Knowledge of the utilization of preventive practices through a telephone survey

OBJECTIVES: To determine knowledge and use of preventive practices (cervical cytology, mammography and taking blood pressure) through a telephone survey. DESIGN: Crossover study. SETTING: Billabona Health Centre (Guipúzcoa). PARTICIPANTS: People over 15 in the Health Centre's catchment area. MAIN RESULTS: The sample size was 800 people. It reached 80% telephone coverage with a reply rate of 86.09% (278 men and 273 women). 76.5% of women stated they had heard of cervical cytology; and 80.2% mammography. 87.5% had had their blood pressure taken on some occasion. CONCLUSIONS: Both cervical cytology and mammography are well-known preventive procedures, although they could always be improved, whereas taking blood pressure is a widespread practice in all age-groups.     

An assessment tool for older patients

A full and detailed assessment of older patients should include social circumstances. An assessment should identify problems of functional activity and use screening tools to aid referral to specialist multidisciplinary staff.     

A patient-initiated system for preventive health care. A randomized trial in community-based primary care practices

PURPOSE OF THE STUDY: From 1983 to 1986, 156 alumina/polyethylene combination hip arthroplasties (131 patients) were performed at the Henri Mondor Hospital. Before 1983, the stainless-steel/polyethylene combination was performed. In this follow-up study, the outcome of the first 156 consecutive alumine-polyethylene combination hip arthroplasties were analyzed with clinical and radiological features. The comparison of the two combinations was analyzed. A survival analysis was performed over a ten years interval. MATERIAL AND METHODS: The femoral component of the prosthesis was made of Titanium alloy (TiA16V4). The femoral head was made of dense alumina (A1203). The head diameter was 32 mm. The socket was made of ultra-high-molecular-weight polyethylene (UHMWPE). Fixation of head to stem was obtained through conical sleeving. We used a posterolateral approach, and a cemented THA without pressurization. At last follow-up evaluation, 90 patients were reviewed, 9 patients were interviewed by phone. Three patients were dead and 20 patients were lost for follow-up evaluation, in the first year. Nine failures were reoperated. The major cause of failure was septic complication of the THA (8). The average age of patients at arthroplasty was 58.1 year. The clinical evaluation was performed with the Merle d'Aubigné, Postel scoring system. The radiographs of 117 hips out of the 156 were available for this evaluation. Radiolucents, failures and wear were analyzed. RESULTS: There was a 5 per cent rate (8 hips) of deep infection due for two hips to the underlying pathology. Ten (6.5 per cent) of the 156 hips had had an episode of dislocation at last follow-up. Eighty-nine per cent of the hips were rated excellent, very good, and good; 9.3 per cent were rated fair: and 1.7 per cent were rated poor. The radiographs of the socket revealed 54 per cent of bone-cement radiolucent and three failures at last follow-up. The radiographs of the stem revealed 29 per cent of bone-cement radiolucent and one failure at last follow-up. There was no revision of the femoral stem. Survival analysis (aseptic failures) depicted 93.45 per cent durability of the arthroplasty at 10 years. The survival analysis for the socket alone, using the same criteria for failure, demonstrated 94.53 per cent survival success at 10 years, and 98.91 per cent for the stem component. The comparison of the two combinations gave us a survival analysis for the socket alone, using aseptic failure as criteria, 79.84 per cent for stainless-steel/polyethylene combination at 8 years, and 97.63 per cent for alumina/polyethylene at the same time. CONCLUSION: The alumina/polyethylene combination with a 32 mm head diameter gave better results than the stainless-steel/polyethylene combinations. The improvement was noted on the acetabular component.     

A nonpharmacologic sleep protocol for hospitalized older patients

OBJECTIVES: To evaluate the feasibility of and adherence to a nonpharmacologic sleep protocol targeted to nurses for acutely ill older patients and to test the effectiveness of the protocol on enhancing sleep and reducing sedative-hypnotic drug (SHD) use. DESIGN: Prospective cohort study. SETTING: A 34-bed general medical unit in a university-affiliated teaching hospital. PARTICIPANTS: A total of 175 consecutive admissions aged 70 years or older. INTERVENTION: A nonpharmacologic sleep protocol consisting of a back rub, warm drink, and relaxation tapes was administered by nursing personnel to patients who complained of difficulty initiating sleep or who requested a SHD. After 1 hour, if the patient still requested it, the nurse administered the SHD. MEASUREMENTS: The main outcomes of sleep quality and SHD use were measured by patient interview and chart abstraction. Feasibility and adherence to the protocol were tracked daily by patient and nurse interviews and chart abstraction. RESULTS: A cohort of 111 patients, mean age 79.3 (+/- 6.4), 68% women, received the sleep protocol. Patients required the protocol for a mean of 4.9 days per patient, totalling 539 patients-days. The overall adherence rate was 400/539 (74%) patient-days. The rate of complete nonadherence was 139/539 (26%), with reasons for nonadherence including nurse nonadherence in 30 (6%), patient refusal in 104 (19%), and medical contraindications in five (1%). The quality of sleep correlated strongly with the number of parts of the protocol received, suggesting a dose-response relationship, with the highest correlation for receiving two to three parts (p = .64, P < 0.001). The sleep protocol was successful in reducing SHD use from the baseline preintervention rate of 51/94 (54%) to 34/111 (31%) (P < .002). The sleep protocol had a stronger association with quality of sleep (p = .75, P = .001) than did SHDs (p = .07, P = .45). However, chronic SHD users were more likely to refuse the protocol than nonusers (64% vs 41%, P < .03) and received SHDs 4.5 times more often than nonusers (67% vs 15%, P = .001). CONCLUSION: The nonpharmacologic sleep protocol provides a feasible, effective, and nontoxic alternative to SHDs to promote sleep in older hospitalized patients. Use of the protocol can substantially decrease use of SHDs.     

The delivery of preventive services in primary care practices according to chronic disease status

OBJECTIVES: The current study examined the relationship between chronic disease status and the receipt of cancer preventive services over a 3-year period. METHODS: Adults (n = 4320) cared for by 167 nonacademic physicians in 42 primary care group practices were studied. Medical records were audited for each patient, as were patient responses to two questionnaires assessing health and sociodemographic characteristics. RESULTS: While the odds of having received counseling to obtain regular checkups were increased for men (1.56) and women (1.46) with hypertension, the odds were reduced (range = 0.32 to 0.81) for having received a sigmoidoscopy (women with diabetes or hypertension, men with hypertension or heart disease), fecal occult blood test (men with diabetes or heart disease, women with heart disease), mammogram or counseling about smoking (women with diabetes), clinical breast exam (women with heart disease), and Pap test (women with diabetes or heart disease). CONCLUSIONS: The presence of common chronic health problems in older adults is associated with lower levels of cancer screening services.     

Health counseling in adolescent preventive visits: effectiveness, current practices, and quality measurement

Most morbidity and mortality among adolescents results from their participation in health-compromising behaviors. Recent guidelines for clinical adolescent preventive services recommend that primary care clinicians routinely screen for and counsel adolescents about these behaviors, identify and address related social, psychological, and biologic factors. Office-based counseling can influence adult health behaviors, but little is known about the effectiveness of office-based counseling for adolescents. In this review we: (a) evaluate available information about the effectiveness of office-based health counseling to improve outcomes; (b) report what is known about the health counseling adolescents receive from primary care clinicians; and (c) critically review different approaches that have been, or might be, used to measure the content and quality of health counseling provided during adolescent medical visits. With the emphasis on accountability in the current health care environment, evidence supporting the effectiveness of counseling is needed to justify investment in this aspect of clinical adolescent preventive services. Challenges to studying the effectiveness of health counseling include the lack of well-defined theory-based models for adolescent office-based counseling, the complexity of measuring counseling quality, and the many factors that influence adolescent outcomes. Reliable and valid measures of counseling quality are needed both to study and to ensure the quality of counseling received by adolescents. No single measure can be expected to fully capture counseling quality, although patient self-report deserves further development.     

Predictors for functional outcome in older rehabilitation patients.

Medical rehabilitation may serve to distinguish older adults capable of independent living from those in need of assistance. Return to independent living was evaluated in 372 older patients, all of whom lived alone before admission. For persons discharged alone, admission performance on the Functional Independence Measure was the only significant predictor of discharge self-care. For those discharged with supervision, age, memory, and depression were also significant predictors of discharge self-care. Thus, older live-alone patients may progress at different rates over rehabilitation, and psychosocial problems may foreshadow loss of independence. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Delirium in hospitalized older patients

Delirium is a common, serious problem for hospitalized older patients. Recognition of delirium poses challenges requiring cognitive assessment and knowledge of the clinical course. Delirium often is of multiple causes and is associated with a poor long-term prognosis. Nonpharmacologic approaches for delirium management are recommended; pharmacologic management should be reserved for patients who pose a danger to themselves or others. Importantly, delirium and its complications may be preventable through a targeted risk factor approach.     

Self-reported prevalence of diabetes and preventive health care practices among people with diabetes in South Carolina

As a result of the neuropathologic process of Alzheimer's disease (AD), significant changes occur in neuromotor function (e.g., paratonia and compulsive grasping). These changes become manifest in the moderately severe stage of AD, when patients begin to require ongoing assistance with activities of daily life (ADL), and they are prominent in the severe stage of AD, when patients are continuously dependent on a caregiver. Patients in these stages often display behavioral disturbances during care activities. These disturbing behaviors result not only from cognitive impairment, but also from a patient's physical inability to cooperate with the caregiver. When care management strategies take into account the characteristic physical restrictions resulting from the neuromotor changes that accompany advanced AD, the caregiving process may be significantly facilitated.     

Cardiac rehabilitation in older coronary patients

The majority of patients presenting with acute coronary disease or undergoing coronary revascularization procedures are older than age 65. Disability rates are very high in these patient populations, particularly in women, the older-old, and patients with clinical manifestations of angina pectoris or chronic heart failure. The presence of mental depression is also an important determinant of poor physical functioning. Cardiac rehabilitation has been demonstrated to safely increase aerobic capacity, muscular strength, and endurance in older coronary populations.     

Evaluating back pain in older patients

Low back pain in the elderly has a much wider range of possible causes than in younger patients. In addition to nonspecific mechanical causes, malignancy presenting as back pain occurs more often in older patients. Other systemic and visceral causes of back pain such as polymyalgia rheumatica, aortic aneurysm, Paget disease, Parkinson disease, and osteoporosis with compression fracture occur almost exclusively in persons over age 50. Keys to diagnosis and management of low back pain in older patients are presented.     

Treating alcoholism: an age-specific intervention that works for older patients

Alcoholism occurs in 10 to 15% of the population over age 65 and may be difficult to diagnose. The diagnosis is based on a history aimed at detecting behavioral problems associated with drinking, administering an in-office screening instrument, and conducting tests of liver function and/or mean corpuscular volume. The most effective treatment approach in this population focuses on the stresses of aging and co-existing depression, rather than on alcohol use itself. This approach has been found equally effective in long-standing alcoholics and those who develop a drinking problem in late life. Generally, older alcoholics are very responsive to treatment.     

Informatics for oncologic preventive screening

The communication between physicians and patients is often deficient. Little time is devoted to it and the patient receives scanty information with a low emotional content. Some features of our medicine can explain this situation. The rationalist and mechanistic biological model, allows to study only those things that can be undertaken with the scientific method. Psychological, social and spiritual aspects are surpassed. It only looks at material aspects of people, limiting the communication. Patients express their symptoms in an emotional way, with multiple beliefs and fears. The physician converts them to a precise, scientific, measurable and rational medical logical type. This language is not understood by patients, generating hesitancy in the communication. The paternalism is based in the power that physicians have over patients. We give knowledge and ask the patient to subordinate and accept our power. The patient loses his moral right to be informed, to ask, to have doubts or to disagree. Our personal communication is almost always formal, unemotional and with no explanations, further limiting communication.     

Effects of depressive symptoms on health behavior practices among older adults with vision loss.

Objective: The authors examined the interface between visual impairment and depressive symptoms on health behaviors, self-care, and social participation among adults ages 65 and older. Method: The authors analyzed data from the 1997–2004 National Health Interview Survey on visual impairment and depressive symptoms for 49,278 adults ages 65 and older, comparing visually impaired adults (n = 8,787) with and without depressive symptoms with a reference group of adults with neither condition (n = 3,136) for outcome measures: physical health, health behaviors, and difficulties with self-care and social participation. Results: Adults with visual impairment and severe depressive symptoms were more likely than adults with neither condition to smoke (14.9%, adjusted odds ratio [AOR] = 1.6), be obese (28.2%, AOR = 1.9), be physically inactive (80.5%, AOR = 3.0), have fair–poor health (76.0%, AOR = 26.5), and have difficulties with self-care (27.9%, AOR = 11.8) and social participation (52.1%, AOR = 10.9). Discussion and Conclusions: Older visually impaired adults with depressive symptoms are vulnerable to health decline and further disablement without timely interventions that target smoking cessation, healthy eating, and increased physical activity. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Determinants of survival in older cancer patients

BACKGROUND: We and others have previously described a number of characteristics that are associated with delays in diagnosis and increased risk for inadequate treatment of older women and men with cancer. These characteristics include poor social support, limited access to transportation, and impaired cognition. However, there is little information on how these factors influence survival of older cancer patients. PURPOSE: The purpose of the study was to determine which patient characteristics predicted survival up to 10 years after the diagnosis of cancer. METHODS: In 1984, we initiated a population-based study of men and women who were 65 years of age or older, living in a six-county area of New Mexico, and newly diagnosed with cancer. For 646 individuals with cancer of the breast (n = 188), prostate (n = 247), or colon or rectum (n = 211), we assessed patient baseline characteristics, disease stage at diagnosis, and adequacy of treatment (definitive or nondefinitive) as determinants of survival for up to 10 years following diagnosis. Multivariate survival models were used to analyze the data; all P values were two-sided. RESULTS: In multivariate analyses, we first included all patient characteristics, except the stage at diagnosis and the adequacy of treatment. In this initial analysis, the following were among variables that were significantly associated with patient survival: age, education, cancer knowledge, ethnic group, and cognitive status. When stage at diagnosis and adequacy of treatment were added to the model, both advanced stage at diagnosis (hazard ratio = 1.7 [95% confidence interval ?CI? = 1.3-2.1] for diagnosis at regional stage versus local stage; hazard ratio = 3.0 [95% CI = 2.0-4.7] for distant stage versus local stage) and inadequate treatment (hazard ratio = 1.6 [95% CI = 1.1-2.3]) were associated with poor survival. However, adding stage at diagnosis and adequacy of treatment to the analysis had little influence on the magnitude of the effect of patient characteristics on survival. In separate analyses of patient data by cancer site, receipt of nondefinitive therapy was associated with increased mortality among patients with colon/rectal cancer (hazard ratio = 7.8 [95% CI = 2.8-21.4]) and breast cancer (hazard ratio = 2.2 [95% CI = 1.1-4.3]) but not among patients with prostate cancer (hazard ratio = 1.0 [95% CI = 0.6-1.9]). CONCLUSIONS: Advanced stage at diagnosis and inadequate treatment of older cancer patients are associated with poor survival. Impaired cognition and inadequate education in elderly patients are also associated with poor survival. This decreased survival does not appear to be a consequence of known barriers to health care that are responsible for delays in diagnosis and for inadequate treatment. IMPLICATIONS: Efforts to facilitate early diagnosis and receipt of definitive treatment for cancer in older individuals may improve their survival.     

Neuroleptic dose reduction in older psychotic patients

We conducted a non-randomized, rater-blind study to safely determine the lowest effective neuroleptic dosage in older psychotic patients and to evaluate the clinical, neuropsychological, and psychosocial effects of neuroleptic dosage reduction. Twenty-seven carefully selected patients with schizophrenia and related psychotic disorders over the age of 45 had their dosage tapered by 25% each month to determine their lowest effective dosage. These patients were compared with patients similar in age, gender, and education who were currently off neuroleptics (n = 19) or maintained on neuroleptics (n = 22). All groups were followed for 11 months. Over the follow-up period, 29% of patients in the taper group, 8% of neuroleptic-free patients, and 0% of patients in the maintenance group experienced some increase in psychopathology, although there was no significant change in mean PANSS score in any group, and no patient required hospitalization. Patients in the taper group were maintained on approximately 60% of their original neuroleptic dosage after restabilization. Extrapyramidal symptoms continued to improve over time in the taper group. Neuropsychological testing did not change significantly over time except for those in the taper group who experienced a decrease in memory-retention on the Hopkins Verbal Learning Test and a significant improvement in digit vigilance and Stroop Interference Index. Carefully selected middle-aged and elderly psychotic patients can have their neuroleptic medications reduced without a significant change in psychopathology. Extrapyramidal symptoms may continue to improve gradually over time. The impact on cognition functioning needs further investigation.