Christine K. Cassel

Delirium in hospitalized older persons : outcomes and predictors

OBJECTIVE: The purpose of this study was fourfold: to determine the rate of delirium among hospitalized older persons, to contrast the clinical outcomes of patients with and without delirium, to identify clinical predictors of delirium, and to validate the predictive model in an independent sample of patients.

Trading Off Longer Life for Worsening Health: The Expansion of Morbidity Hypothesis

This article demonstrates and explains why future declines in mortality will have a diminishing effect on the metric of life expectancy but a large impact on the size of future elderly cohorts. Additionally, the article addresses a hypothesis in which it is argued that morbidity and disability will decline and become compressed into a shorter duration of time before death. Although studies have demonstrated that declining mortality can lead to worsening health, what is missing from the literature is a formal mechanistic hypothesis that describes why this phenomenon takes place. Two primary mechanisms are identified. One is based on arguments in which medical technology is identified to improve the survival of those with disabling conditions; the other is that declining mortality from fatal diseases leads to a shift in the distribution of causes of disability from fatal to nonfatal diseases of aging. Procedures for testing this hypothesis are discussed.

Differences in generalist and specialist physicians' knowledge and use of angiotensin-converting enzyme inhibitors for congestive heart failure.

ObjectiveTo quantify the extent and determinants of underutilization of angiotensin-converting enzyme (ACE) inhibitors for patients with congestive heart failure, especially with respect to physician specialty and clinical indication.DesignSurvey of a national systematic sample of physicians.ParticipantsFive hundred family practitioners, 500 general internists, and 500 cardiologists.Measurements and main resultsPhysicians’ choice of medications were determined for four hypothetical patients with left ventricular systolic dysfunction: (1) new-onset, symptomatic; (2) asymptomatic; (3) chronic heart failure, on digitalis and diuretic; and (4) asymptomatic, post-myocardial infarction. For each patient, randomized controlled trials have demonstrated that ACE inhibitors decrease mortality or the progression of symptoms. Among the 727 eligible physicians returning surveys (adjusted response rate 58%), approximately 90% used ACE inhibitors for patients with chronic heart failure who were already taking digitalis and a diuretic. However, family practitioners and general internists chose ACE inhibitors less frequently (p≤.01) than cardiologists for the other indications. Respective rates of ACE inhibitor use for each simulated patient were new-onset, symptomatic (family practitioners 72%, general internists 76%, cardiologists 86%); asymptomatic (family practitioners 68%, general internists 78%, cardiologists 93%); and asymptomatic, post-myocardial infarction (family practitioners 58%, general internists 70%, cardiologists 94%). Compared with generalists, cardiologists were more likely (p≤.05) to increase ACE inhibitors to a target dosage (45% vs 26%) and to tolerate systolic blood pressures of 90 mm Hg or less (43% vs 15%).ConclusionsCompared with cardiologists, family practitioners and general internists probably underutilize ACE inhibitors, particularly among patients with decreased ejection fraction who are either asymptomatic or post-myocardial infarction. Educational efforts should focus on these indications and emphasize the dosages demonstrated to lower mortality and morbidity in the trials.

Nurses' and physicians' attitudes toward tube-feeding decisions in long-term care.

We studied attitudes of health professionals toward life‐sustaining treatment. A patient management questionnaire sent to staff physicians and nurses in 183 Oregon nursing homes consisted of eight patient sketches which varied age, mental status, and enjoyment of life. Respondents were asked whether they would favor tube‐feeding to correct malnutrition in each case.

Hospital Outcomes Project for the Elderly (HOPE): Rationale and Design for a Prospective Pooled Analysis

Objective: To describe a collaborative investigation that is based on a series of six clinical studies aimed at reducing functional decline in the acutely‐ill hospitalized elderly.

Clinical Decision-Making in Catastrophic Situations: The Relevance of Age: Report of a Conference Convened by the American Geriatrics Society, April 17-18, 1987*

he following report summarizes the efforts of a large group of people convened by the American Geriatrics Society in an effort to contribute T to the clarification of emerging areas of ethical importance in the practice of medicine, particularly in relation to the care of elderly patients. While ethical considerations are of importance in all clinical decisionmaking, care of the elderly presents difficult ethical dilemmas with heightened frequency. At the same time, elaboration and clarification of these ethical dilemmas as they apply to geriatric practice are likely to produce conclusions that will be useful in the care of patients of all ages. By the same token, ethical decision-making in geriatrics is likely to be richly informed by the experience with such issues in the care of younger patients. Against this background, the Society convened a planning conference in Washington, D.C. in September 1986 and sought the help and counsel of the American Academy of Pediatrics in the construction of this conference and in its deliberations. While a number of issues discussed at the planning conference warranted exploration, it was decided that a larger conference should be arranged to focus on ethical issues in clinical decisionmaking in catastrophic situations, and that this effort should concentrate especially on the relevance of age in such decisions. Accordingly, a 2-day conference was held at the National Academy of Sciences on April 17 18, 1987, the results of which are reported here. The conference discussion was structured around the importance of three global areas, namely, autonomy,

The Ethics Committee in the Nursing Home Results of a National Survey

As the complexity, prevalence and visibility of ethical dilemmas in medical care of the elderly have grown, hospitals and nursing homes have attempted to develop mechanisms for responding to these difficult ethical issues. While it is known that many hospitals rely on education and advice provided by an ethics committee, little data exist on the responses of nursing homes, despite the unique nature of ethical issues in a long‐term care setting.

Biomedical Research Involving Older Human Subjects

The increasing life expectancy and increasing proportion of the population over the age of 65 in most developing countries are both unprecedented demographic phenomena. In the United States, l i fe expectancy has increased more in the last century than in all previous recorded history. Even in the last 20 years, there have continued to he unexpected and largely unexplainable declines in mortality rates leading to increasing numbers of people living beyond even the ages of 85, 90 or 100.1 It is not surprising, then, that there is a great interest in studies of aging among researchers in social science and policy studies. Further, since aging is generally associated with an increased risk of medical illness and declining function, research has been stimulated in many different health-related areas, such as clinical disease, basic molecular causes of aging, and health services research. Medical research using elderly subjects has been a rather neglected area until recently. Before the 1960s, the growth in the aged population had just begun to be noticed and had not yet become a popular or fundable research area. Even for some time thereafter, a number of major multicenter research trials systematically excluded people over the age of 65 as subjects. Many of these national studies, such as the Hypenension Detection and Follow Up Program or the University Group Diabetes Program, produced results which were of limited value since the populations in which the prevalence of these two diseases is the highest is that group over age 65. Because of the understanding that older people are more likely to have multiple and chronic illnesses, researchers thought that they would get less confounded samples by excluding such individuals from their studies. More recent studies, which now recognize the importance of understanding the interaction of multiple illnesses with common disorders such as hypertension or diabetes, must go back and over-sample the elderly in these areas. Since the establishment of the National Institute of Aging in 1974, there has been a steady growth of interest in, and resources for, the support of aging research, from both governmental and private sources. Diseases which cause extraordinary levels of suffering and disability, as well as cost to society and families, finally are being researched intensively. These research topics include, but a r e not limited to, Alzheimers disease, osteoporosis, osteoarthritis, Parkinsons disease, urinary incontinence, gait disorders and falls. There have been two reports from the Institute of Medicine calling for increasing training programs for specialists in geriatric medicine and in 1988 the first certification exam documenting special competence in the field of geriatrics for physicians was administered.2 In all of these areas, policy makers emphasize the need for more expens to do both basic and clinical research on problems in geriatric medicine.

Dangerous behavior in a demented patient. Preserving autonomy in a patient with diminished competence

When a cognitively‐impaired elderly man nearly caused a serious fire at home through his inappropriate use of a gas oven, the incident raised questions about his capacity to live alone. Although he clearly wanted to preserve his independence, the health care team felt obligated to assure his safety. The following discussion of dangerous behavior in a demented elderly man elicits and portrays these conflicting values, and highlights the physicians obligations in such ethically and legally complex situations.

Depression in the Elderly

Presentation differs from that in the young, as does choice of therapy, which tends to be empiric. The tricyclics are considered the best treatment, although electroconvulsive therapy may be preferable in severe delusional depression.