Relative importance to elderly patients of effectiveness, adverse effects, convenience and cost of antihypertensive medications. A pilot study.

This pilot study was designed to investigate the attitudes of elderly patients regarding the choice of drugs for the treatment of hypertension. A questionnaire was administered to a sample of elderly patients receiving antihypertensive therapy regarding effectiveness, adverse effects, cost and convenience. Forced choices were used in order to reflect practice realities. 44 patients, mean age 75.2 years, rated effectiveness and adverse effects more important than cost and convenience. Choices regarding adverse effect risk were slightly influenced by costs of the drugs and insurance status of the patients. Choices regarding convenience were heavily influenced by financial considerations. Our study indicates that elderly patients are most concerned about effectiveness and safety, and express a willingness to pay more for these qualities in their antihypertensive drugs.

Risk factors and consequences of bacteriuria in non-catheterized nursing home residents.

BACKGROUND: There has been disagreement over the significance of bacteriuria in nursing home residents. METHODS: During an 18-month period, the risks and consequences of bacteriuria (BU) in 195 residents of a skilled nursing facility without indwelling catheters were examined. Clinical and epidemiologic data and urine for culture were collected every 2 weeks to identify risk factors, symptoms, and occurrences of BU. A mean of 23 cultures per resident was collected. RESULTS: Forty-three percent of the study population (35% of men; 47% of women) had "persistent BU" defined as > 10(5) cfu/ml of urine on > 25% of an individual's collected cultures. Women with persistent BU more frequently were incontinent of bowel and bladder (OR 5.3, 6.3, respectively), more likely to be functionally disabled (OR 3.2), to carry a diagnosis of dementia (OR 2.4), and less likely to have suffered a stroke (OR 0.40). Cancer (OR 6.5) was the only risk factor for persistent BU in men. The number of antibiotic courses prescribed, frequency of hospitalizations, and mortality rates were not significantly different between the two BU groups in either men or women. CONCLUSIONS: Persistent BU is common in nursing home residents. The association of bowel and bladder incontinence and functional disability with persistent bacteriuria suggests that treatment or prevention of these risk factors may prevent or decrease the incidence of bacteriuria. There was no evidence of significant adverse outcomes resulting directly from the bacteriuric state. Higher mortality in the bacteriuric group was the result of underlying functional debility and severity of illness rather than the presence or persistence of BU.

Balance improvements in older women: effects of exercise training.

BACKGROUND AND PURPOSE: Loss of lower-extremity strength increases the risk of falls in older persons. The purpose of this study was to test the hypothesis that a vigorous program of lower-extremity strengthening, walking, and postural control exercises would improve the single-stance balance of healthy older women and lower their risk of falls and fall-associated injuries. SUBJECTS: From a total of 38 respondents, 21 women were randomly assigned to either a treatment group (combined training, n = 12) or a control group (flexibility training, n = 9). The subjects ranged in age from 62 to 75 years (mean = 68, SD = 3.5). METHODS: A randomized control trial compared the effects of two exercise programs on static balance. The combined training group exercised three times per week on knee extension and sitting leg press machines, walked briskly for 20 minutes, and performed postural control exercises, which included simple tai chi movements. The flexibility training group performed postural control exercises weekly. Measurements of balance were obtained on a force platform in double and single stance, at baseline and following 6 months of exercise training. RESULTS: Double-stance measurements were unchanged after training. The mean displacement of the center of pressure in single stance improved 17% in the combined training group and did not change in the flexibility training group. A repeated-measures analysis of variance revealed that the difference in improvement between the combined training and flexibility training groups was not significant. DISCUSSION AND CONCLUSION: This is the first intervention trial to demonstrate improvements in single-stance postural sway in older women with exercise training. Additional studies with more subjects will be needed to determine whether a combined training program of resistance training, walking, and postural exercises can improve balance more than a program of postural control exercises alone.

Tuberculin reactivity is low among residents of a Connecticut nursing home.

Of 131 residents of a suburban New England intermediate and skilled nursing facility, 126 agreed to be evaluated by two-stage administration of purified protein derivative (5TU) for tuberculin reactivity. Only eight patients (6.4%) had a positive reaction, considerably fewer than reported by most previous studies. There were no statistically significant differences between reactors and nonreactors based in age, gender, or length of stay in the facility. There was a tendency toward an association of presence of risk factors and a positive response to tuberculin skin testing, but this did not achieve statistical significance (P = 0.063).

Predictors of advance directive restrictiveness and compliance with institutional policy in a long-term-care facility.

OBJECTIVE: To ascertain factors influencing the level of advance directives selected by nursing home residents or surrogates and the time delay to documentation of these choices in the medical record after implementation of a facility-wide policy. DESIGN: Longitudinal cohort study of nursing home residents followed from date of advance directive policy initiation or time of admission for a maximum of 21 months from study commencement. SETTING: A 315-bed multilevel nursing home. PARTICIPANTS: Four hundred twenty-four nursing home residents (mean age 85, 74.9% female, 96.1% white). OUTCOME MEASURES: Level of advance directive status chosen--full code, do not resuscitate (DNR) or palliative care only--and date documented in the medical record. RESULTS: Factors predictive of restricted advance directives (DNR or palliative care) included age greater than 85 years (P = 0.025), documented use of a surrogate decision maker (P = 0.001), low physical function (P less than 0.001), low cognitive function (P less than 0.001), and having a nursing home-employed physician (P = 0.001). These results were confirmed using logistic regression models. Median time to directive documentation decreased from 54 days for residents admitted in the first quarter to 1 day for residents admitted in the fourth quarter of the year following initiation of an advance directive policy. CONCLUSION: In logistic models, nursing home-employed physicians were more likely to write restricted advance directive orders than community-based physicians even after controlling for resident age, cognitive status, and physical function. In addition, implementation of a formal nursing home advance directive policy can shorten time to physician documentation of resident advance directive status.

Categorical data analysis in primary care research: log-linear models.

Primary care researchers often wish to perform multiple variable analyses using variables measured at a nominal or ordinal level. This paper provides a step-by-step description of log-linear modeling, an approach uniquely well suited to explore and describe interactions among three or more nominal or ordinal variables. The method of log-linear analysis is illustrated with the use of an example from a primary care research project in which the relationships among hypertension, diet, and sodium were examined. The advantages and disadvantages of log-linear models and logistic regression are compared and available computer software programs discussed.

Emergency department screening for syphilis in patients with other suspected sexually transmitted diseases.

STUDY OBJECTIVE: To evaluate targeted screening for syphilis among a high-risk group of emergency department patients. STUDY DESIGN AND TYPE OF PARTICIPANTS: During a four-month period, 260 patients with suspected sexually transmitted diseases other than syphilis had rapid plasma reagins drawn to determine the incidence of otherwise unsuspected syphilis. RESULTS: Twenty-two patients (8%) had a reactive rapid plasma reagin. Of these, 16 (6%) also had a reactive FTA-ABS and were determined to have syphilis. The cost for screening was $104.90 for each patient with syphilis. Using Poisson regression to control for changing rates over time and for prior differences in rates of syphilis detection in the three hospitals involved in the study, it was determined that our intervention led to 2.4-fold as many cases identified as would have been expected considering prior rates and the increasing incidence of syphilis. CONCLUSION: Syphilis screening of this high-risk population in the ED is warranted.

Comparison of tetracaine, adrenaline, and cocaine with cocaine alone for topical anesthesia.

A mixture of tetracaine, adrenaline, and cocaine (TAC) has been used extensively in the repair of small lacerations, especially in children. The purpose of this study was to determine whether cocaine alone would provide anesthesia equal to that of TAC, thus eliminating the risk of tetracaine toxicity and the theoretic risk of side effects from the combination of cocaine and adrenaline and simplifying preparation. One hundred thirty-nine patients were enrolled in a randomized, double-blind study comparing TAC with cocaine. Effectiveness was rated by the treating physician. Using the Wilcoxon rank-sum test, TAC was found to provide significantly better anesthesia than cocaine alone (P = .005). The percentage of patients having good anesthesia in the TAC-treated group was approximately 72%, which is equivalent to the efficacy found in other studies. Good anesthesia was obtained in 52% of the cocaine-treated group. No side effects or increased rates of infection were reported in either group.