Dee Jones

Rehabilitation after myocardial infarction trial (RAMIT): multi-centre randomised controlled trial of comprehensive cardiac rehabilitation in patients following acute myocardial infarction

Background It is widely believed that cardiac rehabilitation following acute myocardial infarction (MI) reduces mortality by approximately 20%. This belief is based on systematic reviews and meta-analyses of mostly small trials undertaken many years ago. Clinical management has been transformed in the past 30–40 years and the findings of historical trials may have little relevance now. Objectives The principal objective was to determine the effect of cardiac rehabilitation, as currently provided, on mortality, morbidity and health-related quality of life in patients following MI. The secondary objectives included seeking programmes that may be more effective and characteristics of patients who may benefit more. Design, setting, patients, outcome measures A multi-centre randomised controlled trial in representative hospitals in England and Wales compared 1813 patients referred to comprehensive cardiac rehabilitation programmes or discharged to ‘usual care’ (without referral to rehabilitation). The primary outcome measure was all-cause mortality at 2 years. The secondary measures were morbidity, health service use, health-related quality of life, psychological general well-being and lifestyle cardiovascular risk factors at 1 year. Patient entry ran from 1997 to 2000, follow-up of secondary outcomes to 2001 and of vital status to 2006. A parallel study compared 331 patients in matched ‘elective’ rehabilitation and ‘elective’ usual care (without rehabilitation) hospitals. Results There were no significant differences between patients referred to rehabilitation and controls in mortality at 2 years (RR 0.98, 95% CI 0.74 to 1.30) or after 7–9 years (0.99, 95% CI 0.85 to 1.15), cardiac events, seven of eight domains of the health-related quality of life scale (‘Short Form 36’, SF36) or the psychological general well-being scale. Rehabilitation patients reported slightly less physical activity. No differences between groups were reported in perceived overall quality of cardiac aftercare. Data from the ‘elective’ hospitals comparison concurred with these findings. Conclusion In this trial, comprehensive rehabilitation following MI had no important effect on mortality, cardiac or psychological morbidity, risk factors, health-related quality of life or activity. This finding is consistent with systematic reviews of all trials reported since 1983. The value of cardiac rehabilitation as practised in the UK is open to question.

Effect of health visitors working with elderly patients in general practice: a randomised controlled trial.

Health visitors were employed specifically to care for two years for a random sample of patients in general practice who were aged over 70. Independent assessments made at the beginning and end of the study showed that the health visitor in an urban practice had some impact on her caseload of patients; she provided more services for them, their mortality was reduced, and their quality of life improved, though the last measure just failed to be statistically significant. The health visitor working in a rural practice had no such effect.

Prevalence of visual impairment in people aged 75 years and older in Britain: results from the MRC trial of assessment and management of older people in the community

Aims: To measure the prevalence of visual impairment in a large representative sample of people aged 75 years and over participating in the MRC trial of assessment and management of older people in the community. Methods: 53 practices in the MRC general practice research framework. Data were obtained from 14 600 participants aged 75 years and older. Prevalence of visual impairment overall (binocular visual acuity <6/18) which was categorised separately into low vision (binocular visual acuity <6/18–3/60) or blindness (binocular visual acuity of <3/60). The prevalence of binocular acuity <6/12 was presented for comparison with other studies. Visual acuity was measured using Glasgow acuity charts; glasses, if worn, were not removed. Results: Visual acuity was available for 14 600 people out of 21 241 invited (69%). Among people with visual acuity data, 12.4% overall (1803) were visually impaired (95% confidence intervals 10.8% to 13.9%); 1501 (10.3%) were categorised as having low vision (8.7% to 11.8%), and 302 (2.1%) were blind (1.8% to 2.4%). At ages 75–79, 6.2% of the cohort were visually impaired (5.1% to 7.3%) with 36.9% at age 90+ (32.5% to 41.3%). At ages 75–79, 0.6% (0.4% to 0.8%) of the study population were blind, with 6.9% (4.8% to 9.0%) at age 90+. In multivariate regression, controlling for age, women had significant excess risk of visual impairment (odds ratio 1.43, 95% confidence interval 1.29 to 1.58). Overall, 19.9% of study participants had a binocular acuity of less than 6/12 (17.8% to 22.0%). Conclusion: The results from this large study show that visual impairment is common in the older population and that this risk increases rapidly with advancing age, especially for women. A relatively conservative measure of visual impairment was used. If visual impairment had been defined as visual acuity of <6/12 (American definition of visual impairment), the age specific prevalence estimates would have increased by 60%.

Reduced hearing, ownership, and use of hearing aids in elderly people in the UK--the MRC Trial of the Assessment and Management of Older People in the Community: a cross-sectional survey.

BACKGROUND Reduced hearing in elderly people is important because it is disabling and potentially treatable. We aimed to assess the prevalence of reduced hearing in elderly people and levels of ownership of hearing aids and use. METHODS We have done a cross-sectional survey of people aged at least 75 years in 106 family practices in the UK. We obtained self-reported data on hearing difficulties for 32,656 people and gave 14,877 a whispered voice test (response rate 78%). FINDINGS 2537 (8%) of 32,656 participants reported a lot of difficulty hearing and 13,630 (42%) a little or a lot of difficulty. 3795 (26%) of 14877 participants who completed the whispered voice test (95% CI 23-29) failed the test, the proportion rising sharply with age. Following wax removal, 343 passed a retest, leaving 3452 (23%, 20-26) who failed the test, even after wax removal if present. 998 (46%) of 2180 people wearing a hearing aid at the time of testing failed the whispered voice test. More than half the people who failed the test did not own a hearing aid. 2200 (60%) of 3846 people who owned a hearing aid said they used it regularly. Level of use was strongly related to perceived benefit. INTERPRETATION Reduced hearing is common and provision of hearing aids inadequate in elderly people. Many people who own a hearing aid do not use it regularly, and even when wearing their aid many still have socially disabling levels of hearing loss. A major source of morbidity in elderly people could be alleviated by improvements in detection and management of reduced hearing.

Randomised comparison of three methods of administering a screening questionnaire to elderly people: findings from the MRC trial of the assessment and management of older people in the community

Abstract Objective: To compare three different methods of administering a brief screening questionnaire to elderly people: post, interview by lay interviewer, and interview by nurse. Design: Randomised comparison of methods within a cluster randomised trial. Setting: 106 general practices in the United Kingdom. Participants: 32 990 people aged 75 years or over registered with participating practices. Main outcome measures: Response rates, proportion of missing values, prevalence of self reported morbidity, and sensitivity and specificity of self reported measures by method of administration of questionnaire for four domains. Results: The response rate was higher for the postal questionnaire than for the two interview methods combined (83.5% v 74.9%; difference 8.5%, 95% confidence interval 4.4% to 12.7%, P<0.001). The proportion of missing or invalid responses was low overall (mean 2.1%) but was greater for the postal method than for the interview methods combined (4.1% v 0.9%; difference 3.2%, 2.7% to 3.6%, P<0.001). With a few exceptions, levels of self reported morbidity were lower in the interview groups, particularly for interviews by nurses. The sensitivity of the self reported measures was lower in the nurse interview group for three out of four domains, but 95% confidence intervals for the estimates overlapped. Specificity of the self reported measures varied little by method of administration. Conclusions: Postal questionnaires were associated with higher response rates but also higher proportions of missing values than were interview methods. Lower estimates of self reported morbidity were obtained with the nurse interview method and to a lesser extent with the lay interview method than with postal questionnaires. What is already known on this topic The optimum method of administering a brief multidimensional screening assessment to elderly people is not known What this study adds Postal questionnaires produce a higher response rate than interviews by nurses or lay interviewers but also higher proportions of missing data Interview by nurses and to a lesser degree by lay interviewers is associated with lower levels of self reported morbidity than are postal questionnaires

A survey of those who care for the elderly at home: Their problems and their needs

One thousand and sixty-six over 70s were interviewed in their own homes, 256 of the subjects had main carers who were non-statutory. These informal carers of the dependent elderly were then interviewed to examine the nature of the care that they provided, the assistance both formal and informal that they received and the consequences such caring had on their quality of life. The evidence from this study supports the view that the family is the main source of assistance to dependent elderly; usually the woman in the family. Very little assistance, either informal or formal, was received by the carers. Consequently there was a great deal of distress and psychological morbidity among the carers.

Effect of a lactation nurse on the success of breast-feeding: a randomised controlled trial.

An evaluation of a lactation nurse by means of a randomised controlled trial is described. The lactation nurse was employed to assist, support, and encourage mothers during the early weeks after parturition in hospital and at home. All mothers who breast-fed at least once were entered into the trial. Altogether 649 mothers were interviewed 12 months later to establish the duration of breast-feeding and to enquire after practices of and attitudes towards infant feeding. The lactation nurse significantly extended the duration of breast-feeding, particularly during the first four weeks and among women of lower social class. Although she did not reduce problems or change practices significantly, all the trends were consistently in the right direction. Mothers in the experimental group were more satisfied with the help they received than were mothers in the control group. It seems likely that the lactation nurse by consistent advice, assistance, support, and encouragement enabled mothers to cope more successfully with difficulties and that this led to significantly fewer ending breast-feeding prematurely.

Association of quality of life in old age in Britain with socioeconomic position: baseline data from a randomised controlled trial

Study objective: To identify socioeconomic differentials in quality of life among older people and their explanatory factors. Design: Baseline data from a cluster randomised controlled trial of the assessment and management of older people in primary care. Outcome measures were being in the worst quintile of scores for, respectively, the Philadelphia geriatric morale scale and four dimensions of functioning from the sickness impact profile (home management, mobility, self care, and social interaction). Setting: 23 general practices in Britain. Participants: People aged 75 years and over on GP registers at the time of recruitment, excluding those in nursing homes or terminally ill. Of 9547 people eligible, 90% provided full information on quality of life and 6298 also did a brief assessment. Results: The excess risk of poor quality of life for independent people renting rather than owning their home ranged from 27% for morale (95% CI 9% to 48%) to 62% for self care (95% CI 35% to 94%). Self reported health problems plus smoking and alcohol consumption accounted for half or more of the excess, depending on the outcome. Having a low socioeconomic position in middle age as well as in old age exacerbated the risks of poor outcomes. Among people living with someone other than spouse the excess risk from renting ranged from 24% (95%CI −10% to 70%) for poor home management to 93% (95%CI 30% to 180%) for poor morale. Conclusions: Older people retain the legacy of past socioeconomic position and are subject to current socioeconomic influences.

Relationships between prescription and non-prescription drug use in an elderly population

This paper explores, at an epidemiological level, the relationship between categories of over-the-counter (OTC) and prescribed (Rx) drugs in a community-resident elderly population. A total of 2818, randomly selected, older adults were interviewed at home about their use of prescribed and non-prescribed medication and other health-related factors. For comparative purposes OTC drugs were classified into 16 therapeutic groups-identical to those used by other researchers; prescribed drugs were classified into 45 British National Formulary (BNF) therapeutic sub-categories. Analyses revealed significant association between certain BNF categories and OTC categories, which may have a clinical explanation. These include a 3-fold increase (P<0.01) of OTC laxative use by those prescribed an antidepressant, and a 4-fold increase (P<0.001) in OTC antacid use among those prescribed oral corticosteroids. Our findings may indicate an attempt by older people to control side effects of prescription medicines with OTC preparations. This study, in part, supports the call by the Royal College of Physicians for further research to determine the effect of interactions (be they pharmacological, behavioural or otherwise) between OTC and prescribed medicines.

Use of pharmacists by older people in the community

A random sample of community dwelling elderly people (> 65 years) was interviewed on two occasions, 6 months apart. Four hundred and thirty five completed both interviews. Subjects were asked about their medication, and about the advice sought from community pharmacists, on both drug and non-drug related health issues. Medication had been altered during the 6-month interval in 101 (23%) of people, but only 15 of these had discussed the change with a pharmacist. The majority of those who did discuss their medication, however, found the exchange helpful. Only 1% of the sample had discussed a health problem not related to drugs with a pharmacist in the previous month, although once again such discussions were felt to be useful. Of the total sample, 79% said they would never discuss medication-related issues with a community pharmacist, and 83% would not discuss other health matters. The majority of this sample - 96% - expressed a preference to discuss these issues with their general practitioner.