Observational study of the medical management of patients with peripheral artery disease.

BACKGROUND: Previous research has suggested that patients with peripheral artery disease (PAD) are not offered adequate risk factor modification, despite their high cardiovascular risk. The aim of this study was to assess the cardiovascular profiles of patients with PAD and quantify the survival benefits of target-based risk factor modification. METHODS: The Vascular and Endovascular Research Network (VERN) prospectively collected cardiovascular profiles of patients with PAD from ten UK vascular centres (April to June 2018) to assess practice against UK and European goal-directed best medical therapy guidelines. Risk and benefits of risk factor control were estimated using the SMART-REACH model, a validated cardiovascular prediction tool for patients with PAD. RESULTS: Some 440 patients (mean(s.d.) age 70(11) years, 24·8 per cent women) were included in the study. Mean(s.d.) cholesterol (4·3(1·2) mmol/l) and LDL-cholesterol (2·7(1·1) mmol/l) levels were above recommended targets; 319 patients (72·5 per cent) were hypertensive and 343 (78·0 per cent) were active smokers. Only 11·1 per cent of patients were prescribed high-dose statin therapy and 39·1 per cent an antithrombotic agent. The median calculated risk of a major cardiovascular event over 10 years was 53 (i.q.r. 44-62) per cent. Controlling all modifiable cardiovascular risk factors based on UK and European guidance targets (LDL-cholesterol less than 2 mmol/l, systolic BP under 140 mmHg, smoking cessation, antiplatelet therapy) would lead to an absolute risk reduction of the median 10-year cardiovascular risk by 29 (20-38) per cent with 6·3 (4·0-9·3) cardiovascular disease-free years gained. CONCLUSION: The medical management of patients with PAD in this secondary care cohort was suboptimal. Controlling modifiable risk factors to guideline-based targets would confer significant patient benefit.

Origins and development of geriatric medicine in Australia.

After a tentative beginning 50 years ago, geriatric medicine has become an accepted part of medical practice in Australia. It includes the rehabilitation of elderly people, general aspects of aged care in the community, undergraduate and postgraduate education and research.

The development of geriatric medicine in Australia.

Geriatric medicine has been slow to evolve in Australia for bureaucratic and other reasons. The rapid increase in the aged population demands that a coordinated approach be taken in the future.

A study of the characteristics and needs of people transferred from acute hospitals to nursing homes.

OBJECTIVES: To describe the categories of people being approved for admission to nursing homes; to consider whether any alternatives would have been more appropriate; and to outline the care needed for each category. PARTICIPANTS AND SETTING: Patients in acute-care facilities in metropolitan Perth for whom a request had been made for nursing home admission. DESIGN: Patients were interviewed (by R B L and M D) and records in the acute hospital were examined. A second interview of those patients still available was conducted after their transfer to the nursing home. RESULTS: Nursing care was considered necessary for 123 of the 201 people seen in the acute hospitals; domestic care in a standard hostel for 24 people; care in a special dementia unit (SDU) hostel for 26 people; and care in a psychiatric institution for 16 people. Twelve others had various specific needs. Several different categories were identified in the group needing nursing care. CONCLUSIONS: Applicants for nursing home admission do not form a homogeneous group; there are several categories with different needs. SDU hostels should be added to the available facilities. In addition to undertaking the assessment of nursing home applicants, personnel from geriatric services should be encouraged to become involved in their continuing care.

Retention and survival of hostel residents--a 12 year study.

BACKGROUND: The admission of a proportion of disabled people to hostels is inevitably followed by their transfer to nursing homes. Our hypothesis was that such admissions are justified in terms of quality of life and the cost to the community, notwithstanding the necessity of subsequent transfer. AIMS: To test this hypothesis by measuring the retention and survival times of residents in hostel and in nursing home; to consider the relevance of these factors to the future policy of the two institutions. METHODS: A retrospective study was made of 159 residents admitted over a period of 12 years to a hostel with 32 places. Times spent in the hostel and in the nursing home were recorded. Probabilities of survival in hostel and in nursing home were calculated according to the Kaplan-Meier method. Comparison with the expected survival of a matched cohort of the total population was determined. Estimation was made, using the SAS software package, of the likely number of places needed in nursing homes for residents following transfer. RESULTS: Although the majority of hostel residents eventually needed nursing home care, a worthwhile proportion of their total institutional time (approximately two-thirds) was spent in the hostel. Ongoing support from the personnel in a geriatric service is likely to increase retention time in the hostel. Because of the ultimate outcome for the majority of residents, planning for hostel care should include consideration of places needed in nursing homes.

A five-year study of residents of a special hostel for people with dementia.

In order to consider whether admission to a special hostel was a desirable policy in view of the likelihood of subsequent transfer to a nursing home, this study compared the time spent by residents in a special hostel with the period in a nursing home after they were transferred out of the hostel. We also estimated the number of nursing home places necessary for residents who were transferred and studied the reasons for transfer. The setting was a special hostel in Perth, Western Australia, for 36 people with moderate or severe dementia. The periods spent in the hostel or a nursing home were calculated for all residents admitted between 1985 and 1990. Forty-two of the 84 residents admitted during the study period were transferred to nursing homes. About two thirds of the total time in the two institutions was spent in the hostel. The two principal reasons necessitating transfer to a nursing home were advancing dementia and the addition of a physical impairment. Because a major proportion of the care of selected people with dementia (who can no longer remain at home) can be undertaken in a special hostel, this facility should be included with standard hostel and nursing home in arrangements for institutional care. Between 20 and 25 nursing home places are necessary for residents transferred from a hostel of this size.

Effects on care-givers of special day care programmes for dementia sufferers.

Two groups of care-givers to dementia sufferers were interviewed to assess their psychological symptoms and the behaviour problems of the dementia sufferers. The first group were using special dementia day care while the second group were about to begin using it. The second group were re-interviewed three months later. Therefore two comparisons could be made; a with/without day care comparison and a before/after admission to day care comparison. Care-givers had a high level of psychological symptoms which were not significantly reduced by using day care. Full-time institutional care did reduce distress. Day centre clients continued to deteriorate as would be expected with a degenerative condition. While special dementia day care centres appear to play a useful role for many care-givers, they may provide too few hours relief per week to markedly reduce the care-givers' psychological symptoms. Family care-givers currently take the major role in caring for dementia sufferers in the community and the burden of care needs to be shared more equitably.

Medical care of elderly people: the place of the general hospital.

A strategy is necessary in order to provide adequate medical care for an increasing number of elderly people. It can either be developed separately or within existing medical services. The characteristics of elderly disabled people need to be considered in order to determine policy. This has been influenced by the legacy from the past developments which have occurred in Britain and elsewhere as well as by certain constraints currently present. A hospital based system which has a regional responsibility is the favoured method. Hospitals and those who are particularly concerned with medical services for elderly people have a reciprocal need for each other. The increasing trend towards specialisation provides an opportunity for the physician concerned with elderly people to serve as a general physician while continuing to exercise his special interests. By this means it would be possible for the medical care of elderly people to be developed within the mainstream of medicine rather than as a separate entity as has been the practice in the past.

Neuroleptic malignant syndrome.

Three cases of the neuroleptic malignant syndrome, which complicated treatment with haloperidol, fluphenazine and, in one case, with several drugs, are described. All three patients recovered and, in two, levodopa appeared to modify the course of the condition. In one patient, myoclonus was present and has persisted. The pharmacological mechanisms involved in this syndrome are discussed.