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Biomedical subjects

C H Winograd

Publications and source records attributed to C H Winograd.

At least 37 records · Page 2Linked to original sources
PubMed1991

Working group recommendations: targeting criteria for geriatric evaluation and management research.

To maximize the cost effectiveness of geriatric evaluation and management (GEM) programs, criteria need to be established for selecting patients most likely to benefit. A working group was convened to define appropriate patient selection (targeting) criteria for each type of GEM program and to consider research questions for future targeting studies. The group outlined targeting criteria for the spectrum of GEM program types and locations. GEM program types included: inpatient GEM units; hospital geriatric consultation service; GEM programs in nursing homes; outpatient GEM programs for functionally impaired persons; and geriatric community outreach/screening programs for functionally independent elders. For each program type, the group outlined targeting criteria based on current literature and experience. Because research has not yet established the effectiveness of many of these patient targeting strategies, the group drafted a set of research questions, pertinent to targeting, that require attention: (1) For each identifiable population of elderly people, who are most likely to benefit from GEM? (2) How should these people best be identified/targeted? (3) What criteria should be used for targeting? (4) How and how often should population screening be performed to identify persons in need of GEM?

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PubMed1991

Durable power of attorney for health care. Are we ready for it?

Health care professionals need to be well informed about advance directives for medical care in the event a patient becomes incapacitated. The Patient Self-Determination Act requires that all patients be advised of their options at the time of hospital admission. Hospitals and health care professionals will need to work together to plan for implementing this law. We surveyed 215 physicians, nurses, and social workers at a Veterans Affairs Medical Center about the California advance directive, the Durable Power of Attorney for Health Care. Attitudes were generally positive. All of the social workers had heard of the durable power of attorney directive, but 36% of physicians and nurses had never heard of it and an additional 20% had no experience with one. For respondents who had heard of the directive, the mean knowledge score was 6.35 of a possible 10 (5 predicted by chance). Respondents brought up the issue of durable power of attorney with patients before a crisis only 19% of the time and determined whether one had been signed for only 16% of older patients in hospital. The most commonly cited reasons for failure to discuss this with patients were lack of proper forms, pamphlets, or a place to refer a patient. Of those who had ever seen such a document in use, 42% were aware of a problem with it at some time. Whereas attitudes toward advance directives are positive, many physicians and nurses had little knowledge of the Durable Power of Attorney for Health Care and were poorly equipped to discuss it with patients. We encourage educating hospital staff to prepare for the enactment of the Patient Self-Determination Act. We also recommend that the concerns raised by professionals about the use of a durable power of attorney be addressed.

Advance Directives↗
PubMed1990

Aggressive oral refeeding in hospitalized patients.

Malnutrition is an important clinical condition leading to increased morbidity and mortality. This report describes an aggressive oral refeeding program of high-caloric foods, which was instituted in severely anorectic patients because of their refusal to eat meals or supplements. After ascertaining a patient's favorite sweet, hospital personnel and family collaborated in providing the food. Frequently, sweets were the patient's only intake for weeks. We saw a gradual return of appetite, inclusion of other foods in the diet, and overall clinical improvement in comorbid conditions. These cases suggest that aggressive oral refeeding with high-caloric foods is an underutilized therapy for multiply impaired elderly patients.

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PubMed1990

The natural history of functional morbidity in hospitalized older patients.

This study provides data on changes in the functional status of older patients that are associated with acute hospitalization. Seventy-one patients over the age of 74 admitted to the medical service of Stanford University Hospital between February and May 1987 received functional assessments covering seven domains: mobility, transfer, toileting, incontinence, feeding, grooming, and mental status. Assessments were obtained by report from the patient's caregiver (or the patient when he or she lived alone) for 2 weeks before admission; from the patient's nurse on day 2 of hospitalization and on the day before discharge; and again from the caregiver (or patient) 1 week after discharge. The sample had a mean age of 84, covered 37 Diagnostic Related Groups, and had a median length of stay of 8 days. Between baseline and day 2, statistically significant deteriorations occurred for the overall functional score and for the individual scores for mobility, transfer, toileting, feeding, and grooming. None of these scores improved significantly by discharge. In the case of mobility, 65% of the patients experienced a decline in score between baseline and day 2. Between day 2 and discharge, 67% showed no improvement, and another 10% deteriorated further. These data suggest that older patients may experience a burden of new and worsened functional impairment during hospitalization that improves at a much slower rate than the acute illness. An awareness of delayed functional recovery should influence discharge planning for older patients. Greater efforts to prevent functional decline in the hospitalized older patient may be warranted.

Activities of Daily Living↗
PubMed1990

Prospective payment and the utilization of physical therapy service in the hospitalized elderly.

We studied the effect, in a university teaching hospital, of the prospective payment system (PPS) on utilization of physical therapy (PT), a non-reimbursable service; subjects were hospitalized patients aged 75 or older with non-PT-related diagnoses (myocardial infarction, pneumonia, congestive heart failure, and colectomy) and PT-related diagnoses (cerebrovascular accident and hip fracture). The proportion of patients referred for PT increased from 68 percent pre-PPS to 85 percent post-PPS for those with PT-related diagnoses and from 13 percent pre-PPS to 19 percent post-PPS for those with non-PT-related diagnoses. The mean number of sessions of PT decreased slightly for both groups: from 8.5 to 7.6 sessions for those with PT-related diagnoses and from 5.2 to 4.5 for those with non-PT-related diagnoses. In patients with PT-related diagnoses whose ambulatory status worsened during hospitalization, referrals for PT increased from 76 percent pre-PPS to 98 percent post-PPS. Referrals of comparable patients with non-PT-related diagnoses did not increase. Changes in provider education and efforts to reduce length of stay may account for these findings.

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PubMed1988

Recovery of function after hip fracture. The role of social supports.

Previous studies have found that social support may reduce mortality after myocardial infarction and reduce overall mortality among the elderly. To determine whether social support also influences the recovery of function among patients who have had hip fractures and to describe other potential predictors of recovery after hip fracture, 111 patients with hip fractures were interviewed and examined before discharge from the hospital. The functional status of surviving patients was assessed again 6 months later. Patients who had a greater number of social supports had more complete recovery of their prefracture level of function (r = .21; P = .04). This association was strongest for patients over 60 years old (r = .31; P = .006); among these patients, this association remained statistically significant after adjustment for other significant (P less than .05) predictors of recovery: arm strength, mental status, and serum albumin. Additional studies should be done to test whether interventions to increase social supports can improve the recovery of function among elderly patients with hip fractures and other illnesses. In the meantime, health professionals should counsel elderly patients about the potential rehabilitative and preventive benefits of social supports.

Activities of Daily Living↗
PubMed1988

Targeting the hospitalized elderly for geriatric consultation.

This empirical study reports the proportion of hospitalized elderly patients who were identified as frail. As a part of a randomized controlled trial, standardized criteria were developed to target the frail hospitalized elderly for geriatric consultation. Twelve-hundred patients aged 65 years and older admitted to the medical and surgical services at the Palo Alto Veterans Administration Medical Center were screened. Because of administrative exclusions of the randomized controlled trial (eg, short stay, lived too far away), 749 (62%) were excluded from the clinical screening process. The remaining 451 patients received clinical screening. Of these patients, almost two thirds (64%) were considered "too independent" to benefit from geriatric consultation (ie, independent in activities of daily living with short term illness), while 12% were judged "too impaired" to benefit (ie, had severe dementia or terminal cancer). Only 24% of those clinically screened (9% of the entire sample) were considered appropriate for geriatric consultation. Strikingly, over 42% of those patients aged 76 or older, were judged "too independent." These data suggest that a large majority of the hospitalized elderly may be too well to benefit from geriatric consultation, thus making targeting by age alone inefficient. A realistic estimate of the percentage of hospitalized patients appropriate for geriatric intervention lies somewhere between 18% (the combined percentage of those found appropriate and those already enrolled in geriatric programs) and 24% (the proportion of the clinically evaluated group found appropriate). Targeting of subjects may be accomplished inexpensively using the authors' explicit criteria. Such targeting may help focus the use of interdisciplinary geriatric expertise on those most in need.(ABSTRACT TRUNCATED AT 250 WORDS)

Activities of Daily Living↗
PubMed1987

Assessment of depression in geriatric medical outpatients: the validity of two screening measures.

The validity of two screening measures for depression was assessed in a geriatric medical outpatient population. Sixty-eight patients completed both questionnaires; 31 also completed a clinical interview allowing for accurate diagnosis. Both screening measures were found to accurately identify those who were depressed. Clinical and research applications are discussed, including the complementary use of these screening measures with the physician's diagnosis.

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PubMed1987

Inpatient geriatric consultation.

Inpatient geriatric consultation services have the potential for educating large numbers of health professionals and influencing the clinical care of large numbers of patients. Such consultation can identify new diagnoses and recommend treatment of conditions whose appropriate management can improve patients' functional level. At San Francisco General Hospital, the most frequent recommendations were medication adjustment, management of dementia, delirium or depression, rehabilitation, and treatment of malnutrition. Of 35 patients slated to go to nursing homes at the time of consultation, 18 were rerouted to lower levels of care, and 14 eventually went home. Preliminary findings at the Palo Alto Veterans Administration Medical Center replicate these data.

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