BMC Geriatrics - Latest Articles

Efficacy of an improved absorbent pad on incontinence-associated dermatitis in older women: cluster randomized controlled trial

Junko Sugama — 2012-05-29T00:00:00Z

Background: Most older adults with urinary incontinence use absorbent pads. Because of exposure tomoisture and chemical irritating substances in urine, the perineal skin region is always at riskfor development of incontinence-associated dermatitis (IAD). The aim of this study was toexamine the efficacy of an improved absorbent pad against IAD. Methods: A cluster randomized controlled design was used to compare the efficacy of two absorbentpads. Female inpatients aged [greater than or equal to]65 years who had IAD and used an absorbent pad or diaper allday were enrolled. Healing rate of IAD and variables of skin barrier function such as skin pHand skin moisture were compared between the usual absorbent pad group (n = 30) and the testabsorbent pad group (n = 30). Results: Thirteen patients (43.3%) from the test absorbent pad group and 4 patients (13.3%) from theusual absorbent pad group recovered completely from IAD. Moreover, the test absorbent padgroup healed significantly faster than the usual absorbent pad group (p = 0.009). On the otherhand, there were no significant differences between the two groups in skin barrier function. Conclusion: The test absorbent pad for older adults with urinary incontinence might be more efficaciousagainst IAD than usual absorbent pad.Trial registrationUMIN-CTR: UMIN000006188

An inpatient rehabilitation model of care targeting patients with cognitive impairment

Katherine McGilton — 2012-05-25T00:00:00Z

Background: The course and outcomes of hip fracture patients are often complicated by the presence ofdementia and delirium, referred to as cognitive impairment (CI), which limits access to inpatientrehabilitation. In response to this concern, members of our team developed andpiloted an in-patient rehabilitation model of care (Patient-Care Rehabilitation Model; PCRM)targeting patients with hip fracture and CI (PCRM-CI). We are now conducting a 3-yearstudy comparing an inpatient rehabilitation model of care for community dwellingindividuals with hip fracture and CI (PCRM-CI) to usual care to determine whether it resultsin improved mobility at the time of discharge from inpatient rehabilitation. Methods: A non-equivalent pre-post design is being used to evaluate the PCRM-CI compared to usualcare. All community dwelling (private home or retirement home) patients following a hipfracture are eligible to participate. Recruitment of both cohorts is taking place at twofacilities. Target accrual is 70 hip fracture patients in the PCRM-CI cohort and 70 patients inthe usual care cohort. We are also recruiting 70 health care providers (HCPs), who are beingtrained to implement the PCRM-CI, and their unit managers. Patient data are collected atbaseline, discharge, and 6 months post-surgery. Evaluations include mobility, physicalfunction, and living arrangement. Additional outcome variables are being collected frommedical records and from the patients via their proxies. Data on the prevalence and severityof dementia and delirium are being collected. Staff data are collected at baseline and one yearafter implementation of the model to determine change in staff knowledge and attitudestoward patients with hip fracture and CI. Bi-monthly semi-structured interviews with unitmanagers have been conducted to examine factors and barriers influencing the modelImplementationData collection began in 2009 and is expected to be completed in 2012. Thecontrol cohort of 70 patients has been recruited, and 45 patients have been accrued to theintervention group to date.DiscussionEvaluation of this model of care is timely given the increasing proportion of persons withcognitive impairment and hip fractures.Trial registrationThe study is registered at http://clinicaltrials.gov, Identifier NCT01566136.

A randomized controlled trial of a senior centre group programme for increasing social support and preventing depression in elderly people living at home in Norway

Hege Bøen — 2012-05-20T00:00:00Z

Background: Late-life depression is a common condition and a challenging public health problem. A lack of social support is strongly associated with psychological distress. Senior centres seem to be suitable arenas for community-based health promotion interventions, although few studies have addressed this subject. The objectives were to examine the effect of a preventive senior centre group programme consisting of weekly meetings, on social support, depression and quality of life. Methods: A questionnaire was sent to a random sample of 4,000 persons over 65 in Oslo, and a total of 2,387 completed questionnaires were obtained. These subjects served as a basis for recruitment of participants for a trial, with scores on HSCL-10 being used as a main inclusion criterion. A total of 138 persons were randomized into an intervention group (N = 77) and control group (N = 61). Final analyses included 92 persons. Social support (OSS-3), depression (BDI), life satisfaction and health were measured in interviews at baseline and after 12 months (at the end of the intervention programme). Perceptions of benefits from the intervention were also measured. Mean scores, SD, SE and CI were used to describe the changes in outcomes. Effect sizes were calculated based on the original scales and as Cohen's d. Paired sample tests and ANOVA were used to test group differeResultsThere was an increase in social support in both groups, but greatest in the intervention group. The level of depression increased for both groups, but more so in the control than the intervention group. There was a decrease in life satisfaction, although the decrease was largest among controls. There were almost no differences in reported health between groups. However, effect sizes were small and differences were not statistically significant. In contrast, most of the participants said the intervention meant much to them and led to increased use of the centre. Conclusions: In all probability, the intervention failed to meet optimistic targets, but possibly met quite modest ones. Since intention-to-treat analysis was not possible, we do not know the effect on the intervention group as a whole. A further evaluation of these programmes is necessary to expand the group programme. For the depressed, more specialized programmes to cope with depression may be a more appropriate intervention.Trial RegistrationDRKS00003120 on DRKS

Implementing the chronic care model for frail older adults in the Netherlands: study protocol of ACT (frail older Adults: Care in Transition)

Maaike Muntinga — 2012-04-30T00:00:00Z

Background: Care for older adults is facing a number of challenges: health problems are not consistently identified at a timely stage, older adults report a lack of autonomy in their care process, and care systems are often confronted with the need for better coordination between health care professionals. We aim to address these challenges by introducing the geriatric care model, based on the chronic care model, and to evaluate its effects on the quality of life of community-dwelling frail older adults.MethodS Design: In a 2-year stepped-wedge cluster randomised clinical trial with 6-monthly measurements, the chronic care model will be compared with usual care. The trial will be carried out among 35 primary care practices in two regions in the Netherlands. Per region, practices will be randomly allocated to four allocation arms designating the starting point of the intervention. Participants: 1200 community-dwelling older adults aged 65 or over and their primary informal caregivers. Primary care physicians will identify frail individuals based on a composite definition of frailty and a polypharmacy criterion. Final inclusion criterion: scoring 3 or more on a disability case-finding tool. Intervention: Every 6 months patients will receive a geriatric in-home assessment by a practice nurse, followed by a tailored care plan. Expert teams will manage and train practice nurses. Patients with complex care needs will be reviewed in interdisciplinary consultations. Evaluation: We will perform an effect evaluation, an economic evaluation, and a process evaluation. Primary outcome is quality of life as measured with the Short Form-12 questionnaire. Effect analyses will be based on the "intention-to-treat" principle, using multilevel regression analysis. Cost measurements will be administered continually during the study period. A cost-effectiveness analysis and cost-utility analysis will be conducted comparing mean total costs to functional status, care needs and QALYs. We will investigate the level of implementation, barriers and facilitators to successful implementation and the extent to which the intervention manages to achieve the transition necessary to overcome challenges in elderly care.DISCUSSION This is one of the first studies assessing the effectiveness, cost-effectiveness and implementation process of the chronic care model for frail community-dwelling older adults.TRIAL REGISTRATION The Netherlands National Trial Register NTR2160.

Radical cystectomy over the age of 75 is safe and increases survival.

Stavros Tyritzis — 2012-04-30T00:00:00Z

Background: Radical cystectomy (RC) is probably underused in elderly patients due to a potential increased postoperative complication risk, as reflected by their considerable comorbidities. Our objective was to estimate the overall complication rate and investigate a potential benefit to patients over the age of 75 subjected to RC in terms of disease-free survival. Methods: A total of 81 patients, 61 men and 20 women, from two urological departments, with a mean age of 79.2+/-3.7 years, participated in the study. The mean follow-up period was 2.6+/-1.6 years. All patients underwent RC with pelvic lymphadenectomy. An ileal conduit, an orthotopic ileal neobladder and cutaneous ureterostomies were formed in 48.1%, 6.2% and 45.7% of the patients, respectively.The perioperative and 90-day postoperative complications were recorded and classified according to the modified Clavien classification system. Survival plots were created based on the oncological outcome and several study parameters. Results: The perioperative morbidity rate was 43.2%; the 90-day morbidity rate was 37%, while the 30-day, 90-day and overall mortality rates were 3.7%, 3.7% and 21%, respectively. Overall mortality rates were recorded at the final year of data gathering (2009). Increased age, increased body mass index (BMI), longer hospitalization and age-adjusted Charlson comorbidity index (ACCI) more than six, were associated with greater hazard for 90-day morbidity. The cumulative mortality / metastasis-free rates for one, two, three and five years were 88.7%, 77.5%, 70.4%, and 62.3%, respectively. Tumour stage and positive nodes were prognostic predictors for oncological outcome. Conclusions: RC in patients over 75 is justified and feasible, due to acceptable complication rates and high 5-year cancer-specific survival, which support an aggressive approach. Prospective studies are needed for the verification of the above results.

The validation of a French-language version of the Aging Perceptions Questionnaire (APQ) and its extension to a population aged 55 and over

Isabelle Ingrand — 2012-04-30T00:00:00Z

Background: Several studies have shown the influence of the perceptions of aging on the cognitive functioning and the mental and physical health of older people. These relationships have not to date been studied in France where validated instruments are lacking. The primary objective of this study was to validate a French-language version of the Aging Perceptions Questionnaire (APQ) in the French general population aged 65 and over. The secondary objective was to study the stability of the dimensions of this instrument among participants aged 55 to 64. Methods: The study was proposed to the cohort of the Observatoire Regional du Vieillissement (OPREVI) (observatory of aging), located in a small town in Poitou-Charentes (western France). An anonymous questionnaire including the APQ was sent by mail to inhabitants aged 55 and over. The original English language APQ was described with adults aged 65 and older. It has 32 items distributed on 7 dimensions: timeline chronic and cyclical, positive and negative consequences, positive and negative control and emotional representations. Results: 656 adults participated in this survey (286 men, 370 women). Among those aged 65 and over (n=394), the seven-factor structure estimated by confirmatory factor analysis was coherent with original findings. Internal consistency as evaluated by Cronbach alpha, was between 0.83 for consequences negative and 0.52 for control negative. Several dimensions were strongly correlated. Among participants aged 55 to 64 (n=262), the same factorial model yielded an acceptable fit. Multi-group confirmatory factor analysis concluded to approximate factorial invariance between the two age groups with a null delta in comparative fit index. Conclusion: This study among French people aged 65 and over, added further evidence of the multidimensional structure of the French version of the APQ which is superimposed to the dimensions of the original Irish version. The same factorial structure applies acceptably to the younger group (aged 55-64). The OPREVI study is ongoing, and will collect data on the physical, material and social characteristics of participants. It will therefore be possible to analyse the variables associated with the perceptions of aging. On the basis of an individual's perceptions of aging as captured by this questionnaire, and his or her clinical profile, tailored multi-dimensional assistance could be made available aiming to provide incentives to anticipate or to adapt to difficulties.

Proactive and integrated primary care for frail older people: Design and methodological challenges of the Utrecht Primary care PROactive Frailty Intervention Trial (U-PROFIT)

Nienke Bleijenberg — 2012-04-25T00:00:00Z

Background: Currently, primary care for frail older people is reactive, time consuming and does not meet patients' needs. A transition is needed towards proactive and integrated care, so that daily functioning and a good quality of life can be preserved. To work towards these goals, two interventions were developed to enhance the care of frail older patients in general practice: a screening and monitoring intervention using routine healthcare data (U-PRIM) and a nurse-led multidisciplinary intervention program (U-CARE). The U-PROFIT trial was designed to evaluate the effectiveness of these interventions. The aim of this paper is to describe the U-PROFIT trial design and to discuss methodological issues and challenges. Methods: The effectiveness of U-PRIM and U-CARE is being tested in a three-armed, cluster randomized trial in 58 general practices in the Netherlands, with approximately 5000 elderly individuals expected to participate. The primary outcome is the effect on activities of daily living as measured with the Katz ADL index. Secondary outcomes are quality of life, mortality, nursing home admission, emergency department and out-of-hours General Practice (GP), surgery visits, and caregiver burden.DiscussionIn a large, pragmatic trial conducted in daily clinical practice with frail older patients, several challenges and methodological issues will occur. Recruitment and retention of patients and feasibility of the interventions are important issues. To enable broad generalizability of results, careful choices of the design and outcome measures are required. Taking this into account, the U-PROFIT trial aims to provide robust evidence for a structured and integrated approach to provide care for frail older people in primary care.Trial registrationNTR2288

Electrocardiographic abnormalities in centenarians: impact on survival

Ramón Rabuñal-Rey — 2012-04-20T00:00:00Z

Background: The centenarian population is gradually increasing, so it is becoming more common to see centenarians in clinical practice. Electrocardiogram abnormalities in the elderly have been reported, but several methodological biases have been detected that limit the validity of their results. The aim of this study is to analyse the ECG abnormalities in a prospective study of the centenarian population and to assess their impact on survivalMethodWe performed a domiciliary visit, where a medical history, an ECG and blood analysis were obtained. Barthel index (BI), cognitive mini-exam (CME) and Charlson index (ChI) were all determined. Patients were followed up by telephone up until their death. Results: A total of 80 centenarians were studied, 26 men and 64 women, mean age 100.8 (SD 1.3). Of these, 81% had been admitted to the hospital at least once in the past, 81.3% were taking drugs (mean 3.3, rank 0-11). ChI was 1.21 (SD 1.19). Men had higher scores both for BI (70 -SD 34.4- vs. 50.4 -SD 36.6-, P=.005) and CME (16.5 -SD 9.1- vs. 9.1 -SD 11.6-, P=.008); 40.3% of the centenarians had anaemia, 67.5% renal failure, 13% hyperglycaemia, 22.1% hypoalbuminaemia and 10.7% dyslipidaemia, without statistically significant differences regarding sex. Only 7% had a normal ECG; 21 (26.3%) had atrial fibrillation (AF), 30 (37.5%) conduction defects and 31 (38.8%) abnormalities suggestive of ischemia, without sex-related differences. A history of heart disease was significantly associated with the presence of AF (P=.002, OR 5.2, CI 95% 1.8 to 15.2) and changes suggestive of ischemia (P=.019, OR 3.2, CI 95% 1.2-8.7). Mean survival was 628 days (SD 578.5), median 481 days. Mortality risk was independently associated with the presence of AF (RR 2.0, P=.011), hyperglycaemia (RR 2.2, P=.032), hypoalbuminaemia (RR 3.5, P<.001) and functional dependence assessed by BI (RR 1.8, P=.024). Conclusion: although ECG abnormalities are common in centenarians, they are not related to sex, functional capacity or cognitive impairment. The only abnormality that has an impact on survival is AF.

Use of warfarin in long-term care: a systematic review

Marjorie Neidecker — 2012-04-05T00:00:00Z

Background: The use of warfarin in older patients requires special consideration because of concerns with comorbidities, interacting medications, and the risk of bleeding. Several studies have suggested that warfarin may be underused or inconsistently prescribed in long-term care (LTC); no published systematic review has evaluated warfarin use for stroke prevention in this setting. This review was conducted to summarize the body of published original research regarding the use of warfarin in the LTC population. Methods: A systematic literature search of the PubMed, Cumulative Index to Nursing and Allied Health Literature, and Cochrane Library was conducted from January 1985 to August 2010 to identify studies that reported warfarin use in LTC. Studies were grouped by (1) rates of warfarin use and prescribing patterns, (2) association of resident and institutional characteristics with warfarin prescribing, (3) prescriber attitudes and concerns about warfarin use, (4) warfarin management and monitoring, and (5) warfarin-related adverse events. Summaries of study findings and quality assessments of each study were developed. Results: Twenty-two studies met the inclusion criteria for this review. Atrial fibrillation (AF) was the most common indication for warfarin use in LTC and use of warfarin for stroke survivors was common. Rates of warfarin use in AF were low in 5 studies, ranging from 17% to 57%. These usage rates were low even among residents with high stroke risk and low bleeding risk. Scored bleeding risk had no apparent association with warfarin use in AF. In physician surveys, factors associated with not prescribing warfarin included risk of falls, dementia, short life expectancy, and history of bleeding. International normalized ratio was in the target range approximately half of the time. The combined overall rate of warfarin-related adverse events and potential events was 25.5 per 100 resident months on warfarin therapy. Conclusions: Among residents with AF, use of warfarin and maintenance of INR levels to prevent stroke appear to be suboptimal. Among prescribers, perceived challenges associated with warfarin therapy often outweigh its benefits. Further research is needed to explicitly consider the appropriate balancing of risks and benefits in this frail patient population.

Validation of the Spiritual Distress Assessment Tool in older hospitalized patients

Stefanie Monod — 2012-03-29T00:00:00Z

Background: The Spiritual Distress Assessment Tool (SDAT) is a 5-item instrument developed to assess unmet spiritual needs in hospitalized elderly patients and to determine the presence of spiritual distress. The objective of this study was to investigate the SDAT psychometric properties. Methods: This cross-sectional study was performed in a Geriatric Rehabilitation Unit. Patients (N = 203), aged 65 years and over with Mini Mental State Exam score [greater than or equal to] 20, were consecutively enrolled over a 6-month period. Data on health, functional, cognitive, affective and spiritual status were collected upon admission. Interviews using the SDAT (score from 0 to 15, higher scores indicating higher distress) were conducted by a trained chaplain. Factor analysis, measures of internal consistency (inter-item and item-to-total correlations, Cronbach alpha), and reliability (intra-rater and inter-rater) were performed. Criterion-related validity was assessed using the Functional Assessment of Chronic Illness Therapy-Spiritual well-being (FACIT-Sp) and the question "Are you at peace?" as criterion-standard. Concurrent and predictive validity were assessed using the Geriatric Depression Scale (GDS), occurrence of a family meeting, hospital length of stay (LOS) and destination at discharge. Results: SDAT scores ranged from 1 to 11 (mean 5.6 +/- 2.4). Overall, 65.0% (132/203) of the patients reported some spiritual distress on SDAT total score and 22.2% (45/203) reported at least one severe unmet spiritual need. A two-factor solution explained 60% of the variance. Inter-item correlations ranged from 0.11 to 0.41 (eight out of ten with P < 0.05). Item-to-total correlations ranged from 0.57 to 0.66 (all P < 0.001). Cronbach alpha was acceptable (0.60). Intra-rater and inter-rater reliabilities were high (Intraclass Correlation Coefficients ranging from 0.87 to 0.96). SDAT correlated significantly with the FACIT-Sp, "Are you at peace?", GDS (Rho 0.45, -0.33, and 0.43, respectively, all P < .001), and LOS (Rho 0.15, P = .03). Compared with patients showing no severely unmet spiritual need, patients with at least one severe unmet spiritual need had higher odds of occurrence of a family meeting (adjOR 4.7, 95%CI 1.4-16.3, P = .02) and were more often discharged to a nursing home (13.3% vs 3.8%; P = .027). Conclusions: SDAT has acceptable psychometrics properties and appears to be a valid and reliable instrument to assess spiritual distress in elderly hospitalized patients.