Background: The growth of life-sustaining medical technology and greater attention to medical care at the end of life have provoked interest in issues related to advance care planning. Objective: To ...investigate how having a living will (LW), resuscitation preferences, health condition, and life attitudes are related in home-dwelling elderly people. Methods: In a cross-sectional descriptive study, detailed assessments were made of 378 home-dwelling elderly individuals participating in a cardiovascular prevention study (DEBATE Study). The participants were inquired about a preexistence of a written document (LW) concerning life-sustaining care, preferences of cardiopulmonary resuscitation (CPR) in their current situation, and attitudes towards life. General health, physical and cognitive functioning, the presence of depression, and quality of life were also assessed. Results: Forty-four of the 378 participants (12%) had a LW. As compared with those without one (n = 334), there were more women 82% (36/44) vs. 63% (210/334) and widows 57% (25/44) vs. 41% (135/334) among those with a LW. They were also more educated and considered their health to be better. Despite having a LW, 46% (20/44) of them preferred CPR in their current condition, a proportion not statistically different from the 58% (194/334) of the individuals without a LW. In the whole sample, 39% (149/378) of the individuals preferred to forgo CPR. As compared with those preferring CPR, they were older, more often women, and widowed. Participants preferring to forgo CPR had a poorer quality of life, were more lonely, and showed signs of depression more often than those preferring CPR. The preference to forgo CPR was related to attitudes towards life regardless of physical or cognitive functioning. Conclusions: Having a LW does not reduce the reported preference of CPR which is related more to current mental status and life attitudes. In-depth assessment of the patient’s preferences should be performed in any comprehensive care plan.
Dehydroepiandrosterone sulfate (DHEAS) was measured in a five-year follow-up study of random persons of three age cohorts (75-, 80-, and 85-years, N = 571) in order to investigate its associations ...with clinical diseases and their risk indicators, as well as its prognostic significance in old age. DHEAS was higher in men (3.1 mumol/L) than in women (1.9 mumol/L) in the 75-year age group. It decreased in men up 85 years. Compared to healthy men, DHEAS was lower in men with a history of or manifest vascular diseases, presence of dementia, diabetes mellitus, malignancies and musculoskeletal disorders, but was similar in all these disease groups. No differences were found in women. DHEAS did not relate to cardioechographic findings, cardiovascular risk factors or predictors of impaired survival prognosis. After controlling for age, DHEAS tended to be lower in the non-surviving than in the surviving men (2.28 mumol/L vs 2.65 mumol/L, p = 0.065). After controlling for disease, DHEAS did not predict increased risk of all-cause or cardiovascular mortality during the 5-year follow-up. In this study, gender differences in DHEAS persisted up to the age of 75 years. Low plasma DHEAS appears to be a secondary phenomenon rather than a specific risk indicator of common diseases in old age.
The prevalences of lowered mood and cognitive impairment, and their combination were investigated in 1993 random subjects of five birth cohorts (at age of 65, 70, 75, 80 and 85 years). The frequency ...of a high Zung-score (> 45), indicating depressive symptoms, in the five age groups was 11%, 13%, 20%, 16%, and 36%, respectively. The corresponding figures for a low MMSE-score (Mini Mental State Examination < 24) were 11%, 9%, 25%, 46%, and 60%; the respective frequencies of subjects fulfilling both criteria simultaneously were 2%, 3%, 8%, 12% and 24%, respectively. Overall, about 30% of the subjects with a low MMSE-score had a high Zung-score. However, more than half of the old subjects (over 75 years) with a high Zung-score also had low MMSE-scores. The data indicate that the combination of impaired cognition and lowered mood doubles in frequency by five-year intervals after the age of 70 years in the general aged population, and that this condition is present in one of four subjects at the age of 85 years.
Elderly individuals constitute an increasing proportion of coronary patients, and up-to-date information is needed of their treatments in the community.
A random sample of 75-, 80-, 85-, 90- and ...95-year-old residents (n = 3,921) of Helsinki, Finland, was studied during 1998-1999. They were sent a postal questionnaire with questions about health, diseases and current drug use.
The response rate of home-dwelling elderly persons was 78% (n = 2,511). Of men and women, 75.8% and 79.8%, respectively, had some regular medication (P< 0.05 between genders). Of home-dwelling individuals with coronary heart disease (CHD, n = 717, 28.6%), 61.0% of women and 68.3% of men used aspirin, 58.4% and 52.9% nitrates, 54.7% and 52.4% beta-blockers, 20.0% and 13.7% (angiontensin-converting enzyme) ACE inhibitors and 25.1% and 21.1% calcium-channel blockers. Only 14.3% and 19.4% were on cholesterol-lowering drugs. The difference in ACE inhibitor, diuretic and digoxin use was statistically significant (P < 0.05) between genders (women used more).
Cardiovascular drug use is very common among the oldest age cohorts, but assuming that knowledge from younger individuals applies, there is a suboptimal use of several evidence-based treatments, especially lipid-lowering drugs, aspirin and beta-blockers in elderly coronary patients.
Objective: To assess the documentation of a do-not-attempt-resuscitation (DNAR) or do-not-hospitalize (DNH) orders in the medical record and to determine factors related to these orders.
Materials ...and methods: Five thousand six hundred and fifty four subjects from three different levels of institutional long-term care (LTC), chronic care hospitals (
n=1989), nursing homes (
n=3310), and assisted living (
n=355) in 67 LTC facilities in 19 municipalities were assessed.
Results: Out of these patients, 751 (13%) had a DNAR order and only 36 (0.6%) had a DNH order. The variation in DNAR orders between individual LTC institutions was enormous, ranging from 0 to 92%. In logistic regression analysis, individual institutions and their local caring cultures had the strongest explanatory value (
R
2=0.49) for advance orders to limit therapy. Impaired activity in daily living (ADL) function (
R
2=0.11), impaired cognition (
R
2=0.07), level of LTC (
R
2=0.05), and diagnoses (
R
2=0.04) did not provide adequate explanations. Terminal prognosis was not significantly associated with advance orders.
Conclusions: We found marked differences in the use of DNAR and DNH orders between caring units. Diseases and ADL status were only weakly significant as background factors. Open discussions, general guidelines, and research about the adequacy of DNAR decisions are needed to improve equality and self-empowerment among the elderly residing in institutions.
Objectivo: Avaliar a documentação da decisão de não reanimar (DNAR) ou de não hospitalizar (DNH) nos registos médicos e determinar factores relacionados com estas ordens.
Materiais e métodos: Foram avaliados 5654 doentes de instituições de cuidados continuados (LTC) de 3 nı́veis diferentes, hospitais de cuidados crónicos (
n = 1989), lares de enfermagem (
n = 3310) e de apoio a doentes (
n = 355) em 67 instituições LTC de 19 municı́pios.
Resultados: Destes doentes, 751 (13%) tinham ordem DNAR e apenas 36 (0,6%) tinham ordem DNH. A variação na DNAR entre instituições NTC individuais foi enorme, variando de 0 a 92%. Na análise de regressão logı́stica as instituições individuais e as suas culturas locais de cuidados tiveram o maior valor explicativo (
R
2 = 0,49) para as directivas avançadas de limite de intervenção terapêutica. Alterações na capacidade para actividades de vida diária (ADL) (
R
2 = 0,11), alterações cognitivas (
R
2 = 0,07), nı́vel de LTC (
R
2 = 0,05) e diagnósticos (
R
2 = 0,04) não proporcionaram explicações adequadas. O prognóstico terminal não estava significativamente associado com as directivas avançadas.
Conclusões: Encontramos diferenças profundas no uso das ordens DNAR e DNH entre unidades de cuidados. As doenças e estado de ADL tinham pouco significado como factores explicativos. São necessárias discussões abertas, recomendações gerais e investigação acerca das decisões adequadas de DNAR para melhorar a equidade e autodeterminação entre os idosos a residirem em instituições.
Objetivos: Evaluar la documentación de las órdenes de no intentar reanimación (DNAR) o de no hospitalizar (DNH) en el registro médico, y determinar los factores relacionados con estas órdenes.
Materiales y métodos: Se evaluaron 5654 sujetos de instituciones de cuidados de largo plazo(LTC), hospitales de cuidados de enfermos crónicos (
n = 1989), casas de reposo (
n = 3310), e instituciones de vida asistida (
n = 355) en 67 instituciones de LTC en 19 municipalidades.
Resultados: De estos pacientes, 751 (13%) tenı́a órdenes de DNAR y solo 36 (0.6%) tenı́a órdenes de DNH. La variación entre las DNAR de las distintas instituciones fue enorme, variando en un rango entre el 0 al 92%. En análisis de regresión logı́stica, las instituciones individuales y sus culturas locales de cuidados tuvieron el valor explicatorio mas fuerte (
R
2 = 0.49) para órdenes que limiten terapias. Las limitaciones en actividades en las funciones de vida diaria (ADL) (
R
2 = 0.11), limitaciones cognitivas (
R
2 = 0.07), nivel de LTC (
R
2 = 0.05) y diagnóstico (
R
2 = 0.04) no proporcionaron explicaciones adecuadas. El pronóstico terminal no estuvo significativamente asociado con órdenes adelantadas.
Conclusiones: Encontramos diferencias marcadas en el uso de la órdenes DNAR y DNH entre las distintas unidades de cuidados. El diagnóstico y el estado de ADL fueron débilmente significativos como factores de antecedentes. Se necesitan discusiones abiertas, guı́as generales, e investigación acerca de lo adecuado de las decisiones de DNAR para mejorar la equidad y poder sobre su tratamiento en los ancianos residentes en instituciones.
Extract: Beta-sitosterol and campesterol were measured in serum lipoproteins of 17 subjects from two families. The serum levels of the two phytosterols were closely correlated with each other (r = ...0.974), less consistently with serum cholesterol (r = 0.489), and not at all with serum triglycerides. As compared to cholesterol, serum free and esterified phytosterols tended to be accumulated in HDL where the phytosterol/cholesterol ratios were almost 40 per cent higher than in VLDL and LDL. The serum phytosterol concentrations, the phytosterol/cholesterol ratios, especially in VLDL and LDL, and the fractional absorption of cholesterol were higher in women than in men. The levels of the phytosterols in whole serum and in each lipoprotein were significantly correlated with the percentage absorption of dietary cholesterol but were independent of the amount of dietary cholesterol and plant sterols. Our findings suggest that, in general, serum levels of noncholesterol sterols are effectively determined by the absorption which in turn is proportionate to the fractional absorption of cholesterol.(author).
BACKGROUND In 1997, a US expert panel developed explicit criteria on potentially inappropriate drugs for the general elderly population. OBJECTIVE To investigate the proportion of inappropriate ...medications among home-dwelling, elderly patients in Helsinki, Finland, between November 1, 1998, and March 31, 1999. METHODS A cross-sectional mail survey was sent to a random sample of 3921 elderly urban residents aged 75, 80, 85, 90, and 95 years. Of these, 3219 were home dwellers. MAIN OUTCOMES MEASURES Prevalence of potentially inappropriate drugs and prevalence of drugs considered inappropriate related to 15 common medical conditions according to recommendations given by the expert panel in 1997. RESULTS The response rate was 78%. Of the respondents, 12.5%, 1.3%, and 0.2% were taking at least 1, 2, or 3 inappropriate drugs, respectively. The most prevalent inappropriate drugs were dipyridamole (3.6%), long-acting benzodiazepines (2.6%), amitriptyline hydrochloride (1.6%), ergot mesyloids (1.6%), muscle relaxants (1.2%), and meprobamate (1.1%). Use of medications considered inappropriate with certain medical conditions was higher: 27.2% of patients with chronic obstructive pulmonary disease were taking β-blockers and 19.3% used sedatives. Of diabetic individuals taking oral hypoglycemics or insulin, 32.5% were taking a concomitant β-blocker. Of those with a peripheral vascular disease, 37.9% were taking β-blockers. However, two thirds of all these patient groups had concomitant coronary heart disease. CONCLUSIONS Compared with previous surveys, the use of inappropriate medications in our home-dwelling, elderly population is conspicuously low. In contrast, use of certain drugs considered inappropriate with different medical conditions was relatively high. However, the inappropriateness of the latter treatments may be questioned in individual patients.Arch Intern Med. 2002;162:1707-1712-->
Coronary artery disease (CAD) is prevalent in the elderly and often leads to disability. Consequently, strategies for optimising the prevention and treatment of CAD in the elderly are important from ...both the individual and societal perspectives. Although it is common knowledge that the elderly are heavy consumers of drugs, there is evidence to show that there is under-prescribing of evidence-based medical therapies in the home-dwelling elderly coronary patient and there may be overuse of some non-evidence-based (antioxidants) and purely symptomatic treatments. In particular, aspirin (acetylsalicylic acid), beta-adrenoceptor antagonists, ACE inhibitors and HMG-CoA reductase inhibitors are under-utilised. Although the evidence base is largely drawn from trials including patients younger than 75 years, it is reasonable to assume that the data applies to patients aged over 75 years and that better use of evidence-based medicines would provide benefits to the home-dwelling aged patient. Evidence from the few multifactorial studies available suggest possible benefits including reduction of cardiovascular events, less disability and better quality of life in old age. At the societal level, this would be reflected in fewer hospitalisations and institutionalisations, which means decreased cost of elderly care.
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