Comprehensive local muscle training increases aerobic working capacity and quality of life and decreases neurohormonal activation in patients with chronic heart failure.

BACKGROUND: Beneficial training outcomes have been reported in patients with chronic heart failure (CHF) following leg exercise training. However, data from more comprehensive training programs are limited. The aim of this study was to test the hypothesis that exercise training applying the concept of comprehensive local muscle training can improve aerobic and functional working capacity as well as quality of life in patients with CHF. METHODS: Twenty-four men and women [age 63+/-9 years (mean+/-S.D.)] with stable, moderate chronic heart failure (left ventricular ejection fraction 30+/-10%), were investigated in a randomized controlled study with a training group of 16 patients and a control group of 8 patients. The training was performed as an aerobic resistance training by activating all the main muscle groups, one at a time. The patients exercised for 1 h, three times per week for 8 weeks. RESULTS: Patient groups did not differ at baseline. Peak oxygen uptake (8%, P<0.03), the distance walked in a 6-min walking test (11%, P<0.002), the health-related quality of life (P<0.001) and plasma norepinephrine levels at rest (32%, P<0.003) and at submaximal intensities (P<0.03) improved after training. No changes were found in the control group, except for decreased peak oxygen uptake (P<0.02) and quality of life scores (P<0.03). CONCLUSIONS: Since comprehensive physical training activating a minor muscle mass at a time markedly improves exercise capacity and quality of life and reduces catecholamine levels, it can be recommended for the rehabilitation of patients with CHF under supervision of a physical therapist.

Subjective lack of social support and presence of dependent stressful life events characterize patients suffering from major depression compared with healthy volunteers.

The aim of this study was to characterize and compare patients with major depression and healthy volunteers concerning stressful negative life events, social support and social network occurring during a 12-month period. Forty outpatients who fulfilled DSM-IV criteria for major depression and 19 healthy volunteers were included in the study. The results showed no significant differences between the patients and the volunteers concerning the number of independent life events, perceived sufficient persons in the network, the number of family members, having a partner, and perceiving family members as offering the best support. Thus, there were differences in the number of both dependent stressful life events, especially increased arguments with partner and family members, and life events including personal illness. The patient group had experienced a greater number of these events compared with the volunteer group. Comparisons between the two groups revealed differences concerning social support and social network. Fewer patients, especially women, felt they had sufficient social support, had fewer persons in the network, less contact with persons in the network, and fewer confidants compared with the volunteers.

The experience of social support in patients suffering from treatment-refractory depression--a pilot study.

The purpose of this study was (1) to ascertain to what extent a group of patients with treatment-refractory depression perceive that they have received sufficient social support, and (2) to define clinical variables that differentiate such patients from those who perceive that they have not received sufficient social support. Twenty-seven treatment-refractory patients with major depression were included in the study. The result showed that only 37% had what was judged as insufficient social support. Those with insufficient and sufficient social support had equally severe depressions, the same number of stressful life events, and the same number of persons in their social network. Patients with insufficient social support were characterized by (1) a subjective conviction that the number of persons in their network was insufficient, and (2) female gender. Emotional support was valued higher than any other kind of support.

Aerobic training involving a minor muscle mass shows greater efficiency than training involving a major muscle mass in chronic heart failure patients.

BACKGROUND: Beneficial training outcomes have been reported in sedentary patients with chronic heart failure (CHF) after exercise training. However, data on training effects in previously trained patients, as well as comparisons of different exercise modes, are lacking. The aim of this study is to compare exercise training on a cycle ergometer (major muscle mass) and aerobic knee-extensor training (minor muscle mass) in previously trained patients with CHF. METHODS AND RESULTS: Twenty-four men and women (age, 63 +/- 10 years [mean +/- SD]) with stable, moderate CHF (left ventricular ejection fraction, 30% +/- 11%) who had completed their first exercise training period more than 1 year ago were allocated to either the exercise or control group. After stratification for sex, age, ejection fraction, and cardiac output response, the training group was further randomized to either cycle ergometer or knee-extensor training for 8 weeks. The control and training patients did not differ at baseline, and the measured variables did not change in the control group during the 8 weeks. Citrate synthase activity in skeletal muscle increased after cycle training (23%; P < .02) and knee-extensor training (45%; P < .008), and blood lactate concentration at submaximal intensities decreased (P < .04) in both groups. However, only after knee-extensor training did the peak oxygen uptake increase (19%; P < .01) and sympathetic nervous system activity, measured as plasma norepinephrine concentration at rest (P < .05) and during exercise (P < .008), decrease. Minnesota Living with Heart Failure questionnaire scores also showed improvement in the health-related quality of life (P < .05) only after knee-extensor training. CONCLUSION: Physical training is beneficial in previously trained patients with CHF. Aerobic training involving a minor muscle mass shows greater efficiency than training involving a major muscle mass.

Social activities in elderly patients with severe mental illness. Lessons from a mental hospital in Sweden.

Mental hospitals offer their patients many different kinds of social activities/facilities. One-hundred-and-twenty-seven patients in the long-term care unit at a mental hospital were included in the study. They were divided into three subgroups on the basis of diagnosis: dementia disorder (n = 65), chronic psychotic disorder (n = 38), and chronic non-psychotic disorder (n = 24). An inventory was made of all possible activities/facilities offered to the patients by the mental hospital, with the objective of ascertaining whether participation in social activities/facilities discriminated between the three diagnostic groups. Sixteen activities/facilities were obtained from an inventory by nurses. Stepwise discriminant analysis identified length of stay in hospital, age and the social activities/facilities that separated the three diagnostic groups. The discriminant function analysis showed that participation in social activities, together with length of stay and age, discriminated very well between the demented and the chronic psychotic groups. The discriminant analysis also indicated that patients with chronic psychotic. disorder were distinguishable by their frequent participation in social activities, long stay in hospital, and low age. The results obtained can be used when the social activities/facilities in a community care setting are being planned for the various diagnostic groups.

The need for quality assurance for a better compliance and increased quality of life in chronic schizophrenic patients.

In many places in the world community care facilities for chronic schizophrenic patients are insufficient, leading to a series of complications which can even be fatal. The lack of facilities contributes to a decrease in patients' compliance. The establishing of a good community care programme for the whole disease period will also considerably increase the efficacy of relapse prevention and give the patient an acceptable quality of life, and hopefully increase the patient's compliance. There is urgent need for therapy standards to be assured and monitored according to strict evaluation criteria to produce a better interplay between the schizophrenic patient and psychiatric staff.

Activities of daily living ratings of elderly people using Katz' ADL Index and the GBS-M scale.

Instruments for measuring activities of daily living (ADL) are useful in estimating institutionalized elderly ill people's need of care. The aim of the present study was to investigate to what extent the GBS-M scale measures ADL status, as determined by Katz' ADL Index. Forty-two elderly patients in long-term care in a psychiatric hospital were rated independently using each of the two scales. The correlation coefficient between results of the ratings was r = 0.93, i.e., high scores on one of the scales gave high scores on the other scale. Fifty per cent of severely demented patients had maximal scores on measures of ADL.

Does community care reduce the need for psychiatric beds for schizophrenic patients?

For schizophrenics, the closing down of the old traditional hospital has in many places ended up in a scenario characterized by homelessness, relapse, patients overcrowding acute psychiatric but also somatic hospital wards, increased suicide figures, low living standards--and an increased burden on the family. The beds for schizophrenics have been considerably reduced in many countries. For schizophrenia the critical low number of institution beds--hospital as well as nursing home--seems to be 0.07% of the general population. Schizophrenia in all phases must be treated as the disease it is, not as a social problem.

The closure of a mental hospital in Sweden. 5 years of transition to district-based long-term care.

A political decision to decentralize psychiatric care in a county of Sweden was made in October 1984. This will lead to the closure of the county's only large psychiatric hospital. Short-term psychiatric care will be provided by three smaller hospitals in the county, while long-term care in hospital will cease completely and be replaced by district-based psychiatric services. All patients (n = 199) in the large hospital's long-term unit were studied over 5 years of the transition period. The results showed that 42% of patients were discharged during the period, mainly to other institutions. Only 8 patients were provided with alternative types of care, such as group homes. Sixty-eight per cent of all patients died, most of them before being discharged (80% of the organically demented patients and 51% of the others). The mortality rate for patients with severely impaired activities of daily living (ADL functioning) was 92% for those who were also organically demented and 84% for the others. The patients who survived the 5-year period were mainly (80%) nondemented patients with relatively well-preserved ADL functioning, but with behavioural disturbances.

The closure of a major psychiatric hospital. Characterization of the long-term population over one year at an early stage of deinstitutionalization.

A political decision to decentralize psychiatric care in a county in Sweden was arrived at in October 1984. This will lead to the closure of the only large psychiatric hospital in the area, which will be replaced by three smaller units. The long-term care in the hospital will cease completely and be replaced by district-based psychiatric services. All patients in the hospital's long-term unit were studied over one year at an early stage of deinstitutionalization. The results showed that 12% of patients were discharged during that year, mostly to other institutions, only 2 patients to their homes. Twenty-five per cent died, and one-year mortality was 40% for patients with severely impaired ADL functioning. The demented patients deteriorated significantly in ADL functioning.

The closure of a major psychiatric hospital: can psychiatric patients in long-term care be integrated into existing nursing homes?

Nursing homes are important alternatives to large hospitals when psychiatrically ill patients are relocated in the community, but their suitability for this type of patient is being questioned. This study compared patients in two traditional Swedish nursing homes (n = 66) and patients in long-term care at a large psychiatric hospital (n = 106). The results showed that both types of institutions housed patients with organic dementia and psychiatric symptoms. The hospitalized demented patients, however, displayed significantly more cognitive impairment, more confusion, and more behavioral disturbances than the nursing home patients. Significant differences were also found between the nursing home patients and hospitalized psychiatrically ill patients without dementia. The latter were younger, had better activities of daily living capacity, but displayed more psychiatric symptoms and behavioral disturbances than the nursing home patients. We concluded that all the patients in long-term psychiatric care will require sheltered accommodation. The demented patients could possibly be integrated into nursing homes, but successful integration would require special arrangements. Psychogeriatric units with staff qualified to care for patients with severe behavioral disturbances would be preferable. It would not be possible to meet the psychiatrically ill patients' special need of care in existing nursing homes. Alternative living arrangements, with care given by staff trained in psychiatry, are recommended.

The closure of a mental hospital in Sweden: characteristics of patients in long-term care facing relocation into the community.

A political decision to decentralize psychiatric care in a county of Sweden was made in October 1984, leading to the closure of the only large mental hospital in the area (290,000 inhabitants). The hospital is of the traditional type, with 490 beds and 1,294 staff members. It has units for long-term care, short-term care and rehabilitation and a unit for research and education. The long-term care is to cease completely and be replaced by community-based alternative types of care. In this study, the long-term population (n = 199) was characterized and their levels of functioning were measured. The results showed that 91% of the patients were 65 years old or more and that more than half of them were organically demented. Only 20% were chronic schizophrenics. All patients were cognitively impaired and 80% were also impaired in ADL functioning. A correlation between length of stay in hospital and ADL functioning was found in the organically demented group, but not in the group of chronic psychiatrically ill patients. Thirty-nine per cent of the population were severely impaired in ADL functioning and needed nursing care around the clock; 34% were moderately impaired and needed help and support that could be given in alternative types of care; 27% were not impaired at all to mildly impaired and could be relocated to some type of service apartment. Thus, all patients needed sheltered living arrangements and care provided by staff with adequate training.

The closure of a major psychiatric hospital. Reactions of the psychogeriatric nursing staff.

A political decision to decentralize psychiatric care in a province in Sweden was arrived at in October 1984, leading to the closing down of the only psychiatric hospital in the area (290,000 inh.). The hospital is of the traditional type with 490 beds and 1,294 staff. It has units for long-term care, short-term care and rehabilitation, as well as a unit for research and education. The psychogeriatric patients are to be transferred to their home districts. All of the psychogeriatric staff have been guaranteed new jobs under the auspices of the County Council's medical services. This study is concerned with the nursing staff's reactions to the decentralization and the kind of problems they were faced with. A questionnaire was sent to all nursing staff, and for the psychogeriatric unit (199 patients) the personnel turnover was also registered. The results show that the greatest problems for the nursing staff were the splitting up of their working teams and having to establish relations with new colleagues. They were also worried about longer and more expensive journeys to new places of work. Most of the nursing staff considered the information given about the consequences of the political decision very poor. More than half of the nursing staff (54%) thought the patients would be provided with better care by decentralized psychiatric health services. Many stated that the decision had affected them so that their interest in further education (37%) and in working in a new type of psychiatric care (43%) had increased.(ABSTRACT TRUNCATED AT 250 WORDS)