A longitudinal study of joint pain in older people.

BACKGROUND: Joint pain is extremely common in older people, but its natural history has been little described in the UK literature. METHODS: A UK general practice population was followed for 1 yr in 1998. There were 4804 subjects aged 75 yr and over who accepted the offer of health screening. Assessments by postal questionnaire using the Elderly At Risk Rating Scale, which includes one question specifically covering joint pain. RESULTS: Some degree of joint pain was reported by 83%. This was related to age and female gender. The presence of pain was strongly related to mobility, energy and sadness. Over 1 yr, 18% acquired or had increased frequency of pain, while 14% had reduced frequency of pain. Resolution was associated with preserved indoor mobility, and functional recovery. There was little relationship between joint pain and adverse outcomes. CONCLUSIONS: Joint pain is very common in older people, fluctuates in frequency over time, and is strongly linked to psychological factors as well as disability. A positive approach to active management of joint pain is justified, and will be rewarded by improved quality of life for older people.

Defining the appropriate use of community hospital beds.

BACKGROUND: Patients of GPs who have access to community hospitals (CHs) as well as district general hospitals (DGHs) tend to spend on average more days in hospital each year. Increasing attention is being paid to the efficient management of medical admissions; however, there has been no previous prospective study investigating the appropriateness of CH admissions. AIM: To develop a protocol to assess the clinical appropriateness of admission and length of stay of patients in CHs and to simultaneously compare the appropriateness of admissions to all DGHs and CHs in the county. DESIGN OF STUDY: A protocol named Community Hospital Appropriateness Evaluation Protocol (CHAEP) was developed to assess CH admissions through a process of consultation and a series of pilot studies. The appropriateness evaluation protocol (AEP) was also reviewed and used to assess DGH admissions. SETTING: A prospective cohort of 440 DGH admissions from five DGH sites and 440 CH admissions from nine CHs. METHODS: The admissions were assessed and followed for 28 days. If an admission failed to satisfy any of the criteria then the researcher interviewed the clinician to decide whether it was justified to override the protocol and still classify the admission as appropriate. To assess validity, a proportion of these 'clinical overrides' and the researcher's classifications were reviewed retrospectively by a clinical panel. The kappa statistic was used to assess the level of agreement. RESULTS: Applying the CHAEP, 82% of CH admissions satisfied a criterion for admission and a further 3% were given clinical overrides. A lower intensity of care was required for the majority of the remainder while three admissions required DGH care according to AEP criteria. Sixty-eight per cent of bed days satisfied day-of-care criteria within CHAEP and only a further 2% were given clinical override. These results were similar to those found with the AEP at the DGHs where 75% of admissions (plus 16% given clinical override) and 55% of days-of-care (plus 20% given clinical override) satisfied the AEP criteria. The review panel generally did not agree with the clinician's use of the clinical override at the CHs. Agreement between research nurse and review panel was better for the AEP and DGH (kappa = 0.9, 95% confidence interval (CI) = 0.7-1.0) than for the CHAEP and CH (kappa = 0.37, 95% CI = 0.1-0.8). CONCLUSIONS: The CHAEP could be used to audit the appropriateness of admission and length of stay in CHs. Other health communities would need to review the CHAEP before it could be applied within their context.

Variation in general practice medical admission rates for elderly people.

BACKGROUND: Emergency medical admissions are rising, particularly in the elderly. Variation in admission rates between general practices has received little attention, and requires explanation. METHODS: A retrospective review was carried out of emergency medical admissions to the District General Hospital (DGH) and the Community Hospitals (CHs) in West Gloucestershire in subjects over 75 years of age during 3 years. A survey of general practitioner (GP) attitudes to emergency admissions was carried out. RESULTS: A five-fold spread in DGH and CH admission rates for elderly medical emergencies was found, and a three-fold spread of overall admission rates. Rates were consistent within a practice each year. The spreads of practice mortality rates and myocardial infarction admission rates were smaller. The variation between practices was not explained by the Jarman Index or by attitudes identified in GPs. Practices with high admission rates had slighter higher annual hospital mortality rates, but lower episode fatality rates. CONCLUSION: Admission rates show considerable variation between practices, which is only partly explained by morbidity rates, and consistency over 3 years.

Preventing falls on an elderly care rehabilitation ward.

OBJECTIVE: Comparison of two flooring types--carpet and vinyl--in the bed areas, and two modes of physiotherapy--conventional therapy and additional leg strengthening exercises--in avoiding falls. DESIGN: Randomized 2 x 2 controlled trial. SETTING: Elderly care rehabilitation ward in a community hospital. SUBJECTS: Fifty-four consecutive patients referred for rehabilitation. OUTCOME MEASURES: The incidence of falls, and the change in strength. RESULTS: There were 10 falls on carpet, and only a single fall on vinyl floor covering (relative risk 8.3, 95% confidence interval 0.95-73, p = 0.05). There were four falls in those receiving additional exercise, and seven falls in those receiving only conventional physiotherapy (relative risk 0.21, 95% confidence interval 0.04-1.2, p = 0.12). Fifty-nine per cent of patients were able to complete strength measurements on admission and discharge. In these, handgrip strength improved more in those given additional exercise than conventional physiotherapy (2.1 kg versus -0.3 kg, p < 0.05). CONCLUSION: There is no evidence to support either intervention in preventing falls on a rehabilitation ward, but within this low-powered study, there was a strong trend towards vinyl being superior.

The prognosis of falls in elderly people living at home.

BACKGROUND: there are few longitudinal studies of the prognosis of falling at home. OBJECTIVE: to determine outcomes in older people who fall once and more than once. DESIGN: longitudinal prospective cohort study. SETTING: primary care in the UK. SUBJECTS: 1815 subjects over 75 who had a standardized and validated health check. METHOD: annual interviews over 4 years. Practice records were used to establish death and admission to institutions. RESULTS: risk of death was increased at 1 year [odds ratio (OR) 2.6, 95% confidence interval (CI) 1.4-4.7] and 3 years (OR 1.9, 95% CI 1.2-3.0) for recurrent fallers but not single fallers (OR 0.9, 95% CI 0.5-1.6 at 1 year; OR 0.97, 95% CI 0.7-1.4 at 3 years). Risk of admission to long-term care over 1 year was markedly increased both for single fallers (OR 3.8, 95% CI 1.8-8.3) and recurrent fallers (OR 4.5, 95% CI 1.7-12). Functional decline was not related to faller status, the latter being very variable from one year to the next. CONCLUSIONS: the stronger relationship between falling and admission to long-term care rather than mortality supports the hypothesis that the perceived risks for those who fall only once are exaggerated.

The Gloucestershire Longitudinal Study of Disability: outcomes in nonresponders, responders, and subsequent defaulters.

Routine health checks of older adults (age > 75 years) are a potential source of disability data to inform general practitioners, trusts, and health authorities. The value of the data heavily depends on the representativeness of those agreeing to the checks. The aim of this study was to determine the outcomes of responders, subjects who refused the offer of a health check, and those who defaulted from regular health checks after the first year. A sample of 1815 subjects more than 75 years old, drawn from seven general practices, who started an annual routine health check in 1990. All were interviewed by their practice nurse using the Elderly At Risk Rating Scale. Survival and hospital admission rates were ascertained for responders and refusers. The average age of the responders was 81.1 (standard deviation [SD] 4.7); for refusers, 80.5 (SD = 7.7); and for dropouts, 80.2 (SD = 4.2). In women, the age-adjusted survival was 37.6 months (95% confidence interval [CI] 36.3-38.9) in refusers (70% survival) and 39.5 months (95% CI 38.4-40.6) in responders (73% survival); the respective figures in men were 37.4 months (95% CI 35.6-39.1, 67% survival) and 36.8 months (95% CI 34.9-38.7, 66% survival). Crude mortality rates of responders and the inhabitants of areas that matched the locations of the practices were similar. Hospital admission rates and mean length of stay were similar in responders and refusers. Similarly, those who defaulted did not differ from continued responders in their mortality or hospital admission rates. Nonresponders to elderly health checks and defaulters have similar health outcomes to responders.

Development of a modified Winchester disability scale--the elderly at risk rating scale.

OBJECTIVE: To show that the elderly at risk rating scale (EARRS) satisfies the requirements of an assessment tool for routine health checks in people over 75 and would also be suitable as a method of collecting epidemiological data on the needs of the elderly in a locality. DESIGN: Development and validation of a questionnaire based on a modification of the Winchester rating scale, by a series of prospective, comparative studies before the use of the instrument in a community survey. SETTING: Elderly care day hospital and the community. SUBJECTS: Elderly patients referred to an elderly care day hospital; population survey of subjects over 75 living at home. MAIN OUTCOME MEASURES: Reliability of responses using the kappa statistic; comparison of the scale with the Barthel index of daily living. RESULTS: EARRS has satisfactory validity and reliability when repeated by the same observer or a different observer, with a mean weighted kappa score above 0.80 in both instances. As a measure of disability in the community, it is better than the Barthel score in that it avoids the ceiling effect. The score is correlated with age, social situation, and receipt of support services, and individual questions scale appropriately to adverse outcomes. CONCLUSION: The EARRS satisfies the requirements of an assessment tool for health checks in the elderly, It is suitable for both population surveys and routine practice in primary care, has proved popular with practice nurses, and is easy to complete.

Successful control of Clostridium difficile infection in an elderly care unit through use of a restrictive antibiotic policy.

Toxin-producing Clostridium difficile is the commonest bacterial cause of nosocomial diarrhoea and is a well recognized cause of hospital outbreaks in elderly care units. High C. difficile disease rates have been associated with the use of broad-spectrum antibiotics, especially cephalosporins. An outbreak of C. difficile infection in the elderly care unit at Gloucestershire Royal NHS Trust continued despite increased ward cleaning and strict implementation of infection control measures. A restrictive antibiotic policy that would maintain colonization resistance in the gastrointestinal tract was introduced throughout this unit. Patients admitted with suspected infection were prescribed intravenous (i.v.) benzylpenicillin 1.2-1.8 g every 6 h to cover streptococcal infections and i.v. trimethoprim 200 mg twice daily to cover urinary tract pathogens and Haemophilus influenzae. If the patient had septic shock a single iv dose of gentamicin was given (120-180 mg) to cover more resistant gram-negative bacilli. The following were monitored before and after the policy change. The number of cases of C. difficile toxin-positive diarrhoea; cefuroxime and total antibiotic use on the elderly care wards; patient mortality rates; and length of hospital stay: two hundred and fifty-two and 234 patients respectively with a discharge diagnosis of infection were admitted before and after the antibiotic policy change. Mortality rates and length of hospital stay were unchanged. Cefuroxime prescribing and total antibiotic prescribing costs fell by 5150 pounds sterling and 8622 pounds sterling respectively in the 7 month period after the change. Thirty-seven cases of C. difficile diarrhoea occurred in the period before and 16 in the period after the policy change. The incidence of C. difficile diarrhoea and of cefuroxime use has remained low since then. The use of narrow-spectrum antibiotics for hospital treatment of community-acquired infections in the elderly should be encouraged. Outbreaks of C. difficile diarrhoea should be managed with the combined approach of infection control and strict antibiotic policies.

Gloucester hospital-at-home: a randomized controlled trial.

Hospital-at-Home schemes have been claimed to hasten the discharge of elderly orthopaedic patients, and are becoming increasingly popular with health service managers. In an attempt to measure the benefits of such a scheme when applied to elderly medical patients, we prospectively randomized 60 consecutive referrals of patients approaching discharge either to the Hospital-at-Home (HAH) rehabilitation team, or to conventional discharge (CD) preparation and domiciliary support. Patients allocated to HAH were discharged on average 5 days earlier than CD, while 64% of each group remained at home during 6 months follow-up. Improvements in independence were modest, and similar in the two groups, though a trend favoured HAH.

The diagnosis of small bowel bacterial overgrowth in elderly patients.

OBJECTIVE: To examine the frequency of small bowel bacterial overgrowth in elderly subjects. DESIGN: Prospective observational study. SETTING: Department of Health Care of the Elderly in a university teaching hospital. PATIENTS: Thirteen elderly control subjects having undergone normal gastroscopy with normal hematology and anthropometry; 39 consecutive referrals of elderly patients with clinical or biochemical evidence of malnutrition. MAIN OUTCOME MEASURES: Duodenal bacterial counts and the 14C-glycocholate, hydrogen, and 14C-xylose breath tests. RESULTS: Five of the 13 control subjects and 21 of 39 patients with malnutrition had high duodenal bacterial counts (greater than 10(5) organisms/mL), whereas only seven patients were judged to have clinically significant bacterial overgrowth. The 14C-xylose breath test showed a high specificity (89%) but a low sensitivity (30%) when compared with the results of duodenal culture. The hydrogen breath tests and the 14C-glycocholate test showed a similar picture of moderately high specificity and low sensitivity (77% and 20%, respectively, for the hydrogen breath test, 76% and 33%, respectively, for the 14C-glycocholate test). CONCLUSIONS: A positive xylose breath test was the best predictor of high duodenal bacterial counts. However, since many elderly subjects have high duodenal bacterial counts, the overdiagnosis of bacterial overgrowth syndrome will result if duodenal culture is relied upon exclusively.

Geriatric outpatient clinics: an audit of clinical action, transport and general practitioners' views.

An audit was performed of patients attending geriatric outpatient clinics for review during a calendar month. Patients were asked to complete a brief questionnaire and 93% of case notes were available for study. In 97 attendances, management was altered in 36, a new medical problem found in 16, and 49 patients were discharged. Forty-seven attendances followed recent discharge from hospital; 19 of these patients had no evident clinical benefit from attendance, although the majority were discharged. There may be scope for a liaison nurse to take over the follow-up of some patients to save their attending a clinic. A survey of local general practitioners suggested they would welcome this.

A life-threatening respiratory complication of gastro-oesophageal reflux in a patient with tetraplegia.

Recurrent attacks of life-threatening dyspnoea and choking occurred in a patient with tetraplegia. Conventional investigations for gastro-oesophageal reflux were normal, but 24-hour oesophageal pH recording revealed gross reflux in association with an attack of dyspnoea. Surgical correction of the reflux abolished the attacks. The possibility of autonomic dysreflexia as the mechanism linking reflux and respiratory symptoms in this patient is discussed.

Is 24 h ambulatory oesophageal pH monitoring useful in a district general hospital?

53 of 61 patients successfully completed 24 h ambulatory monitoring of oesophageal pH. The indications were: symptoms suggestive of gastro-oesophageal reflux but with normal endoscopy (19 cases); atypical chest pain with normal endoscopy (21 cases); or respiratory symptoms possibly due to reflux (13 cases). A temporal association between abnormal reflux and the presenting symptoms was demonstrated in 25 patients (47%). 6 patients were shown to have respiratory symptoms after episodes of reflux which resolved on treatment of the reflux alone. Reflux occurring only in the erect posture was observed in some patients and may have been a manifestation of the irritable bowel syndrome. Reflux as a cause of symptoms was excluded in 14 patients. The procedure was well tolerated in most patients, simple to operate, and inexpensive.

The value of 5-aminosalicylic acid in inflammatory bowel disease for patients intolerant or allergic to sulphasalazine.

The use of sulphasalazine in inflammatory bowel disease is often limited by intolerance or allergy. In previous studies 5-aminosalicylic acid (5ASA), the active ingredient of sulphasalazine, coated with an acrylic resin, has been shown to be as effective as sulphasalazine in maintaining remission. In this study coated 5ASA was given to 37 patients intolerant or allergic to sulphasalazine. Thirty-three patients have tolerated 5ASA satisfactorily, and most experienced improved control of their disease. Four patients reported similar side effects with sulphasalazine and 5ASA.

Sigmoidoscopy/proctoscopy service with open access to general practitioners.

Many hospitals now offer barium enema examinations to general practitioners on an open access basis, so bypassing the traditional sequence of first carrying out a sigmoidoscopy. An open access sigmoidoscopy/proctoscopy service was therefore opened with requests for a barium enema being denied unless preceded by sigmoidoscopy. During the first three and a half years 1458 patients referred direct from their general practitioners were examined using a rigid sigmoidoscope. Patients were also examined with a proctoscope if thought appropriate. After the first year of the service a subsequent examination with a fibreoptic sigmoidoscope was also carried out if the presenting symptom was bleeding for which no cause could be found with the rigid instruments. A total of 516 abnormalities were found to account for symptoms in 506 patients giving a diagnostic rate of 35%. The most common lesion was piles (307 cases). Other relatively common disorders included inflammatory bowel disease (107 cases), benign tumours (44), and malignant tumours (38). Of 41 patients subsequently undergoing fibreoptic sigmoidoscopy a cause for the bleeding was found in 32, the most common being a malignant tumour (16). Most general practitioners in the district used the service and a questionnaire survey indicated that most found it very helpful. Requests from general practitioners for a barium enema fell substantially over the period.

A study of constipation in the elderly living at home.

A cross-sectional survey of bowel habit has been carried out on 201 elderly patients living at home. Although symptoms of constipation were common, reported bowel frequency was similar to younger people. Constipation was most clearly associated with poor mobility and depression. Digital rectal examination was generally unreliable as an indicator of constipation. Using the abdominal radiograph as the final arbiter, true constipation was present in less than half of those complaining of constipation.