Adult day health care organizational and program characteristics.

A survey of 31 adult day health care (ADHC) programs assessed the extent to which the programs were implemented as intended by the VA. The study described and compared the host communities, ADHC organizational characteristics, program characteristics, and patient use of services. Four of the centers were operated by the Department of Veterans Affairs in VA Medical Center facilities. The remaining 27 centers were community providers serving veterans on contract through four additional VA Medical Centers. Veterans Administration programs were located in larger facilities, with lower client/staff ratios and fewer hours of operation than community contract programs. Patients on the average made 45 visits to the VA-ADHC programs and 58 visits to the contract ADHC programs. The VA and contract programs were generally found to have been implemented as planned, i.e., they followed VA guidelines for staffing, space, and equipment.

Effects of VA adult day health care on health outcomes and satisfaction with care.

It was hypothesized that ADHC would have a positive effect on the health of patients and their care givers and result in greater satisfaction with care than customary care. Measurement of health outcomes for patients included assessment of overall, psychological, and social health, and survival. Care giver assessment concentrated on psychosocial health. Findings indicated no difference in health outcomes between patients assigned to ADHC or their care givers and their counterparts assigned to customary care. Further analysis of subgroups found that there were 3 subgroups of patients for whom those assigned to ADHC had better outcomes (as indicated by lower Sickness Impact Profile scores) than those assigned to customary care. These subgroups included those who were 1) not married, 2) most satisfied with their social support network, and 3) not hospitalized at the time of enrollment in the study. Patients and their care givers assigned to ADHC were more satisfied with their care than those in nursing homes, but not more satisfied than those in hospital-based home care. Care givers reported significantly greater satisfaction with patient care in ADHC than did care givers of patients receiving care in nursing homes or ambulatory care clinics.

Effects of contract adult day health care on health outcomes and satisfaction with care.

The second phase of the ADHC Evaluation Study was designed to assess ADHC provided under contract by community ADHC programs. Outcomes for the 163 patients enrolled in this prospective cohort evaluation were compared with those of patients assigned to ADHC provided directly by VA (VA-ADHC) and customary care in the randomized trial phase of the study. In spite of identical admission criteria, contract ADHC patients were significantly different from VA-ADHC and customary care patients on several characteristics and were more impaired in health status at study intake. They were also more impaired in physical health status at 12 months, even after controlling for baseline differences. There were no significant differences in any other patient or care giver health outcomes. Contract ADHC patients were more satisfied than customary care patients in nursing homes (but not more satisfied than patients in home care), whereas VA-ADHC patients were more satisfied than those in contract ADHC. It is suggested that differences in physical function are due to differences in patient health status at intake rather than a detrimental effect of contract ADHC.

Long-term EEG-video-audio monitoring: computer detection of focal EEG seizure patterns.

Twelve individuals with medically refractory partial seizures had undergone EEG-video-audio (EVA) monitoring over 1-15 (mean 10.5) days. We selectively reexamined available 15-channel EEGs (video-cassettes) totaling 461 h and containing 253 EEG focal seizures. Computer analysis (CA) of these bipolar records was performed using a mimetic method of seizure detection at 6 successive computer settings. We determined the computer parameters at which this method correctly detected a reasonably large percentage of seizures (81.42%) while generating an acceptable rate of false positive results (5.38/h). These parameters were adopted as the default setting for identifying focal EEG seizure patterns in all subsequent long-term bipolar scalp and sphenoidal recordings. Factors hindering or facilitating automatic seizure identification are discussed. It is concluded that on-line computer detection of focal EEG seizure patterns by this method offers a satisfactory alternative to and represents a distinct improvement over the extremely time consuming and fatiguing off-line fast visual review (FVR). Combining CA with seizure signaling (SS) by the patients and other observers increased the correct detections to 85.38% CA is best used in conjunction with SS.

Long-term EEG-video-audio monitoring: detection of partial epileptic seizures and psychogenic episodes by 24-hour EEG record review.

Twenty-seven patients with medically refractory paroxysmal disorders underwent EEG-video-audio (EVA) monitoring in an inpatient neurology-neurosurgery unit over 1-15 (mean 8.9) days. Fast visual review of all EEG records (5,784 h) and subsequent analysis of synchronized EVA patterns demonstrated a total of 208 partial epileptic seizures (ES) in 12 individuals and 87 psychogenic episodes (PE) in 15 subjects. Clinical ES lasted 83.3 s on the average and were most frequent from day 7 to 9 of monitoring (42.3%) and during sleep (56.4%). PE were longer in duration (mean 724.5 s), most numerous during the first 2 days of monitoring (41.4%), and occurred exclusively during wakefulness. Subjects with PE signaled (by pressing on a push button) more events (35.6%) than did the individuals with ES (27.9%). Multiple observers raised the proportion of alarms to 69.0% of PE compared to 39.9% of ES. Following the alarm, nurses reached the patients' bedside within a brief time (mean 22.2 s). To differentiate partial ES from PE or to establish the association of these disorders, EVA monitoring is best performed around the clock over a period of 1-2 weeks. The limited number of paroxysmal events, especially ES, signaled by the patients should be considered when designing studies of the effectiveness of pharmacologic, surgical, and other treatments.

Social networks: we get by with (and in spite of) a little help from our friends.

Studies of social support networks have almost exclusively measured only their positive aspects. In this research, we investigated both the helpful or positive and the upsetting or negative aspects of social networks in a longitudinal study of spouses caring for a husband or wife with Alzheimer's disease, a progressive senile dementia. Measures of helpful and upsetting aspects of the care givers' networks, derived from interviews and daily interaction ratings, were studied for their relations with overall network satisfaction and depression at an initial interview period (n = 68) and at a follow-up period about 10 months later (n = 38). Results from hierarchical multiple regression analyses, in which care givers' age and sex and a measure of the spouses' health status were controlled, showed that the care givers' degree of upset with their networks was strongly associated with lower network satisfaction and increased depression at both time periods. Helpful aspects bore little or no direct relation to either depression or network satisfaction. Helpful aspects of the network did, however, interact with network upset in predicting network satisfaction, and depression (combined probabilities test, p less than .05). Longitudinal predictions of follow-up depression, after age, sex, care givers' health status, and initial depression levels were controlled, showed that changes in upsetting aspects of one's network were predictive of changes in depression over time. We interpreted these results within an attributional framework that emphasizes the salience of upsetting events within a social network.