Laurence J. Robbins

Binding the Elderly: A Prospective Study of the Use of Mechanical Restraints in an Acute Care Hospital

Little information exists on the use of mechanical restraints among nonpsychiatric inpatients. This prospective study evaluates their use among consecutive medical and surgical admissions to an acute care hospital. Daily direct observation of patients and hospital record review provided data on potential predictors of restraint, reasons for their application, complications, and outcome. Cox regression analysis was used to calculate relative risk of restraint while adjusting for duration of hospitalization as well as other variables.

RELIABILITIES, NORMS AND FACTOR STRUCTURE OF THE BEHAVIORAL DYSCONTROL SCALE '

This is a report on the statistical properties of a research and clinical measure of cognitive and behavioral functioning, which has so far demonstrated utility among elderly persons. This instrument, the Behavioral Dyscontrol Scale, is adapted from Lurias approach to the assessment of frontal lobe dysfunction. The scale shows high internal consistency and very good interrater reliability. In a clinically stable, elderly population, test-retest reliability is high. Normative data are presented for three different samples: 47 young adults, 141 cognitively normal elderly persons, and our total elderly sample of 229. A principal components analysis yielded 3 factors consistent with Lurias theory.

Behavioral disturbance and impairment of executive functions among, the elderly

Among the elderly, measures of general cognitive ability are not consistently related to the capacity for independent functioning. Some elder patients perform well on global tests of cognition, yet demonstrate behavior that is disruptive to their lives and those of their families. The genesis of these behavior problems is poorly understood, and caregivers, both professional and non-professional, frequently attribute their behavior to wilful misconduct. We propose that there are sufficient data concerning the so-called executive functions of the brain and their impairment in both normal aging and various types of dementia, to support the hypothesis that many behavioral disturbances among demented older adults are a function of different degrees of loss of the capacity to engage in purposeful, goal-directed activity. The executive functions are complex, and include the capacities for planning, organization and active problem solving, and the ability to engage in purposeful, goal-directed behavior. Impaired executive functioning is common in dementia, but also may be present in the context of an age-related decline in the speed and capacity of information processing and varying levels of general cognitive impairment. We review data in support of this model, and discuss a patient whose case illustrates deficits in the independent regulation of behavior, an important executive function mediated primarily by the prefrontal area. In the discussion we address several hypotheses suggested by this perspective.

The effect of prescription size on acquisition of maintenance medications

AbstractObjective: To determine whether large prescriptions (≥90 days’ supplies) enhance the acquisition of maintenance medications by patients. Design: Study 1: multisite, retrospective cohort study evaluating outpatient digoxin use. Study 2: single-site, retrospective cohort study to confirm Study 1. Setting: Study 1: Ten Veterans Affairs Medical Centers in the Rocky Mountain region. Study 2: The only facility from Study 1 (site C) that dispensed large prescriptions of maintenance medications. Patients: Randomly selected outpatients receiving two or more digoxin prescriptions (n=176 in Study 1,n=114 in Study 2). Intervention: None. Results: The main outcome measure was the proportion of prescribed doses of maintenance medications obtained. In Study 1, patients who received at least one large digoxin prescription obtained a mean of 13 7.2% of their prescribed digoxin doses over a mean of nine months, compared with 91.3% for patients who received only small prescriptions of <90 days’ supplies (p=0.02). Patients receiving large prescriptions were more likely to obtain at least 100% of their prescribed amounts of digoxin (adjusted OR=11.4, 95% CI=1.3–96.8, p=0.03). At site C, patients in Study 1 obtained a mean of 129.0% of all maintenance drugs given in large supplies, compared with 95.2% of drugs prescribed only in small supplies (p=0.006). In Study 2, acquisition of digoxin increased progressively from 89.7% among individuals who received only small digoxin prescriptions to 113.0% for those who received only large supplies (p=0.002), over a mean of 14 months. Conclusions: Large prescriptions facilitate the acquisition of maintenance medications but may lead to oversupplies, while small prescriptions impose a barrier to obtaining these drugs.

Child-resistant Packaging and the Geriatric Patient

Child-resistant packaging of prescriptions and over-the-counter medications has reduced the incidence of accidental overdose by 75 percent. While critics express concern about poorer compliance among patients confronting more difficult bottle closures, the documented protection of young children that the packaging affords supports continued reliance on it.”Previous attempts to identify the prevalence of problems with child-resistant packaging among the elderly have relied largely on anecdote, telephone surveys, and quest i o n n a i r e ~ . ~ ~ ~ Two prospective studies of patients’ ability to use child-resistant containers failed to separate the aged atient from younger cohort^.^,^

Academic Affiliation With a Nursing Home: Impact on Patient Outcome

In a prospective study, 46 patients discharged from a teaching hospital to a “teaching unit” nursing home, where primary medical care was provided by faculty geriatricians, medical students, and medical housestaff, were compared with 78 similar patients discharged to one of five community nursing homes without a teaching affiliation. At the time of hospital discharge, patients were determined to have a terminal, rehabilitative, or long stay prognosis based on a review of hospital discharge summaries using specific criteria. Among 34 study and 55 control patients with a long stay prognosis, ten of the study group compared with seven of the control group returned home (P = .03). Seven of 34 long stay patients in the study group were rehospitalized, while 15 of a matched control group of 34 required hospitalization (P = .04). There was no increase in mortality or emergency service use in the study population. Patients considered to be terminal or rehabilitative showed no difference in ultimate outcome or hospital use. In the study group patients experienced an average reduction in total medications prescribed from 6.2 to 5.3, while patients in the control group had an increase from 5.4 medications prescribed to 7.6 (P < .001). Of 16 study patients discharged from the teaching unit nursing home, all remained home at least three months after discharge; only 12 of 18 control group patients discharged from the nursing home remained at home at three months (P < .01). Long‐term care by geriatric faculty, students, and housestaff appeared to have favorably influenced patient outcomes.

Providing All-Inclusive Care for Frail Elderly Veterans : Evaluation of Three Models of Care

Frail elderly veterans aged 55 and older who met state nursing home admission criteria were enrolled in one of three models of all‐inclusive long‐term care (AIC) at three Veterans Affairs (VA) medical centers (n=386). The models included: VA as sole care provider, VA‐community partnership with a Program of All‐inclusive Care for the Elderly (PACE), and VA as care manager with care provided by PACE. Healthcare use was monitored for 6 months before and 6 to 36 months after enrollment using VA, DataPACE, and Medicare files. Hospital and outpatient care did not differ before and after AIC enrollment. Only 53% of VA sole‐provider patients used adult day health care (ADHC), whereas all other patients used ADHC. Nursing home days increased, but permanent institutionalization was low. Thirty percent of participants died; of those still enrolled in AIC, 92% remained in the community. VA successfully implemented three variations of AIC and was able to keep frail elderly veterans in the community. Further research on providing variations of AIC in general is warranted.