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PubMed2006

Executive dysfunction in homebound older people with diabetes mellitus.

OBJECTIVES: To describe patterns of cognitive deficits and activities of daily living (ADLs) in older people with diabetes mellitus. DESIGN: Cross-sectional, population-based study. SETTING: Three homecare agency areas in Boston, Massachusetts. PARTICIPANTS: Two hundred ninety-one homebound people aged 60 and older; 40% with diabetes mellitus. MEASUREMENTS: Demographic data; evidence of diabetes mellitus and other diseases; Mini-Mental State Examination and tests of memory and executive function; ADLs. RESULTS: Executive and visuospatial functions were more impaired in individuals with diabetes mellitus than in those without, as assessed using Block Design (mean score+/-standard deviation 17.1+/-8.6 vs 20.5+/-9.6, P=.003) and Trails B (median seconds to accomplish the task: 255 vs 201, P=.03). For memory, word retention score was lower in those with diabetes mellitus than without (39.1+/-28.9 vs 48.0+/-29.7, P=.01), but the other memory tests did not show a difference between these two subgroups. More individuals with diabetes mellitus suffered from depressive symptoms than those without (55% vs 42%, P=.03). The ADL scores of those with diabetes mellitus were higher than those without. CONCLUSION: The pattern of cognitive deficits in people with diabetes mellitus suggests frontal-subcortical dysfunction, as seen in microvascular disease of the brain. The impairment in ADLs may be associated with this executive dysfunction, which cerebral microvascular disease in diabetes mellitus may cause.

Activities of Daily Living↗
PubMed2006

Ethical issues in mobile psychiatric treatment with homebound elderly patients: the Psychogeriatric Assessment and Treatment in City Housing experience.

Unique and challenging ethical difficulties arise during mobile psychiatric treatment of elderly patients. This article outlines and analyzes five of these challenges that have been encountered during nearly 20 years of experience with the Psychogeriatric Assessment and Treatment in City Housing Program in Baltimore, Maryland. The ethical challenges reviewed are: establishing the treatment contract versus the right to refuse treatment, protecting confidentiality versus patient protection, protecting autonomy versus asserting beneficence, treatment termination versus open-ended treatment, and cost versus benefit of care. Ethical challenges with homebound elderly patients are unique because of patient characteristics as well as features of the treatment environment.

Aged↗
PubMed2006

A multidisciplinary program for delivering primary care to the underserved urban homebound: looking back, moving forward.

The coming decades will see a dramatic rise in the number of homebound adults. These individuals will have multiple medical conditions requiring a team of caregivers to provide adequate care. Home-based primary care (HBPC) programs can coordinate and provide such multidisciplinary care. Traditionally, though, HBPC programs have been small because there has been little institutional support for growth. Three residents developed the Mount Sinai Visiting Doctors (MSVD) program in 1995 to provide multidisciplinary care to homebound patients in East Harlem, New York. Over the past 10 years, the program has grown substantially to 12 primary care providers serving more than 1,000 patients per year. The program has met many of its original goals, such as helping patients to live and die at home, decreasing caregiver burden, creating a home-based primary care training experience, and becoming a research leader. These successes and growth have been the result of careful attention to providing high-quality care, obtaining hospital support through the demonstration of an overall positive cost-benefit profile, and securing departmental and medical school support by shouldering significant teaching responsibilities. The following article will detail the development of the program and the current provision of services. The MSVD experience offers a model of growth for faculty and institutions interested in starting or expanding a HBPC program.

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PubMed2006

Severe elder obesity and 1-year diminished lower extremity physical performance in homebound older adults.

OBJECTIVES: To determine whether severe obesity in older people is independently associated with diminished lower extremity physical performance (LEP) in a random sample of homebound older adults that were considered ambulatory. DESIGN: Prospective cohort with 1 year of follow-up (2000-02). SETTING: In-home assessments of homebound older adults in four North Carolina counties. PARTICIPANTS: Random sample of 282 home-delivered meal recipients aged 60 and older who completed both in-home assessments (n = 253) or were nursing home residents (n = 29) at the 1-year follow-up assessment of the Nutrition and Function Study. MEASUREMENTS: Objective measures were selected for baseline and 1-year LEP (timed walking, static and dynamic balance, and chair rise) and baseline body mass index (BMI, based on measured weight and knee height). BMI was categorized as underweight/normal (<25.0 kg/m2), overweight (25.0-29.9 kg/m2), moderately obese (30.0-34.9 kg/m2), and severely obese (> or =35.0 kg/m2). Based on summary scores, overall LEP was categorized as poor, intermediate, or good. Sample characteristics included depressive symptomatology, fear of falling, medical conditions, and medication use. RESULTS: Almost 23% of participants were moderately obese and 15% severely obese. Only severe obesity independently increased the odds (odds ratio 2.9-7.0) for diminished performance at 1 year in individual tests and in overall LEP performance. Severe obesity was independently associated with poor LEP at both assessments or with decline in LEP at 1 year. CONCLUSION: These results highlight the need to distinguish between moderate and severe obesity in older people in terms of relationships with key functional outcomes. The findings identify severe obesity in older people as an important target for future interventions. In particular, this calls for greater understanding of intervention goals, whether to primarily target weight reduction or improvement in physical performance.

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PubMed1994

Oral status and well-being of home delivered meal recipients.

The relationship between oral health status and well-being of community dwelling frail elders was studied through questionnaires delivered to and filled out by 592 elders receiving home delivered meals. Oral status covered oral function, dental problems, oral hygiene practices and appliance use in the sample. Oral status was measured in a sub sample of 50 subjects given an oral examination, using the criteria above and soft tissue status. Plaque, calculus, and caries were measured in dentate subjects of the sub sample. Well-being was measured using standardised scales. The results indicate that oral status was related to well-being status.

Adult↗
PubMed2004

Development of oral home telecare programme for the home-dwelling elderly: a pilot study.

OBJECTIVES: The aim of the pilot study was to develop and evaluate a telecare programme for home-dwelling elderly to provide education on oral and general health care. DESIGN: A field trial with a computer system linking a university with a structured network. SUBJECTS: A group of home-dwelling elderly males with a mean age of 73.3 years. METHODS: Qualitative assessment following videophone interviews with clients and their families. RESULTS: Clients and families were able to gain a better understanding and knowledge of oral health care particularly the skills required to perform new oral care procedures. CONCLUSIONS: Preventive oral homecare via videophone offers the potential for providing a long-term structure for maintaining oral health particularly with limited social resources.

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PubMed2006

An exploration of nurse practitioner care to homebound frail elders.

PURPOSE: To identify and classify care activities of nurse practitioners (NPs) providing primary care for frail homebound elders and to describe NPs' perceptions of the outcomes of their care activities. DATA SOURCES: Three focus groups were held with 24 NPs with at least 1-year experience in caring for frail homebound elders to elicit NPs' descriptions of their practice. In addition, individual interviews with 10 NPs and participant observation of 2 NPs visiting elders in their homes validated the data. The total sample size was 36 NPs. Field notes and audiotapes were transcribed for analysis and coded using Brykczynski's existing domains and competencies of NP practice. CONCLUSIONS: Most of the care activities of NPs providing primary care to frail elders in their home involve management of patient health and illness, case management, and the teaching-coaching function. The NP informants believe that they prevent medication errors, falls, emergency room visits, hospitalizations, and even death. They reported that they improve their patients' quality of life and help to provide a peaceful death when death is imminent. IMPLICATIONS FOR RESEARCH: Further refinement of the proposed model is needed in order to examine the effectiveness of NP care on clinically relevant patient outcomes.

Adult↗
PubMedDate not supplied

A comparison of prescription medication use by nursing home and homebound dental patients.

The elderly consume a disproportionate number of prescription medications dispensed in the United States. Although medication use among nursing home residents has been documented, little information is available regarding the medication use of homebound elderly. This study compared the medication use of nursing home and homebound patients treated by a mobile dental homecare program. A total of 338 dental records were reviewed, identifying the number and type of medications used. In addition, medications with xerostomic potential were identified.

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PubMedDate not supplied

Assessment of the oral health status of the medically compromised homebound geriatric patient: a descriptive pilot study.

This pilot study was designed to assess the oral health status of homebound elderly and determine their dental care needs. Fifty-one subjects enrolled in a hospital-based home care program were recruited for this study. Subjects were visited in their homes by both a dentist and a physician. Care plans and medications were reviewed for each subject. Initial assessments to receive informed written consent were conducted by the physician. Oral health assessments by the dentist included comprehensive examinations for soft tissue pathology, periodontal health, caries, restoration, and tooth condition, as well as existing prosthesis assessment, plaque index, and grip strength. A Physical Self-Maintenance Scale was administered in order to determine the level of dependence of this population for their oral hygiene self-care. The oral health status of these homebound elderly was found to be poor, with 84% of the subjects requiring dental care.

Activities of Daily Living↗
PubMedDate not supplied

Perceived barriers to oral health care among the homebound.

Questionnaires and oral examinations were completed on 50 clients of a social service agency which provides home-based services to functionally dependent elderly. Nearly 61% of all respondents classified their oral health as frail/poor, and 82% reported a perceived need for some oral health care. When asked if they considered themselves homebound, 60% reported being homebound from 1-10 years (mean = 4.7 years). Two or more home services were received by 80% of the homebound group compared with just 45% of the not-homebound group. Paying for dental care, transportation difficulties, and poor health were the most frequently identified barriers that limited access to oral health care.

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PubMedDate not supplied

Disposal options for infectious medical waste generated during home-based dental care.

The number of dentists providing mobile care is increasing. One of the challenges the mobile dentist faces is proper handling and disposal of infectious medical waste generated during patient care. Mobile dentists must concern themselves with meeting Federal, state, and local regulations. Federal agencies that have jurisdiction over this issue are the Environmental Protection Agency (EPA) and the Occupational Safety and Health Administration (OSHA). EPA guidelines are summarized and clarified with respect to pre-transportation and transportation issues. Compliance with OSHA standards are addressed through presentation of a sample protocol for handling infectious medical waste. It is beyond the scope of this paper to discuss in detail the policies of each municipality, and practitioners are advised to consult with state and local authorities regarding proper handling and transportation of this material. Using the information presented in this paper, the mobile dentist can approach this complex issue in an organized manner.

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PubMedDate not supplied

Oral hygiene and oral symptoms among the elderly in long-term care.

Dental teams examined 1910 elderly adults living in long-term care settings (1358 institutionalized, 552 homebound) from all 19 counties in Norway to document oral hygiene, oral symptoms and ability to receive dental treatment. The Mucosal-Plaque Score (MPS) was used to assess oral status. The MPS was significantly better in women than in men, in individuals with dentures than in those with any remaining teeth, and in people who were homebound rather than those who lived in institutions. The MPS did not differ between age groups or geographic regions. According to the Treatment Ability Index, nearly a quarter of the sample was able to receive comprehensive dental care. Reports of "any oral symptom" and "eating/chewing problems" decreased with age and were most prevalent for individuals who had dentures. The MPS had only slight impact on oral symptoms, chewing ability and dry mouth (p > 0.05). Dry mouth was found in 16.9% and was most prevalent in individuals with dentures.

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PubMed2002

Planning for death but not serious future illness: qualitative study of housebound elderly patients.

OBJECTIVE: To understand how elderly patients think about and approach future illness and the end of life. DESIGN: Qualitative study conducted 1997-9. SETTING: Physician housecall programme affiliated to US university. PARTICIPANTS: 20 chronically ill housebound patients aged over 75 years who could participate in an interview. Participants identified through purposive and random sampling. MAIN OUTCOME MEASURES: In-depth semistructured interviews lasting one to two hours. RESULTS: Sixteen people said that they did not think about the future or did not in general plan for the future. Nineteen were particularly reluctant to think about, discuss, or plan for serious future illness. Instead they described a "one day at a time," "what is to be will be" approach to life, preferring to "cross that bridge" when they got to it. Participants considered end of life matters to be in the hands of God, though 13 participants had made wills and 19 had funeral plans. Although some had completed advance directives, these were not well understood and were intended for use only when death was near and certain. CONCLUSIONS: The elderly people interviewed for this study were resistant to planning in advance for the hypothetical future, particularly for serious illness when death is possible but not certain.

Advance Directives↗