Institutional efforts to promote advance care planning in nursing homes: challenges and opportunities.

In an empirical study of Connecticut-area for-profit and nonprofit nursing homes, authors examine use of institution-specific advance care planning forms among nursing home residents.

Analysis of change in self-reported physical function among older persons in four population studies.

Change in self-reported physical function was examined using baseline and 5 years of follow-up data between 1982 and 1991 from the four Established Populations for Epidemiologic Studies of the Elderly studies. In East Boston, Massachusetts (n = 3,809), Iowa and Washington Counties, Iowa (n = 3,673), New Haven, Connecticut (n = 2,812), and North Carolina (n = 4,163), noninstitutionalized persons aged 65 years and older were asked a series of questions to assess their physical function: a modified Katz Activities of Daily Living (ADL) scale, three items from the Rosow-Breslau Functional Health Scale, and questions on physical performance, adapted from Nagi, as well as information on demographic, social, and health characteristics. Longitudinal statistical analyses (random effects and Markov transition models) were used to evaluate improvement, stability, and deterioration in functional ability at both an individual and a population level over multiple years of data. The average decline in physical function associated with age was found to be greater than previous cross-sectional studies have suggested, and the rate of decline increased with increasing age. Considerable individual variation was evident. Although many people experienced declines, a smaller but substantial portion experienced recovery. Women reported a greater rate of decline in physical function and were less likely to recover from disability.

Urinary incontinence knowledge among community-dwelling people 65 years of age and older.

OBJECTIVES: We determined elderly persons' knowledge about the epidemiology and treatment of urinary incontinence (UI) as part of a preintervention survey for the Educational Demonstration of Urinary Continence Assessment and Treatment for the Elderly (EDUCATE). DESIGN: An intact-group pretest-posttest design was employed to measure the effects of multimethod educational interventions on the knowledge, attitudes, and practices of physicians and older people concerning UI. PARTICIPANTS: A random sample of community-dwelling people aged 65 years and older from two counties in Massachusetts was selected (n = 1,140). MEASUREMENT: A 14-item urinary incontinence quiz was developed from information presented in the AHCPR UI Guideline Panel's recommendations. Participants answers to the quiz were part of a 20-minute telephone interview. RESULTS: For nine of the fact items, the elderly respondents were more likely to give the correct answer than the incorrect answer. However, for only four of those nine did the percentage of correct responses exceed 50% (there were substantial proportions of "don't know" responses). For several fact items, those who were younger, female, or had more formal education were more likely to provide correct responses. CONCLUSIONS: There are substantial gaps in the knowledge of older persons about urinary incontinence, especially among men, those age 85 and older, and those with lower levels of education. These knowledge gaps may contribute to misinterpretation of symptoms and underreporting of symptoms to health care professionals. This pattern of findings indicates a greater need for community education on urinary incontinence.

Acute delirium and functional decline in the hospitalized elderly patient.

BACKGROUND: Delirium is often considered a transient cognitive syndrome. Its effect on long-term physical function, however, has not been well defined. METHODS: In a prospective study of 325 hospitalized community and nursing home elderly, we analyzed the effect of in-hospital delirium on subsequent physical function. ADL performance was assessed prior to admission, and at 3 and 6 months after hospital discharge. RESULTS: There was a strong univariate (unadjusted) association between incident delirium and functional decline (p < .02). Delirious subjects lost a mean of almost one ADL, as measured 3 months after hospital discharge. Using multivariate linear regression analysis, with adjusted change in function as the dependent variable, delirium persisted as the sole predictor of loss of function (p = .009) at 3 months after discharge. The functional decline persisted at 6 months after hospital discharge. CONCLUSION: This finding of a nontransient, perhaps permanent consequence of delirium invites reexamination of the definition of delirium from that of an acute, reversible syndrome to one of acute onset with long-term sequelae.

Delirium. The occurrence and persistence of symptoms among elderly hospitalized patients.

We evaluated the occurrence and persistence of delirium in 325 elderly patients admitted to a teaching hospital from either a defined community or a long-term care facility. Of the study participants, 34 (10.5%) had Diagnostic and Statistical Manual of Mental Disorders, Third Edition--defined delirium at initial evaluation; of the remaining patients, 91 (31.3%) developed new-onset delirium. An additional 110 patients also experienced individual symptoms of delirium without meeting full criteria. Preexisting cognitive impairment and advanced age were associated with increased risk of incident delirium in the community sample but not the institutional one. Delirium was not associated with an increased risk of mortality, but it was associated with a prolonged hospital stay and an increased risk of institutional placement among community-dwelling elderly. Only five patients (4%) experienced resolution of all new symptoms of delirium before hospital discharge, and only 20.8% and 17.7%, respectively, had resolution of all new symptoms by 3 and 6 months after hospital discharge. These data suggest that delirium is a common disorder that may be substantially less transient than currently believed and that incomplete manifestations of the syndrome may be frequent.

Active life expectancy for 10,000 Caucasian men and women in three communities.

Active life expectancies (ALEs) were calculated using increment-decrement life table techniques for 10,000 Caucasian men and women from three geographic areas. This technique is more appropriate than the single decrement model originally used, and resulting ALE was substantially greater among initially independent men and women aged 65 years: from 9.3 for men and 10.6 for women to 11.3 to 13.0 for men and 15.5 to 17.1 for women. These increases may be attributable to factors other than the change of method, however, including the change in time from 1975 to 1982 and the change from one state to three communities. The sex differences suggest that the added years of life that women have enjoyed over men are neither solely added years of vigor nor solely added years of disability, but added years with the same mix of independence/dependence that the shorter-lived males experience. The age patterns suggest that at any age the future presents a relatively constant expectation of the total duration of dependency, and concordantly, as one ages, there is a relatively uniform decrease in the proportion of active life to remaining years.

An empirical study of diagnostic criteria for delirium.

OBJECTIVE: The objective of this study was to determine empirically how many patients are identified as delirious or nondelirious according to DMS-III, DMS-III-R, and ICD-10 criteria. METHOD: Daily, a trained research assistant using a structured instrument to detect the presence of symptoms of delirium evaluated 325 elderly patients who were admitted to a general hospital for acute medical problems. Each patient's symptoms were then compared with these diagnostic criteria sets to determine if the patient met criteria for delirium. RESULTS: DSM-III criteria were the most inclusive: they identified 125 patients as delirious. DSM-III-R identified a somewhat different group of 106 patients as delirious. ICD-10 criteria identified only 30 patients as delirious. CONCLUSIONS: The development of new criteria for delirium (e.g., DSM-IV) will have to balance the need to define a pure group of patients for research purposes with the need to include cases of clinical interest. Changes in criteria should be based on data such as those presented in this paper.

A prospective study of incident comprehensive medical home care use among the elderly.

This prospective study directly examines, in a defined community population, the extent to which a wide array of characteristics predict utilization of an important long-term care (LTC) service--medical home care--over a two-year interval among the cohort of 3,706 people aged 65 or older. The overall age-sex adjusted rate of two-year incident home care use was 3.2 per cent. For both men and women, the rates among the aged 85 or older group were approximately 12 times the rates of those aged 65 to 74. The multivariate predictors of incident home care, adjusted for age and sex, were five: receiving help with at least one activity of daily living (ADL), being dependent in Rosow-Breslau functional health areas, being homebound, more errors in mental status items, and no involvement with social groups. The dominance of indicators of frailty in physical function and cognitive function are consistent with the predictors of another group of LTC clients, those who subsequently enter nursing homes. However, in the present study the ratios of medical home care use were similar for those living alone and for those living with others in the multivariate model, suggesting the possibility of differences between home care and institutional LTC clients.