John R. Burton

Behavioral Training for Urinary Incontinence in Elderly Ambulatory Patients

Research questions addressed by this study were: 1) Is the treatment of chronic urinary incontinence (UI) in elderly, nondemented ambulatory patients using bladder‐sphincter biofeedback as effective when performed by an internist/geriatrician and a nurse practitioner as that reported by behavioral scientists?; and 2) how does bladder‐sphincter biofeedback compare to a program of behavioral training that does not utilize biofeedback? Twenty‐seven patients with ill were assigned based on the number of baseline accidents documented in a self‐maintained log, their sex, and the predominant pattern of symptoms (urge or stress) to one of two treatment groups: biofeedback (13 patients) or behavioral training not utilizing biofeedback (14 patients). Patients were given up to six treatments. Patients in both groups achieved a highly significant (P < .001) reduction in urinary accidents 1 month following treatments compared with their baseline number of accidents. The average reduction of accidents over this time period was 79% for the biofeedback group and 82% for the group receiving behavioral training without biofeedback. All patients showed improvement and no patient experienced any side effect. A internist /geriatrician and a geriatric nurse practitioner may achieve success utilizing behavioral therapy with or without biofeedback for the treatment of chronic urinary incontinence for ambulatory elderly patients.

Post-traumatic renal failure in military personnel in Southeast Asia: Experience at clark USAF Hospital, Republic of the Philippines

Abstract A mortality of 63 per cent was noted in sixty-seven cases of post-traumatic renal failure occurring in Vietnam casualties, which is similar to that noted during the Korean conflict and in civilian institutions. We analyzed our data to determine the factors responsible for the high mortality in these patients. Frequent dialysis therapy was utilized, and the daily blood urea nitrogen averaged 92 mg/100 ml in those who survived and 100 mg/100 ml in those who died. Uremic symptoms were uncommon, and complications directly attributable to renal failure were not associated with increased mortality. Neither the clinical severity of the renal failure as measured by the daily urine volume nor the need for dialysis therapy showed a uniform relationship to survival. The high mortality could partially be attributed to the severe trauma in our patients. Multiple wounds were common, and 54 per cent had intra-abdominal injury. Only patients with isolated wounds on the extremities had a significantly higher survival. Infection occurred in 89 per cent of our patients and was the direct cause in 72 per cent of the deaths. Septic deaths were due to gram-negative pneumonia, septicemia or intra-abdominal infection. Wound infections alone did not affect survival but were the probable source for most of the fatal systemic infections. There was a high incidence of infection at multiple sites, antibiotic resistant bacteria and failure to respond to adequate antibiotic therapy. Jaundice and hemorrhage were complications also attributable to infection, and each occurred in 45 per cent of our patients, with associated mortalities of 90 and 80 per cent, respectively. Early and frequent dialysis therapy in our patients did not prevent the high incidence of septic complications seen in posttraumatic renal failure. Further emphasis on frequent debridement of wounds may be helpful. Improvement in parenteral nutrition may also be beneficial because of the marked catabolism noted in these patients.

Autopsies and Death Certificates in the Chronic Care Setting

All autopsies (n = 34) performed over a period from July 1, 1981 to June 30, 1988 in a teaching nursing home were reviewed to determine the autopsy rate, to evaluate premortem versus postmortem diagnostic discrepancies, and to see if educational efforts could improve each. The autopsy rate was 3.5%. Major discrepancies appeared in 47.1% of cases. Pneumonia was the most frequent and most frequently missed diagnosis. Only 23 of 34 death certificates reflected the cause of death as documented in the chart, and only 12 had concordant diagnoses with those from autopsy. After a collective educational effort, the autopsy rate increased from a rate (average of initial six years) of 2.4% to 10.8% in the last year. The autopsy rate is low, but can be improved with educational efforts. Death certificates, in this population, may be misleading when used for general statistical purposes.

Prospective evaluation of clinical criteria to select older persons with acute medical illness for care in a hypothetical home hospital

OBJECTIVE: To evaluate criteria to select older persons who need hospitalization for common acute medical illnesses for care in a hypothetical home hospital.

The evolution of nursing homes into comprehensive geriatrics centers: A perspective

Nursing homes typically have been a relatively isolated component of health care in the United States. Now, however, nursing homes are experiencing a change in the patients they serve. In recent years, nursing home patients have been admitted sicker and after a shorter hospital stay than in the past. Such changes are likely to continue to occur as the size of the population of frail elderly continues to increase and as insurers look for alternatives to high cost hospital care. An additional stimulus to change is that the public is asking for innovation in noninstitutionalized long‐term care.

Behavioral treatment of isolated systolic hypertension in the elderly

Fifteen hypertensive patients were recruited from a geriatric medicine clinic for a “research project designed to evaluate a Behavioral Stepped-Care treatment program of high blood pressure (HBP).” All patients met the selection criteria of the Isolated Systolic Hypertension (ISH) in the Elderly (SHEP) clinical trial. During baseline, subjects recorded BP at home 9 times/day (3 times each, shortly after awakening, during the middle of the day, and within an hour of retiring) for 1 month and mailed that data to us daily. In addition, they came to the clinic weekly and had their BP recorded by a nurse. During treatment 1, systolic (SBP) feedback, they were trained to lower SBP at home using their sphygmomanometers. They also continued to monitor BP and to obtain weekly professional BP readings. During treatment 2 (relaxation), they were trained to relax; they followed the self-administration and data-collection protocol as in treatment 1. Each treatment phase lasted 3 months. Average monthly self-determined BP fell significantly from 166.4/85.8 (SBP/DBP) mm Hg during baseline to 153.3/81.2 by the end of the relaxation phase; average monthly professionally measured BP fell significantly, from 164.7/87.1 to 156.9/81.5. These findings show that a nurse-supervised, patient-administered behavioral treatment program of ISH can yield sustained, significant falls in BP.

Screening Tools for Geriatric Assessment by Specialists

This chapter provides practical guidance for any clinician looking for information concerning tools that are of value in assessing an older patient.