Persistent pain in nursing home residents.
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Chronic Disease↗
Biomedical subjects
T Wetle
Publications and source records attributed to T Wetle.
Accuracy of survey questions for geriatric urinary incontinence.
PURPOSE: Risk factors, natural history, consequences, therapeutic responses and costs are all likely related to type of urinary incontinence, for example stress or urge. Yet few epidemiologic type specific data are available and only 1 study has been validated urodynamically. We compare the accuracy of a typical questionnaire used in a large epidemiologic study with the criterion standard of multichannel video urodynamic testing. MATERIALS AND METHODS: The questionnaire was administered before urodynamic testing to 132 subjects 65 years old or older, of whom 80% were women, all were mobile and none was severely demented. Responses to questionnaire items were compared to the criterion standard, singly and in combination, using a total of 4 a priori and post hoc strategies, including a computerized regression tree program. RESULTS: Overall, no analytic strategy correctly classified more than 67% of patients and none accurately classified even a single type of incontinence, including stress incontinence. CONCLUSIONS: Short questionnaires commonly used in epidemiologic studies correlated poorly with video urodynamic testing in incontinent older adults. Previously published information regarding prevalence of the types of incontinence should be reviewed in the light of these data.
Aged↗
Discussions about end-of-life care in nursing homes.
OBJECTIVE: To measure the frequency with which nursing home residents and their surrogates discuss with clinicians the resident's wishes concerning future treatment and to assess the influence of the Patient Self Determination Act (PSDA) on the frequency and nature of such discussions. DESIGN: Retrospective cohort study of residents admitted to nursing homes before and after the PSDA. SETTING: Six large (at least 120 licensed chronic care beds), randomly selected nursing homes in Connecticut. PARTICIPANTS: Six hundred randomly selected nursing home residents admitted during 1990 and 1994 to one of the six study nursing homes. MEASUREMENTS: Documented discussions concerning future treatment wishes were abstracted from residents' nursing home medical records. Participants in the discussion, as well as the timing (i.e., date) and content of the documented discussions were recorded. Sociodemographic and health status factors were also obtained from the medical record. RESULTS: A large majority of residents (71.5%) had no discussion of future treatment wishes documented in their medical record. However, the percentage of residents with documented discussions had increased since the implementation of the PSDA (36.7% post-PSDA vs 20.3% pre-PSDA). Of those in the post-PSDA cohort who had had discussions, 90% had only one discussion within the first year of admission, and more than half (58.1%) of those who had discussions discussed only life-support systems (cardiopulmonary resuscitation, artificial nutrition and hydration, and ventilation) rather than broader preferences for future treatment, including proxy decision-making. CONCLUSIONS: Despite the increased prevalence of discussions about future treatment wishes since the enactment of the PSDA, no discussions were documented for most residents. For those with documented discussions, such conversations occurred rarely and were narrow in scope, suggesting that residents' and families' roles in medical decision-making in nursing homes may be limited.
Advance Care Planning↗
Assessing capacity to participate in discussions of advance directives in nursing homes: findings from a study of the Patient Self Determination Act.
OBJECTIVE: To better understand the implementation of the Patient Self-Determination Act (PSDA) in long-term care, with a focus on the informing process as it affects advance directives. DESIGN: Retrospective cohort study of nursing home admissions, using medical record reviews, and a companion qualitative survey using key informant interviews. SETTING: Eleven nursing homes in Connecticut. PARTICIPANTS: A total of 600 residents randomly selected from six randomly chosen nursing homes and 19 key informants selected from five purposely sampled nursing homes in Connecticut. MEASURES: Institutional compliance with the PSDA requirement to provide written information about advance directives at admission and aspects of the informing process, including to whom the information is given. RESULTS: Compliance with the PSDA requirement to provide information at admission is high (90.7 of admissions in the post-PSDA cohort received information within 1 week of admission). However, in nearly 70% of admissions in which information was provided, someone other than the residents received the information. Staff often cited the resident's cognitive impairment as a reason for excluding residents from this informing process. However, even among those residents judged to be alert and oriented at admission, someone other than the resident received the information 47.7% of the time. CONCLUSIONS: Substantial numbers of residents may be inappropriately excluded from participating in discussions because of difficulties in determining decisional capacity to discuss future treatment wishes. The research highlights the difficulties of enhancing resident participation and autonomy in long-term care through procedural regulations such as the PSDA. More reliable methods of determining resident decisional capacity are needed to integrate the full intent of the PSDA into clinical practice in long-term care.
Advance Care Planning↗
Principles underlying selection of outcomes in Alzheimer disease research.
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Alzheimer Disease↗
Difficulty with holding urine among older persons in a geographically defined community: prevalence and correlates.
OBJECTIVE: The goal of this study was to estimate the prevalence and correlates of difficulty holding urine among a population of community-dwelling older people. DESIGN: Population-based cross-sectional study. SUBJECTS: A population census identified all residents aged 65 years and older residing in East Boston, Massachusetts, in 1982. MEASURES: Data collected via in-home interviews were used to estimate the prevalence of difficulty holding urine and to provide information regarding potential correlates of urinary difficulty. RESULTS: Of the 3809 study participants (85% response rate), 28% reported having "difficulty holding urine until they can get to a toilet" at least some of the time, and 8% reported difficulty "most" or "all of the time." Difficulty was associated with age and sex; 44% of women and 34% of men reported some difficulty (P < .001), and 9% of women and 6% of men (P < .001) reported difficulty most or all of the time. For respondents aged 65 to 74 years, 40% reported some difficulty, compared with 47% of those aged 85 and older (Ptrend < .001); difficulty most or all of the time was reported by 6% of those aged 65 to 74 and 12% of those aged 85 and older (Ptrend < .001). Difficulty holding urine was associated with important health and functional measures including depression, stroke, chronic cough, night awakening, fecal incontinence, problems with activities of daily living, decreased frequency and ease in getting out of the house, and poor self-perception of health. CONCLUSIONS: Difficulty holding urine is a prevalent condition among older people living in the community and is associated highly with a number of health conditions and functional problems.
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Short-term variability of self report of incontinence in older persons.
OBJECTIVE: Virtually all estimates of the prevalence and incidence of incontinence in the community rely on self-reported continence status. The goal of this study was to assess the reliability of this measure in older adults. DESIGN: Telephone interviews administered approximately 2 weeks apart. SETTING: Community-based congregate living facility. PARTICIPANTS: A convenience sample of approximately 100 residents was contacted by letter; 48 of 51 (94%) who indicated their willingness to participate were interviewed. They included eight men and 40 women > 70 years old (79% > 80 years old), virtually all of whom were independent in basic ADLs and 83% of whom reported their health as good or excellent. MEASUREMENT: Responses to a structured questionnaire. MAIN RESULTS: The prevalence of urinary incontinence was 40% at baseline and 44% on re-interview; the prevalence of fecal incontinence was 17% on both occasions. All Spearman correlations for items related to urinary incontinence characteristics were between .80 and .86, except for a question related to stress incontinence (r = .62); correlations for fecal incontinence were .67-.69. CONCLUSION: Prevalence estimates of incontinence are stable over a 2-week period. However, the variability of individual responses, while relatively low, was within the range previously reported for estimates of incidence and remission rates of incontinence in community-dwelling elderly. This, variability should be taken into consideration when interpreting previous studies and designing future ones.
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Case managers and physicians: communication and perceived problems.
OBJECTIVE: To describe case managers' perceptions of the physician-case manager relationship. DESIGN: A qualitative field study using in-depth open-ended interviews was used to elicit case managers' experiences and practices. A multidisciplinary team analyzed transcripts using an adaptation of the "grounded theory" approach of Glaser and Strauss. PARTICIPANTS/SETTING: Case managers were selected for interview using a maximum variation sampling strategy within an established state-wide case management agency. MAIN OUTCOME MEASURES: Transcript analysis allowed for the organization of observations into themes, which were merged across interviews to generate theses. RESULTS: Case managers report that: (1) The case manager role is poorly understood by physicians. (2) Physicians lack insight into the social and environmental aspects of home-bound elderly people. (3) Access to physician services is often difficult to obtain. (4) Power struggles occasionally surface in care planning. (5) Decisions by physicians and case managers regarding the care of frail elderly are often made from different agenda. CONCLUSIONS: From the perspective of case managers, gaps in interprofessional communication may hinder the optimal care of frail elderly individuals.
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Contradictions in case management: client-centered theory and directive practice with frail elderly.
New long-term care legislation and managed care legitimate case management for gatekeeping and advocacy for frail elderly. Qualitative in-depth interviews with case managers who are social workers and nurses were used to address the question: To what extent is client-centered theory reflected in case management practice? Differences between reported client-centered theory and directive practice were identified by five themes: (a) client wishes versus system constraints; (b) the paradox of working to keep clients home versus the perceived inevitability of nursing home placement; (c) client centeredness versus the case manager's care plan; (d) client self-determination versus strategies of persuasion; (e) informing the client about case management versus the reality of practice. Ethical implications, competing demands, and environmental constraints are discussed. Suggestions are made to better integrate client-centered theory with directive practice.
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Relative importance to elderly patients of effectiveness, adverse effects, convenience and cost of antihypertensive medications. A pilot study.
This pilot study was designed to investigate the attitudes of elderly patients regarding the choice of drugs for the treatment of hypertension. A questionnaire was administered to a sample of elderly patients receiving antihypertensive therapy regarding effectiveness, adverse effects, cost and convenience. Forced choices were used in order to reflect practice realities. 44 patients, mean age 75.2 years, rated effectiveness and adverse effects more important than cost and convenience. Choices regarding adverse effect risk were slightly influenced by costs of the drugs and insurance status of the patients. Choices regarding convenience were heavily influenced by financial considerations. Our study indicates that elderly patients are most concerned about effectiveness and safety, and express a willingness to pay more for these qualities in their antihypertensive drugs.
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Predictors of advance directive restrictiveness and compliance with institutional policy in a long-term-care facility.
OBJECTIVE: To ascertain factors influencing the level of advance directives selected by nursing home residents or surrogates and the time delay to documentation of these choices in the medical record after implementation of a facility-wide policy. DESIGN: Longitudinal cohort study of nursing home residents followed from date of advance directive policy initiation or time of admission for a maximum of 21 months from study commencement. SETTING: A 315-bed multilevel nursing home. PARTICIPANTS: Four hundred twenty-four nursing home residents (mean age 85, 74.9% female, 96.1% white). OUTCOME MEASURES: Level of advance directive status chosen--full code, do not resuscitate (DNR) or palliative care only--and date documented in the medical record. RESULTS: Factors predictive of restricted advance directives (DNR or palliative care) included age greater than 85 years (P = 0.025), documented use of a surrogate decision maker (P = 0.001), low physical function (P less than 0.001), low cognitive function (P less than 0.001), and having a nursing home-employed physician (P = 0.001). These results were confirmed using logistic regression models. Median time to directive documentation decreased from 54 days for residents admitted in the first quarter to 1 day for residents admitted in the fourth quarter of the year following initiation of an advance directive policy. CONCLUSION: In logistic models, nursing home-employed physicians were more likely to write restricted advance directive orders than community-based physicians even after controlling for resident age, cognitive status, and physical function. In addition, implementation of a formal nursing home advance directive policy can shorten time to physician documentation of resident advance directive status.
Activities of Daily Living↗
Public-private partnerships: the Connecticut model for financing long-term care.
Responses to the growing crisis in long-term care financing have included efforts to negotiate partnerships between the private and public sectors for the purpose of developing innovative models for long-term care insurance. One such set of models has been encouraged by support from the Robert Wood Johnson Foundation's "Long Term Care Insurance Program" grants. The Connecticut Partnership for Long Term Care uses a cooperative approach to encourage the development of private sector long-term care insurance products that are integrated with Medicaid eligibility determinations. The Connecticut model is described, accompanied by a history of its development, and a comparison is made with other models currently under consideration by national policy analysts.
Connecticut↗
Determinants of expenditures and use of services among elderly HMO enrollees.
This study examined determinants of expenditures and use of services by a group of elderly HMO enrollees. Study subjects were 895 elderly members of the Fallon Community Health Plan who enrolled between January 1, 1980 and December 31, 1983. We explored whether the determinants of expenditures and utilization varied across different types of services, specifically inpatient hospital care and ambulatory care. Having a heart problem, a mobility/disability, and arthritis were consistent predictors of high resource use. Having a mental health problem and a history of past hospitalization were also significant predictors across most models. The health policy implications of these data and their implications for quality assurance within the HMO setting are discussed.
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A taxonomy of ethical issues in case management of the frail older person.
Present-day case managers find themselves facing a broad range of ethical issues and value conflicts. For managers of the frail older person, these issues may relate to (a) the client, (b) the client's family, (c) the manager's agency, (d) interdisciplinary interactions, (e) interagency dynamics, and (f) the entire service system. An eight-point strategy for conflict resolution can be effectively applied to these ethical conflicts.
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Short-term variability of measures of physical function in older people.
Self reported physical function was assessed in telephone interviews approximately 3 weeks apart for a sample of 193 persons aged 69 or older. Three measures of physical function were used: a modified Activities of Daily Living scale, three items proposed by Rosow and Breslau, and five items from among those used by Nagi. Agreement between first and second interviews was very good; most subjects reported no impairment in function at either interview. Among those who reported some impairment, the degree of limitation within the specific activities reported as limited and the total number of activities with any degree of limitation agreed exactly for most and within one level for almost all subjects. There was no evidence to suggest that age or cognitive impairment affected the variability of the responses, and reported declines and improvements in function were about equally common.
Activities of Daily Living↗
Clinical decision making in the care of the aged.
This study examines the decision-making process of health care providers working with older patients. Data were obtained through telephone interviews from a random sample of 251 health care providers at three Veterans Administration medical centers. Responding to a hypothetical clinical vignette, the majority of providers chose to give the one remaining bed in an ICU to a younger versus an older patient. Individuals relied on the patient's expected quality of life as well as the medical risk to the patient as important factors in this decision. In another vignette, less than 15% of the sample strongly supported a life-prolonging intervention for an 85-year-old man whose obstructive pulmonary disease had taken a terminal course. Expected quality of life was the most important determinant of the decision not to intubate. Respondents of different professions consistently ranked DNR orders as the decision with which they were most comfortable and termination of life supports as the decision with which they were least comfortable. A discussion of the different medical, social, and institutional factors that influence decision making is provided.
Age Factors↗
Geriatric medical decisions: factors influencing allocation of scarce resources and the decision to withhold treatment.
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Aged↗