Although it has been suggested that wider use of advance directives will lead to a reduction in health care costs near the end of life, little empiric data exist to support this prediction. This study was designed to ascertain the rates of DNR orders and their associated costs. METHODS: A retrospective chart review was conducted on the hospital records of 852 of 953 hospital deaths that occurred in a referral hospital. Data were collected on resuscitation status, timing of DNR orders, participants in decision making, and physician and hospital charges. RESULTS: Of the 852 records reviewed, 625 (73%) had a DNR order at the time of death. The use of DNR orders for patients who died ranged from 97% of those on an oncology service to 43% of deaths on cardiology services. One hundred seven patients (17%) had the DNR order before admission. Of 512 patients who had a new DNR order in the hospital, approval was obtained from the patient in only 19%. Patients who died with a DNR order had longer hospital stays (median, 11.0 days) compared with those who died without a DNR order (6.0 days). The time from DNR order to death was 2 days overall with 2.0 days for medical patients and 1.0 day for surgical patients. Average charges for each patient who died were $61,215 with $10,631 for those admitted with a DNR order, and $73,055 for those who had a DNR order made in hospital. CONCLUSION: This study demonstrates high variability in the use of DNR orders between various medical and surgical services. These range from a high of 98% on an oncology service to a low of 43% on cardiology. Most patients have a DNR order at the time of death, but these typically occur late in the course of the hospital stay. Death in the hospital is costly and total hospital and professional charges are significantly lower when a patient is admitted with an established nonresuscitation order compared with those for whom a DNR is established while in the hospital. This study provides a basis against which to measure the impact of efforts such as the Patient Self-Determination Act of 1990 to increase the use of advance directives, as well as monitor their effect on health care expenditures.

Kinematics of recovery from a stumble.

BACKGROUND: Injuries most frequently related to accidents in elderly persons are falls during locomotion and stair ascent and descent. Although numerous risk factors have been related to falling behavior, effective strategies to predict and prevent falls have not evolved. The rationale underlying this study was that systematic experimental and analytical investigation of the effects of perturbations during locomotion and the subsequent requisites for recovery could lead to the development of clinically relevant evaluation(s) capable of identifying a predisposition to falling. The present study is the first biomechanical investigation of recovery from an anteriorly directed stumble. METHODS: Seven healthy, young males participated in this study. While the subjects walked along a walkway in the laboratory, stumbles were unexpectedly induced using a mechanical obstacle. Videotape records of these trials were analyzed and selected sagittal plane kinematics extracted. RESULTS: The perturbation caused an increase in the maximum trunk flexion angle from 4.3 degrees (control) to 18.3 degrees (p = .057), and this change was significantly associated with preperturbation walking velocity (p = .036). The maximum hip and knee flexion angles increased from 26 to 47 degrees (p = .039) and from 60 to 89 degrees (p = .009), respectively. The increases in maximum hip flexion velocity (79%) and maximum knee extension velocity (36%) were not significant. CONCLUSIONS: Identification of the principal elements of control during perturbed locomotion can contribute to understanding the relationship between specific age-related performance deficits and some types of falling behavior. The results suggest that recovery from a stumble is dependent upon lower extremity muscular power and the ability to restore control of the flexing trunk.

Modeling recovery from stumbles: preliminary data on variable selection and classification efficacy.

OBJECTIVE: The primary purpose of this preliminary investigation was to determine the functional relationship between selected information processing time and response execution variables and measures of postural stability in elderly women. A secondary purpose was to explore the efficacy of a neuromotor model using selected variables to retrospectively identify subjects with a self-reported history of falling. DESIGN: Descriptive, retrospective, cohort. SETTING: General community. SUBJECTS: Convenience sample of 17 community-dwelling females with a mean age of 72.2 years. MAIN OUTCOME MEASURES: Postural stability variables included the amplitude and frequency of postural sway during static vision-aided no-vision conditions. Information processing and response execution variables were collected using a simple-choice reaction time paradigm for an isometric knee extension task. RESULTS: Postural stability and information processing variables were functionally independent. Based upon significant intergroup differences, simple and choice pre-motor reaction time and non-vision aided anterior posterior sway amplitude were selected for inclusion in a discriminant analysis. The resulting discriminant function was significant (P = 0.01), correctly categorizing all of the subjects with a self-reported history of falling and identifying six out of seven of the non-fallers. CONCLUSIONS: These preliminary results suggest that it is feasible to identify a predisposition to falling by detecting an inability to respond successfully to a postural disturbance.

Cardiopulmonary resuscitation: how useful? Attitudes and knowledge of an elderly population.

Two hundred forty-eight elderly outpatients completed a survey designed to assess knowledge about the procedural aspects and efficacy of in-hospital cardiopulmonary resuscitation. We found that older people overestimate the percentage survival to actual hospital discharge following in-hospital cardiopulmonary resuscitation by nearly 300%. Most older people also have definite opinions about the appropriate application of cardiopulmonary resuscitation for different clinical circumstances. Most believe that patients with advanced Alzheimer's disease or widespread cancer should not be resuscitated, while patients with depression or early Alzheimer's disease should. Inaccurate beliefs about cardiopulmonary resuscitation efficacy can adversely impact on decision making about resuscitation by older patients. Educational efforts for the elderly may lead to more informed decision making and thereby more appropriate use of this technology.

Managing hypertensive emergencies and urgencies in the geriatric patient.

The aging cardiovascular and renal systems put the elderly patient at increased risk of end-organ damage from marked hypertension. Thus, the office-based physician needs to be skilled in making the diagnosis of a hypertensive urgency or emergency based on accurate blood pressure readings and an assessment of the heart, brain, retina, and kidney. Hypertension urgency and emergency are distinguished from each other by the clinical decision of how quickly the blood pressure must be lowered. The clinician has a wide variety of agents from which to choose for pharmacologic treatment, with the goal being a smooth and safe reduction in blood pressure.

Working group recommendations: research on content and efficacy of geriatric evaluation and management interventions.

Methods of conducting comprehensive geriatric evaluation and management (GEM) are proliferating in a variety of clinical settings. However, rigorous evaluations of efficacy for this new approach to care of older patients have demonstrated a favorable impact on patient outcome in only a few studies. All of these have been controlled single site studies, and replication is needed. If replication studies show similar results, further studies should be undertaken to define the minimum necessary intervention to achieve the desired outcome. Controlled trials are needed to determine if consultative geriatric evaluation and/or primary patient management is effective. Further innovative work is needed in model development for geriatric assessment and management in outpatient settings. Finally, studies of geriatric evaluation and management in other environments, such as home care or the nursing home, are recommended.

Atrial fibrillation in the elderly: management update.

Non-valvular atrial fibrillation is associated with a markedly increased risk of embolic stroke in elderly persons. Evidence is accumulating that anticoagulation with warfarin or aspirin may be effective in reducing this risk.

Antibody response of an elderly population to a supplemental dose of influenza B vaccine.

Recent reports have suggested that the antibody response of elderly persons to standard doses of influenza vaccine is depressed. We examined the effect of an additional threefold dose of influenza B vaccine on the antibody response in elderly, ambulatory veterans. One hundred thirty-one male subjects aged 70 years and older were randomized to receive one of three influenza vaccine regimens: Group I received standard trivalent influenza vaccine containing 15 micrograms of B/USSR/100/83 in one arm and placebo in the other; Group II received standard trivalent vaccine in one arm and a supplemental dose of 45 micrograms of B/USSR in the other; Group III received the same dose as group II combined in one arm with a placebo in the other. Antibody levels were measured at baseline, 1 month, and 5 months. Nearly 80% of the participants achieved levels of antibody to B/USSR considered protective; seroconversion rates varied from 40% to 61%. No significant differences in antibody response to B/USSR occurred among the vaccine groups, and there were more side effects at higher doses. The higher dose groups did, however, achieve greater antibody levels to the drifted influenza B virus which circulated during the year of the study. Response to the influenza A components of the vaccine, however, may have been blunted in Group III which received a large dose of A and B antigens all at one site.

Inefficacy of pneumococcal vaccine in a high-risk population.

Use of pneumococcal vaccine remains controversial. To further study this question, 89 patients hospitalized at the Denver Veterans Administration Medical Center with pneumococcal bacteremia were chosen as the case group for a case-control study. The control group was made up of patients matched on the basis of age, date of admission, and comorbid conditions. Vaccination status in the bacteremic patients and control patients was determined, as were pneumococcal serotypes among the bacteremic patients. If the vaccine were protective, vaccination rates should be higher among the control patients, and serotype distribution should be different in vaccinated and nonvaccinated bacteremic patients. There were no differences between vaccination rates among bacteremic patients (29 percent) and control patients (24 percent). Furthermore, 65 percent of the blood isolates from nonvaccinated bacteremic patients were serotypes included in the vaccine, as compared with 69 percent of the isolates in vaccinated bacteremic patients. Pneumococcal vaccine did not appear to be protective in this high-risk population.

Evaluation of eight methods for estimating creatinine clearance in men.

Eight methods for estimating creatinine clearance (CLcr) were compared in 65 men with serum creatinine concentrations (SCr) less than or equal to 1.5 mg/dL (group 1) and 65 men with SCr greater than 1.5 mg/dL (group 2). All patients had SCr values that did not fluctuate by more than +/- 10% for two weeks before and two weeks after measurement of CLcr. For each patient, predictions of CLcr by each of eight currently used formulas were compared with measured CLcr values; both regression analysis and predictive error analysis were used. Group 1 patients ranged in age from 32 to 64 years (mean, 53), weighed from 48 to 105 kg (mean, 73), and were from 63 to 79 inches in height (mean, 69). Group 2 patients ranged from 26 to 63 years of age (mean, 53), weighed from 34 to 141 kg (mean, 80), and were from 63 to 76 inches in height (mean, 70). Measured CLcr values ranged from 29.8 to 197 mL/min in group 1 and from 2.8 to 118 mL/min in group 2. Ranges of SCr values were 0.7-1.5 mg/dL (mean, 1.1) in group 1 and 1.6-7.1 mg/dL (mean, 2.8) in group 2; the formula of Cockcroft and Gault, which uses age, body weight, and SCr, had the highest correlation and the greatest accuracy in group 1, whereas the formula of Jelliffe, which uses body surface area and SCr, had the highest correlation and the greatest accuracy in group 2. Estimation of creatinine clearance can be improved by identification and use of the formula that is best suited to a specific patient population.