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PubMed1994

A prospective community-based pilot study of risk factors for the investigation of elder mistreatment.

PURPOSE: To identify risk factors for the investigation of elder abuse, neglect, self-neglect, exploitation, and abandonment in a population-based observational cohort of community living elders. STUDY POPULATION: Population-based sample of 2,812 community-living men and women in New Haven, Connecticut who were over age 65 in 1982. METHODS: Matching process whereby cohort members who were investigated by Connecticut's State Ombudsman on Aging in 1985 or 1986 were identified. ANALYSIS: Relative risks for ombudsman investigation in 1985 or 1986 were calculated based on risk factors status at baseline interview in 1982. RESULTS: Sixty-eight (2.4%) members of the cohort received investigation. Features at cohort entry significantly associated with investigation in multiple logistic regression included: requiring assistance with feeding (Adjusted OR 3.5, 95% CI 1.2, 11.7), being a minority elder (Adj. OR 2.3, 95% CI 1.4, 2.8), over age 75 at cohort inception (Adj. OR 1.9, 95% CI 1.1, 3.1), and having a poor social network as defined by a social network index (Adj. OR 1.7, 95% CI 1.0, 2.7). When stratified by race, requiring assistance with feeding was associated with ombudsman investigation in minority elders (Adj. OR 10.8, 95% CI 2.8, 40.5) but not non-minority elders (Adj. OR 1.1, 95% CI 0.5, 7.5). CONCLUSION: Functional disability, minority status, older age, and poor social networks were associated with investigation for elder mistreatment in this prospective, community-based population of men and women over the age of 65.

Activities of Daily Living↗
PubMed2004

Fall-risk assessment and management in clinical practice: views from healthcare providers.

OBJECTIVES: To determine the extent to which healthcare providers reportedly address evidence-based fall risk factors in older patients after exposure to an educational intervention and to determine barriers reportedly encountered when these healthcare providers intervene with or refer older patients with identified fall-risk factors. DESIGN: Cross-sectional study using a structured interview. SETTING: Geographic area of Connecticut where the Connecticut Collaboration for Fall Prevention (CCFP) has been implemented. PARTICIPANTS: Emergency department (ED) physicians, hospital-based discharge planners or care coordinators (nurses or social workers), home health agency nurses, and office-based primary care physicians (total n=33) after exposure to the CCFP implementation team. MEASUREMENTS: Self-reported practices (direct intervention or referral) and barriers when addressing seven evidence-based risk factors for falls: gait and transfer impairments, balance disturbances, multiple medications, postural hypotension, sensory and perceptive deficits, foot and footwear problems, and environmental hazards. RESULTS: Respondents were most likely to report directly intervening with or referring older patients for gait and transfer impairments (85%) and balance disturbances (82%) and least likely to do so when encountering foot or footwear problems (58%) and sensory or perceptive deficits (61%). ED physicians reported lowest rates of direct intervention or referral for foot or footwear problems (20%), home health agency nurses for sensory or perceptive deficits (50%), and office-based primary care physicians for foot or footwear problems (50%). Patient compliance was the most commonly reported barrier to successful direct intervention across several risk factors, whereas inadequate availability of other healthcare providers and lack of Medicare reimbursement were the most commonly reported barriers to successful patient referrals. CONCLUSION: After exposure to the CCFP implementation team, the majority of healthcare providers reported directly intervening or referring patients when addressing all risk factors, but results pinpointed specific healthcare provider groups with room for improvement in assessment and management of specific risk factors. Patient education appears to be a necessary adjunct to healthcare provider training, because patient compliance was a reported barrier to optimal intervention by healthcare providers.

Accidental Falls↗
PubMed1985

Psychiatric disorders (DSM-III) and cognitive impairment among the elderly in a U.S. urban community.

Results are presented on the current prevalence rates of psychiatric disorder in 2,588 non-institutionalized persons aged 65 and older who were drawn from a probability sample of New Haven, Connecticut, and 12 surrounding towns in South Central Connecticut. Based on the Diagnostic Interview Schedule (DIS), 6.7% of the respondents had a psychiatric diagnosis (DSM-III), and based on the Mini-Mental Status Exam (MMS), 3.4% had severe cognitive impairments during the past 6-month period. Therefore, more than 10% currently had either a psychiatric or a severe cognitive problem. Overall, these rates of psychiatric disorders are lower than those found in adult populations under age 65. As with younger samples, anxiety and affective disorders were among the most common psychiatric problems. The majority of elderly reported themselves in good emotional and physical health and felt they had sufficient finances to meet their needs. The rate of severe cognitive impairment did not increase until after age 79. Among those 80 years and older, cognitive impairments were more common in women than men, probably due to differential survival rates. Since less than 6% of the elderly sample are living in institutions these results among non-institutionalized elderly point to the relative psychiatric well-being of the majority of the elderly. However, in view of the longer life expectancy, the next decade will see an increase in the absolute number of persons with cognitive impairments.

Age Factors↗
PubMed2002

Dental caries experience of female inmates.

OBJECTIVES: The purpose of this study was to determine the extent of dental caries and level of unmet dental need among female offenders in a federal prison in Connecticut. METHODS: All inmates admitted into the Federal Correctional Institution at Danbury, Connecticut, from May 31, 1997, to May 21, 1998, were given oral screening examinations (n=500; age range=20-65 years). The data were analyzed in terms of race/ethnicity and age groupings. DMF and D/DF scores were determined. RESULTS: The mean DMFT and DMFS scores were 16.8 and 57.0, respectively; the scores were higher for non-Hispanic whites and Hispanics than non-Hispanic blacks, and increased with age. The mean DT/DFT and DS/DFS scores were 36.8 percent and 36.0 percent, respectively. These scores were higher for non-Hispanic blacks than non-Hispanic whites and Hispanics, and decreased with age. CONCLUSIONS: Female prisoners had high levels of dental caries and racial disparities persisted in the prison.

Adult↗
PubMed1995

Coexistence of antibodies to tick-borne pathogens of babesiosis, ehrlichiosis, and Lyme borreliosis in human sera.

Serum specimens from persons with or without Lyme borreliosis were analyzed by indirect fluorescent antibody staining methods for total immunoglobulins to Babesia microti, Ehrlichia chaffeensis (Arkansas strain), and Ehrlichia equi (MRK strain). There was serologic evidence of human exposure to multiple tick-borne agents in 15 (6.6%) of 227 serum samples obtained in Connecticut and Minnesota. Of these, 10 serum samples were from Connecticut patients who had erythema migrans and antibodies to Borrelia burgdorferi (range, 1:160 to 1:40, 960). A maximal antibody titer of 1:640 was noted for a B. microti infection, whereas titration end points of 1:640 and 1:1,280 were recorded for E. chaffeensis and E. equi seropositives, respectively. In specificity tests, there was no cross-reactivity among the antisera and antigens tested for the four tick-borne pathogens. On the basis of serologic testing, a small group of persons who had Lyme borreliosis had been exposed to one or more other tick-borne agents, but there was no clinical diagnosis of babesiosis or ehrlichiosis. Therefore, if the clinical picture is unclear or multiple tick-associated illnesses are suspected, more extensive laboratory testing is suggested.

Animals↗
PubMed1979

Occupations of fathers of patients with Wilms's tumour.

A case-control study of 149 Connecticut-born children with Wilms's tumour reported to the Connecticut Tumor Registry during the period 1935--1973 and of 149 matched controls was undertaken in order to explore the possibility that children with Wilms's tumour may have been exposed perinatally to carcinogenic agents. The occupation of the father at the time of the child's birth was investigated and used as an indicator of potential sources of carcinogens to which infants in the study may have been exposed. An association was found between paternal occupations related to lead in the group developing Wilms's tumour compared with the controls.

Carcinogens↗
PubMed1984

Dust exposure and mortality in an American chrysotile asbestos friction products plant.

Cohort studies in three American asbestos factories were undertaken to investigate the effect of fibre type and manufacturing process on lung cancer, mesothelioma, and asbestosis. Reports have been published on a chrysotile textile plant in South Carolina and a mainly textile plant in Pennsylvania, which also used amphiboles. In the third plant in Connecticut friction products and packings were made from chrysotile only. In a cohort of 3641 men employed for one month or more, 1938-58, 3513 (96.5%) were traced, 1267 (36%) had died, and death certificates were obtained for 1228 (96.9%). Individual exposures were estimated (in mcpf . years) from impinger measurements. Life table analyses using Connecticut mortality rates gave an SMR for all causes of 108.5 (USA 107.9). The SMR (all causes) for men who had worked for less than a year was 129.9 and for those who had worked for a year or more, 101.2. The equivalent SMRs for respiratory cancer were 167.4 and 136.7 respectively. Excluding men who had worked for less than a year, there was possible evidence of some increase in risk of lung cancer with increasing exposure, supported also by a "log-rank" (case-control) analysis, of the same order as that observed in chrysotile mining and milling. These findings may be compared with chrysotile textile manufacture where the risk of lung cancer was some 50-fold greater. It is suggested that the differences in risk are perhaps related to the higher proportion of submicroscopic fibres in textile manufacture that may result from the traumatic carding , spinning, and weaving processes. No case of mesothelioma was found, consistent with a much lower risk of this tumour with chrysotile than with amphiboles. Twelve deaths (nine in men with very short and low asbestos exposure) were given ICD code 523 (pneumoconiosis); all but two were ascribed to anthracosilicosis or silicosis and none to asbestosis.

Adult↗
PubMed1978

Psychiatrists' familiarity with legal statutes governing emergency involuntary hospitalization.

The authors sent out questionnaires regarding knowledge of statutes governing emergency involuntary hospitalization to psychiatrists in Connecticut and in the District of Columbia. Fifty-five percent (N=207) of the sample in Connecticut and 25% (N=87) of the sample in the District of Columbia responded. The responses showed that few of these psychiatrists had a thorough familiarity with the legal statutes governing emergency involuntary hospitalization in their jurisdictions. The most frequently cited criterion was the dangerousness standard, especially in the District of Columbia sample, and many psychiatrists were not sure of the nature of their statutory authority when their patients met the criteria for emergency hospitalization.

Commitment of Persons with Psychiatric Disorders↗
PubMed2003

Violent victimization of persons with co-occurring psychiatric and substance use disorders.

OBJECTIVE: This study examined the frequency with which persons in the community with psychiatric disorders, substance use disorders, and both types of disorders are victims of violence. METHODS: The relationship between diagnosis, gender, and victimization over a one-year period was examined in two cross-sectional data sets, one drawn from a study of adaptation to community life of persons with severe mental illness in Connecticut (N=109) and the other drawn from assessments made by caseworkers in a Connecticut outreach project for persons with psychiatric and substance use disorders (N=197). Analysis of variance was used to evaluate the frequency of victimization across diagnostic categories in each data set. RESULTS: People with co-occurring psychiatric and substance use disorders had significantly more episodes of victimization than those with either a psychiatric or a substance use disorder only. Gender was not associated with victimization. Qualitative data from focus groups indicated that social isolation and cognitive deficits leading to poor judgment about whom to trust may leave people with serious mental illness vulnerable to drug dealers. CONCLUSIONS: Social environmental mechanisms, such as exploitation by drug dealers, may play an important role in maintaining victimization among persons with co-occurring disorders.

Adult↗
PubMed1995

Implementing assertive community treatment teams.

The Connecticut Department of Mental Health began creating assertive community treatment teams in 1987. The authors describe the approach taken by the department in defining the assertive community treatment model, in creating new assertive community treatment teams, and in monitoring the creation and functioning of these teams to ensure that fidelity to the assertive community treatment model is maintained. Assertive community treatment teams can be created even in the absence of funding for new staff by reconfiguring current community-based staff and by moving staff from state hospitals to the community. Preliminary data from a randomized trial in Connecticut comparing assertive community treatment with high-quality case management in areas with an array of community services indicated that the intended models were replicated, with variations in practice style across programs. Clients in assertive community treatment were in the hospital about half as often as clients in standard services and were also less likely to be without a permanent residence. Training and ongoing monitoring of assertive community treatment teams are necessary to detect practices that diverge from the intervention model so that corrective action can be taken.

Adult↗
PubMed1991

Title III services: variation in use within a state.

Using data from Connecticut's management information system for Title III funds, we found, first, that such services are reaching at least one person in every town and thus modestly fulfilling a gateway function; about 9% of Connecticut's elderly use Title III services, with 20% of the oldest old obtaining such services. Nutrition services are reaching the most elderly, both numerically and geographically; among the oldest old (85+), home care service use was most widespread. Indices of use were not statistically related to specific characteristics of the towns' populations (i.e., percentage of elderly, poor, or minority elderly), but small cities and rural towns had the highest use levels. Presence of nutrition sites within the town and service through two of the five area agencies on aging (AAAs) were also correlated with high service use, controlling for the rural-urban continuum. Those two AAAs received the highest per capita amount of Title III funds, based on the state's targeting formulas.

Aged↗
PubMed1991

Nutrition service availability: an interaction potential model.

Availability, defined as a measure of the supply of services relative to the needs in the community, is critical to older people, particularly the socially isolated and frail elderly who are less mobile than most of the population. This research proposes an interaction potential model to examine variation in availability of services by considering the capacity and location of service providers and demand for these services. The model does not constrain older people to meet their demand within their towns' borders. Several measures of availability are calculated for nutrition services in an area agency on aging region of Connecticut, using different beta values to represent varying levels of mobility for the total older population; considerable variation exists, depending on mobility assumptions. Availability measures can be used as independent variables in analyses of variation in actual use of services; a strong correlation exists between use and availability in Connecticut.

Aged↗
PubMedDate not supplied

What's happening in quality improvement at the local hospital: a state-wide study from the Cooperative Cardiovascular Project.

The objective of this study was to investigate what happened to improve the quality of care for acute myocardial infarction (AMI) at all 32 nonfederal hospitals in Connecticut and to assess the impact of the Cooperative Cardiovascular Project (CCP) on quality improvement (QI) activities for AMI. We performed a questionnaire study with secondary analyses using the CCP database. On-site interviews were conducted with QI directors at all 32 Connecticut nonfederal hospitals that participated in the Health Care Financing Administration's Cooperative Cardiovascular Project (CCP) in 1992-93 and 1995. The interviews sought information about the makeup of QI departments, specific approaches used to improve the care of patients with AMI, and the perceived value of the CCP to each individual hospital. Results showed that the number of full-time equivalents (FTEs) and FTEs per beds employed in QI departments ranged from 1 to 30 and from 0.4 to 7.9, respectively, with a registered nurse most often serving as the department head (27/32). Over half of the departments (17/32) had additional responsibilities. The majority (25/32) used some combination of physician champions, multidisciplinary QI teams, standing orders, or critical pathways to effect change in AMI care. Finally, 26 of the 32 hospitals believed the CCP was valuable because it provided credible benchmark data, a catalyst for change, or a specific focus on processes of care needing improvement in AMI. Despite great variability in institutional resources, all 32 hospitals used a similar combination of QI approaches to effect change in AMI care. However, there is variable scientific evidence supporting these approaches. Externally sponsored projects such as the CCP appear to play a useful role for individual hospitals. Defining the optimal methods of QI is difficult given that hospitals are using complex combinations of nonstandardized improvement interventions.

Connecticut↗
PubMed2004

The use of warfarin in veterans with atrial fibrillation.

BACKGROUND: Warfarin therapy is effective for the prevention of stroke in patients with atrial fibrillation. However, warfarin therapy is underutilized even among ideal anticoagulation candidates. The purpose of this study was to examine the use of warfarin in both inpatients and outpatients with atrial fibrillation within a Veterans Affairs (VA) hospital system. METHODS: This retrospective medical record review included outpatients and inpatients with atrial fibrillation. The outpatient cohort included all patients seen in the outpatient clinics of the VA Connecticut Healthcare System during June 2000 with a diagnosis of atrial fibrillation. The inpatient cohort included all patients discharged from the VA Connecticut Healthcare System West Haven Medical Center with a diagnosis of atrial fibrillation during October 1999 - March 2000. The outcome measure was the rate of warfarin prescription in patients with atrial fibrillation. RESULTS: A total of 538 outpatients had a diagnosis of atrial fibrillation and 73 of these had a documented contraindication to anticoagulation. Among the 465 eligible outpatients, 455 (98%) were prescribed warfarin. For the inpatients, a total of 212 individual patients were discharged with a diagnosis of atrial fibrillation and 97 were not eligible for warfarin therapy. Among the 115 eligible inpatients, 106 (92%) were discharged on warfarin. CONCLUSIONS: Ideal anticoagulation candidates with atrial fibrillation are being prescribed warfarin at very high rates within one VA system, in both the inpatient and outpatient settings; we found warfarin use within our VA was much higher than that observed for Medicare beneficiaries in our state.

Aged↗
PubMed2005

A survey of training and practice patterns of massage therapists in two US states.

BACKGROUND: Despite the growing popularity of therapeutic massage in the US, little is known about the training or practice characteristics of massage therapists. The objective of this study was to describe these characteristics. METHODS: As part of a study of random samples of complementary and alternative medicine (CAM) practitioners, we interviewed 226 massage therapists licensed in Connecticut and Washington state by telephone in 1998 and 1999 (85% of those contacted) and then asked a sample of them to record information on 20 consecutive visits to their practices (total of 2005 consecutive visits). RESULTS: Most massage therapists were women (85%), white (95%), and had completed some continuing education training (79% in Connecticut and 52% in Washington). They treated a limited number of conditions, most commonly musculoskeletal (59% and 63%) (especially back, neck, and shoulder problems), wellness care (20% and 19%), and psychological complaints (9% and 6%) (especially anxiety and depression). Practitioners commonly used one or more assessment techniques (67% and 74%) and gave a massage emphasizing Swedish (81% and 77%), deep tissue (63% and 65%), and trigger/pressure point techniques (52% and 46%). Self-care recommendations, including increasing water intake, body awareness, and specific forms of movement, were made as part of more than 80% of visits. Although most patients self-referred to massage, more than one-quarter were receiving concomitant care for the same problem from a physician. Massage therapists rarely communicated with these physicians. CONCLUSION: This study provides new information about licensed massage therapists that should be useful to physicians and other healthcare providers interested in learning about massage therapy in order to advise their patients about this popular CAM therapy.

Adult↗
PubMed1992

Financing long-term care with limited resources: combining the resources of the public and private sectors.

Under Connecticut's recently implemented public/private partnership to finance long-term care, individuals will no longer need to impoverish themselves in order to receive Medicaid assistance. To encourage those people who can afford to buy a private long-term care insurance policy to do so, the state promises to shield one dollar in assets from Medicaid "spend-down" rules for every dollar a private policy pays out for Medicaid-covered services. This article describes the Partnership, shows how dwindling resources and budget constraints affected the development of this model, and then contrasts Connecticut's experience with that of other states and describes what can be learned from this demonstration.

Aged↗
PubMed2005

Cotinine levels and green tobacco sickness among shade-tobacco workers.

STUDY OBJECTIVE: Symptoms consistent with Green Tobacco Sickness (GTS) were found in 4% (13/331) to 15% (45/303) of the migrant, mostly Latino, shade-tobacco workers who sought medical care at a Connecticut clinic. The objective of this study was to determine whether or not shade-tobacco farm workers absorb nicotine from the tobacco leaves and have a corresponding increase in both salivary cotinine levels (a breakdown product of nicotine) and symptoms consistent with GTS. METHODS: The study utilized a prospective cohort design to evaluate salivary cotinine and symptoms consistent with GTS in a population of shade tobacco farm workers compared to a control group of nursery workers. The workers were assessed at two points in time, the early tobacco planting season and the harvest season. RESULTS: There was not a significant increase in salivary cotinine levels among shade-tobacco workers. Salivary cotinine levels over the work season did not significantly increase in shade-tobacco workers when compared with nursery workers. During the harvest season, none of the tobacco workers reported symptoms consistent with GTS. CONCLUSIONS: Migrant workers in Connecticut who harvest shade-tobacco appear to have a low-risk of occupational nicotine dermal absorption and a low incidence of GTS. The work practices associated with harvesting shade-tobacco, in addition to the fact that shade tobacco may actually have a lower level of nicotine than either burley or flue cured tobacco, may explain these results. Our study appears to reinforce the GTS prevention recommendations made by investigators in other tobacco growing regions, specifically the importance of minimizing close skin contact with tobacco leaves and avoiding dermal contact with the plants when they are wet.

Adult↗
PubMed2003

Informed consent for medical procedures: local and national practices.

BACKGROUND: No studies have assessed whether clinicians obtain informed consent for invasive medical procedures, and there are no explicit national standards to guide the process. HYPOTHESIS: Informed consent practices are inconsistent for commonly performed invasive medical procedures. METHODS: A simple questionnaire was electronically mailed and/or faxed to training program directors of critical care medicine and internal medicine departments, and to ICU directors in the state of Connecticut. The questionnaire listed common invasive medical procedures and asked the respondents to check those for which practitioners routinely obtain informed consent in their hospital. RESULTS: The three samples, national intensivists (88 respondents), Connecticut intensivists (29 respondents), and national internists (56 respondents) demonstrated heterogeneity of consenting practices. The rate of obtaining consent for common vascular access procedures ranged from 20 to 90%. The rates of obtaining consent for Foley catheterization and nasogastric intubation were uniformly < 10%, and those for endoscopic procedures were > 90%. Separate consent (beyond the general consent to treat) was not uniformly obtained for the transfusion of blood products (range, 74 to 93%) and common diagnostic medical procedures (eg, thoracentesis, paracentesis, or lumbar puncture; range, 77 to 96%). Surgical intensivists reported that the obtaining of consent for invasive procedures was less routine compared to medical intensivists. Lower rates of consent were noted by those respondents who used a "blanket" consent form, which was signed at the time of hospital admission, to cover subsequent procedures. CONCLUSIONS: In this relatively small sample, there was no uniform practice of informed consent for commonly performed invasive medical procedures. Consent was routinely obtained for GI endoscopy, bronchoscopy, and medical research, and was not obtained for Foley catheterization and nasogastric intubation. The obtaining of consent for vascular cannulation and diagnostic procedures was not routine in the ICUs of a substantial number of respondents. Explicit standards that delineate specifically which procedures require consent may be required to assure more uniform practices.

Connecticut↗