Biomedical subjects

David R Mehr

Publications and source records attributed to David R Mehr.

25 records · Page 2Linked to original sources

PubMed2002

Primary prevention of disease of old age.

Although increasing disability is a common concomitant of old age, several interventions may prevent or delay disabling diseases. The "young-old" differ little from middle-aged people in their potential to benefit from many interventions. As age increases, clinicians need to become increasingly circumspect about interventions with a potential for harm and for benefit. By carefully weighing existing disease burden, the state of our knowledge about prevention, and patient values, however, clinicians may develop a reasonable preventive program in consultation with the patient and, where there is diminished competence, relevant family members. As we gain new knowledge about genetic and other risk factors, we may be able to more accurately and effectively target preventive services to maximize benefits and minimize harms in the population as a whole.

Aged↗

PubMed2002

Severe dementia and adverse outcomes of nursing home-acquired pneumonia: evidence for mediation by functional and pathophysiological decline.

OBJECTIVES: To assess whether the severity of dementia is related to unfavorable outcomes of nursing home-acquired pneumonia and how this relationship is mediated. DESIGN: Prospective cohort study. SETTING: Psychogeriatric wards of 61 nursing homes in the Netherlands. MEASUREMENTS: Dementia severity and the possible mediators swallowing disturbance, aspiration, insufficient food intake, weight loss, and dehydration were measured and related to the following outcomes: death (rate), cure rate, and increase in discomfort at the onset of pneumonia. PARTICIPANTS: Demented patients (n = 374) treated with antibiotics for pneumonia. RESULTS: Dementia severity was independently related to death rate within the first week after pneumonia (hazard rate ratio = 3.0 for the most severely demented quartile versus the least demented quartile, 95% confidence interval (CI) = 1.1-8.3) and to 3-month mortality (odds ratio (OR) 2.5, 95% CI = 1.1-5.4). The latter relation was in part mediated by aspiration and weight loss (OR dementia severity adjusted for these mediators declined from 2.5 to 1.9, 95% Cl = 0.8-4.3). Dementia severity was not related to cure rate within 2 weeks nor to an in-crease in discomfort after 3 days compared with before the pneumonia. CONCLUSION: The functional and pathophysiological consequences of progressive dementia account in part for increased 3-month mortality after pneumonia. Mid-term mortality is expected to be high only in the most severely demented patients and in less severely demented patients who aspirated or who lost weight. Implications for end-of-life decision-making and effectiveness of preventive and curative interventions are discussed.

Adult↗

PubMedDate not supplied

The cost of treating pneumonia in the nursing home setting.

OBJECTIVE: To determine the costs of treating pneumonia in the nursing home setting and explore what factors are most responsible for that cost with a view to reducing cost. DESIGN: Prospective cohort study. SETTING: Thirty-six Missouri nursing homes participating in the study from April 1997 through September 1998. PARTICIPANTS: Nursing home residents with pneumonia who were not hospitalized (n = 502). We included residents evaluated in the emergency department (ED) and returned to the nursing home without admission. MEASUREMENTS: Residents were evaluated by project nurses. Examination findings, diagnostic testing, and treatment information for 30 days following evaluation were abstracted from medical records. Bills were obtained for individuals evaluated in the ED. RESULTS: There was significant variation in the cost of treating pneumonia in nursing homes. Episode costs were higher for residents seen in the ED of a hospital, residents with decubitus ulcers, black residents, and residents in larger facilities. Although total episode costs were related to illness severity, most of the variation in cost is not explained by resident or illness characteristics. The average cost for treating an episode of pneumonia in the nursing home, over and above usual care, was $458. CONCLUSIONS: There is wide variation in treatment for residents with similar clinical presentations. For residents at low risk of mortality, using less expensive antibiotics and reducing ED evaluation could result in cost reductions, although the effect on outcomes is unknown.

Aged↗

PubMedDate not supplied

End-of-life decision making in nursing home residents with dementia and pneumonia: Dutch physicians' intentions regarding hastening death.

When patients with severe dementia become acutely ill, little is known about the extent to which physicians take actions intended to hasten death. For 143 nursing home patients with dementia who died of pneumonia after a decision not to treat with antibiotics, we asked Dutch facility-employed physicians whether they intended to hasten death and any estimated life shortening. In 53% of cases, the physicians reported an explicit intention to hasten death; in another 41% of cases they reported taking into account a probability or certainty that the withholding of antibiotics or other palliative treatments would hasten death. Opiates were frequently used for symptom control (43%), but the administration of medications specifically intended to induce death was rare (2%). Considering all treatments, physicians estimated that life was shortened by 24 hours or less in 46% of patients and 1 month or longer in 24% of patients. The frequent withholding of antibiotics with an intention to hasten death may reflect a willingness to abandon a cure-oriented approach in dying patients for whom prolongation of life is not an aim. The results reflect the importance of explicit goals for medical interventions in patients with end-stage dementia where life-prolonging treatments may be seen as prolonging suffering.

Aged↗

PubMedDate not supplied

Antibiotic treatment and survival of nursing home patients with lower respiratory tract infection: a cross-national analysis.

PURPOSE: Although lower respiratory tract infections are a leading cause of death in frail elderly patients, few studies have compared treatments and outcomes. We assessed the effects of different antibiotic treatment strategies on survival of elderly nursing home residents with lower respiratory tract infections in the United States and the Netherlands, where treatment approaches are quite different. METHODS: We combined data from 2 prospective cohort studies of lower respiratory tract infections conducted in 36 nursing homes in the United States and 61 in the Netherlands. We included residents whose infections were treated with antibiotics: 806 in the United States and 415 in the Netherlands. Outcome measures were 1-month and 3-month mortality. We used logistic regression to adjust for differing illness severity. RESULTS: Dutch residents had higher mortality than US residents (28.1% vs 15.1% at 1 month, respectively; P <.001). After adjusting for illness severity with logistic regression, the differences between the Dutch and US populations were not significant (odds ratio 1.34; 95% confidence interval, 0.94-1.90). Predicted mortality was overestimated for more severely ill US residents at 1 month but not at 3 months. No antibiotic regimen was consistently associated with increased or decreased mortality. CONCLUSION: Despite differences in illness severity and treatment, adjusted mortality did not differ between the 2 countries. Although we cannot exclude a short-term survival benefit from more aggressive treatment in the United States, differences in baseline health appear prognostically more important than the type of antibiotic treatment.

Aged↗

PubMedDate not supplied

Randomized trial of 2 interventions to increase older women's exercise.

OBJECTIVE: To test 2 interventions to increase older women's physical activity. METHODS: A randomized 2-way factorial experimental design compared the effects of 2 limited-contact interventions, motivational sessions and periodic prompts, among 190 women. Experimental participants received a 3-encounter motivational intervention. Those randomized to prompts received weekly telephone or mail-delivered cues. RESULTS: The prompting intervention consistently increased exercise and physical activity scores. The motivational intervention did not affect outcome scores. CONCLUSIONS: Prompting is a low-cost strategy for increasing exercise and physical activity among older women. Future research should examine alternative modes for prompt delivery.

Aged↗

PubMedDate not supplied

Helping older patients and their families decide about end-of-life care.

Three-fourths of those who die in America are 65 or older. In all but the cases where death is sudden and unexpected, decisions frequently must be made about whether to limit treatment. In this paper, we provide a framework and specific tools that may help physicians in talking to older patients and their family members about end-of-life care. After briefly reviewing the demography of dying and methods of advance care planning, we propose a four-step process for deciding about end-of-life care: 1. Identifying patient preferences. 2. Communicating about medical prognosis. 3. Defining goals of care. 4. Implementing a management plan consistent with those goals. The paper concludes with special considerations about four common experiences of dying as an older person: chronic diseases with acute exacerbations (e.g. congestive heart failure or chronic obstructive lung disease), cancer, end stage dementia, and unexpected catastrophic decline.

Advance Directives↗