Objectives: To compare rates of falling between nursing home residents with and without dementia and to examine dementia as an independent risk factor for falls and fall injuries.
Design: Prospective ...cohort study with 2 years of follow‐up.
Setting: Fifty‐nine randomly selected nursing homes in Maryland, stratified by geographic region and facility size.
Participants: Two thousand fifteen newly admitted residents aged 65 and older.
Measurements: During 2 years after nursing home admission, fall data were collected from nursing home charts and hospital discharge summaries.
Results: The unadjusted fall rate for residents in the nursing home with dementia was 4.05 per year, compared with 2.33 falls per year for residents without dementia (P<.0001). The effect of dementia on the rate of falling persisted when known risk factors were taken into account. Among fall events, those occurring to residents with dementia were no more likely to result in injury than falls of residents without dementia, but, given the markedly higher rates of falling by residents with dementia, their rate of injurious falls was higher than for residents without dementia.
Conclusion: Dementia is an independent risk factor for falling. Although most falls do not result in injury, the fact that residents with dementia fall more often than their counterparts without dementia leaves them with a higher overall risk of sustaining injurious falls over time. Nursing home residents with dementia should be considered important candidates for fall‐prevention and fall‐injury‐prevention strategies.
Objectives: To compare black and white nursing home residents with respect to the incidence of nursing home (NH)‐acquired pressure ulcers (PUs) and to examine the role of resident characteristics and ...facility characteristics in explaining differences between the racial groups.
Design: Prospective cohort study conducted between 1992 and 1995.
Setting: Fifty‐nine Maryland NHs.
Participants: A total of 1,938 residents (301 black, 1,637 white) aged 65 and older newly admitted to participating NHs.
Measurements: The outcome variable was the first occurrence of a Stage 2, 3, or 4 PU as determined based on medical record review. The predictor variable was race (black, white). Eight resident characteristics (age, sex, number of activity of daily living dependencies, bedfast, PU on admission to facility, incontinence, dementia, and whether the resident was on Medicaid) and three facility characteristics (number of beds, for‐profit ownership status, and urban/nonurban location) were considered as possible confounding variables.
Results: The incidence of PUs was 0.38 per person‐year in the NH. The rate for blacks was significantly higher than for whites (0.56 vs 0.35 per person‐year) (P<.001). In multivariate analysis, controlling for eight resident characteristics and three facility characteristics, race was significantly associated with PU incidence (hazard ratio comparing blacks with whites=1.31, 95% confidence interval=1.02–1.66).
Conclusion: Blacks have a higher incidence of NH‐acquired PUs than whites; resident characteristics appear to mediate the higher risk. Future research should aim to identify modifiable factors that explain differences between racial groups in PU risk and to develop solutions to prevent the suffering and cost associated with PUs.
This study examined the effects of parental longevity and self-rated life expectancy on mortality, building upon the established model of self-rated health predicting mortality. A community sample of ...Australians aged 70 and over was surveyed in 1992 and 1995. The associations of interest were examined separately by sex using weighted multiple logistic regression. Parental ages at death were not associated with mortality for either men or women. In multivariate models, self-rated life expectancy had an independent effect on men's mortality and did not reduce the effect of self-rated health on mortality. Our findings from Australia are consistent with results from many countries; the effect of self-rated health on mortality is stronger for men than for women. We also found that the effect of self-rated life expectancy on mortality is stronger for men than for women. The independent effects of self-rated health and self-rated life expectancy indicate a need for a more detailed search for explanatory mechanisms.
To determine why older people are optimistic, realistic, or pessimistic on self-rated health relative to standard medical health measures, 48 persons older than age 65 were interviewed in an ...in-depth, semistructured format. Comparisons were made between optimists and poor-health realists, both of whom have serious health problems, to discover the ways in which these groups develop their disparate self-ratings of health. When asked about the meanings they attach to health, respondents variously referred to topics including family history, social comparisons, subjective age, and life expectancy to form their ratings. These results begin to clarify the ways in which different people view similar states of health, building on recent research showing that health pessimists are at an elevated risk of mortality, while health optimists reduce their mortality risk.
To explore how older persons form preferences for site of medical care by examining their perceptions of home care and hospital care.
Qualitative analysis of in-depth interviews using the constant ...comparative method.
Respondents' homes.
Twenty-nine persons age 65 to 89 years who had been hospitalized with congestive heart failure, chronic obstructive pulmonary disease, or pneumonia and were receiving home care services.
Respondents, who thought of home care only as a means to provide low-intensity and low-frequency services, were initially skeptical about expanded home care services to treat acute illness. Regardless of their opinions about home and hospital, all respondents preferred the site associated with the greatest chance of survival. If the sites offered equal survival, 52% of the respondents preferred treatment at home because of freedom from the constraints of the hospital and the comfort of familiar surroundings. For respondents who preferred the hospital, the home represented a frightening and lonely place to be sick. Respondents' views of the home and hospital were shaped by their social supports, self-reliance, religious beliefs, and past illness experiences.
Because survival appears to be the most important determinant of preference, home treatment of acute illness is a viable alternative only if it provides outcomes equivalent to those of hospitalization. Strongly held perceptions that home care can only be a low-intensity service may limit preferences for home treatment. When expected outcomes at the two sites are similar, the challenge to the health care system will be incorporating patient preference about the process of care into decisions about the appropriate site of care.
Survival analyses are used to examine the predictive value of spouse-rated limitations due to health problems and spouse-rated life expectancy for 3-year mortality in a community sample of elderly ...Australian married couples, net of health status indicators, health behaviors, and sociodemographic factors. Tests for gender differences in the effects and for empirical overlap with self-ratings of health and life expectancy were also done. Findings show that both spouse-ratings are predictive of husbands' mortality, while for wives' mortality the parallel measures are not predictive in the adjusted model. Wives' ratings are not substitutes for other health indicators or for self-ratings of health and life expectancy. The independent effect suggests that wives are more astute reporters or judges of their husbands' mortality risk or that wives' perceptions indicate tangible influences on husbands' health and mortality risk. Future analyses should be directed toward finding mechanisms linking spouse perceptions to health outcomes.
PURPOSE: Home care is increasingly being used as a substitute for hospital care. This study examined older patients’ perceptions of the home and of the hospital as treatment sites for acute illness ...and the patient characteristics that are associated with these perceptions.
SUBJECTS AND METHODS: A series of questions derived from open-ended interviews supplemented by literature review were administered by telephone in a cross-sectional, descriptive study to community-dwelling persons age 65 years or older who had been hospitalized 2 months earlier with congestive heart failure, chronic obstructive pulmonary disease, or pneumonia.
RESULTS: Among 246 participants, nearly equal proportions agreed with statements that the home and the hospital would be comfortable sites of care (54% versus 55%), that the home and the hospital would provide rapid recovery (41% versus 37%), and that home treatment and hospital treatment would be burdensome on family and friends (40% versus 33%). Although 93% would feel safe in the hospital, only 42% would feel safe at home. Perceptions were not associated with sociodemographic characteristics, primary diagnosis, self-rated health, depression, or social support. Functionally dependent patients had more positive perceptions of treatment at home.
CONCLUSIONS: Evaluation of perceptions of home and hospital can facilitate assessing the acceptability of shifting acute care from hospital to home. Our findings suggest that successful expansion of acute home care will require flexibility in the use of home and hospital as well as education to change perceptions about the safety and efficacy of treatment at home.
Previous evaluative studies of outpatient geriatric assessment have focused on a limited set of outcomes related to functioning, health services utilization, and costs. The purpose of this study was ...to identify important goals for care as described by patients and family caregivers being cared for in this setting. Using a cross-section of 226 consecutive sets of patients and their primary family caregivers, physicians, and case managers, goals of care for individual patients were coded from open-ended interview responses. The most common categories of goals expressed by family caregivers were obtaining education and referrals (57.5%) and improving social and family relationships (53.0%). The process of establishing and meeting such goals should be explicitly included in the design of future evaluations of outpatient geriatric assessment.
To compare Charlson indices based on chart data and ICD-9 data for agreement overall and on rating specific comorbid conditions, and to compare mortality risks associated with these indices. ...Prospective cohort study. Six general medicine wards at Yale-New Haven Hospital. 524 consecutive patients who had no clinical evidence of delirium at enrollment, admitted between November 6, 1989 and July 31, 1991, aged 70 years or older. Death within 1 year of the index hospital admission date. Scores using the chart-based data were significantly higher than those using ICD-9 data. About half of the individual conditions showed fair-to-good agreement between the two scores, whereas the other half showed poor agreement. A comparison of mortality prediction indicated that the weightings assigned to individual comorbidities differed substantially from those used in Charlson's original index. While mortality prediction of each individual index was comparable, the ICD-9 and chart indices contributed independently to mortality prediction in the presence of the other. Low agreement between Charlson scores based on the two methods of data collection and their cumulative contribution to mortality prediction suggest that these indices may include different information. Our results suggest that the original Charlson index may not provide optimal risk adjustment for elderly general medicine samples. We suggest development of an empirically–derived index of comorbid conditions and weights may be warranted for older general medical patients.
Few studies have examined the relationship between marital quality and adjustment to the impending loss of a terminally ill spouse. Most studies of marital quality and grief have been based on ...retrospective reports of the marriage rather than pre-loss assessments. Here, we tested the pre-loss cross-sectional effects of having a security-enhancing marriage on traumatic grief and depressive symptoms among 59 caregivers aged 50 and over of terminally ill spouses. We also examined whether insecure attachment styles were associated with traumatic grief and depressive symptoms. Findings suggest that security-increasing marriages and insecure attachment styles put spouses at risk for elevated traumatic grief symptoms. Results also indicate that marital quality and attachment style did not interact and that neither was significantly associated with depressive symptoms. The differences in the relationship of marital quality and attachment styles to the two outcomes suggest that the etiology of traumatic grief and depressive symptoms may be distinct.
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