Marshall J. Graney

A randomized, controlled trial of a geriatric assessment unit in a community rehabilitation hospital

We conducted a randomized trial in a community rehabilitation hospital to determine the effect of treatment in a geriatric assessment unit on the physical function, institutionalization rate, and mortality of elderly patients. Functionally impaired elderly patients (mean age, 78.8 years) who were recovering from acute medical or surgical illnesses and were considered at risk for nursing home placement were randomly assigned either to the geriatric assessment unit (n = 78) or to a control group that received usual care (n = 77). The two groups were similar at entry and were stratified according to the perceived risk of an immediate nursing home placement. After six months, the patients treated in the geriatric assessment unit had significantly more functional improvement in three of eight basic self-care activities (P less than 0.05). Those in the lower-risk stratum had significantly more improvement in seven of eight self-care activities. Both six weeks and six months after randomization, significantly more patients treated in the geriatric assessment unit than controls (79 vs. 61 percent after six months) were residing in the community. During the year of follow-up, the control patients had more nursing home stays of six months or longer (10 vs. 3; P less than 0.05). However, there was no difference between the groups in the mean number of days spent in health care facilities (acute care hospital, nursing home, or rehabilitation hospital). Survival analysis showed a trend toward fewer deaths among the patients treated in the geriatric assessment unit, and mortality was significantly reduced in the patients considered to be at lower risk of immediate nursing home placement (P less than 0.05). We conclude that the treatment of selected elderly patients in a specialized geriatric rehabilitation unit improves function, decreases the risk of nursing home placement, and may reduce mortality. The beneficial effects on mortality and function appear greatest for patients at a moderate rather than high risk of nursing home placement.

DIFFERENCES IN BLADDER COMPLIANCE WITH TIME AND ASSOCIATIONS OF BLADDER MANAGEMENT WITH COMPLIANCE IN SPINAL CORD INJURED PATIENTS

PURPOSE Controversy continues on the optimal method of bladder management in spinal cord injured patients. We investigated the effects of bladder management on bladder compliance and changes in compliance with time. MATERIALS AND METHODS We retrospectively reviewed the charts, and video urodynamic and upper tract radiographic studies of 316 patients with spinal cord injury. Patients were categorized according to interval since injury and bladder management method, including clean intermittent catheterization, spontaneous voiding and chronic Foley catheterization. Those with upper tract complications were compared with asymptomatic controls at the bladder compliance threshold values of 10.0, 12.5, 15.0 and 20.0 cc/cm. water. RESULTS No significant differences were noted among bladder management method groups for followup, level, completeness or mechanism of injury. A bladder compliance threshold of 12.5 cc/cm. water was selected for the remaining comparisons based on the frequency of complications compared with asymptomatic controls. Patients using intermittent catheterization had a significantly higher incidence of normal compliance than the Foley management group for suprasacral, complete and incomplete injury (p<0.01). Normal bladder compliance was more common in patients with suprasacral than sacral and incomplete than complete spinal cord injury for each bladder management type. Logistic regression analysis of compliance versus bladder management and age of injury (interval since injury) revealed that intermittent catheterization and spontaneous voiding were associated more with normal compliance than Foley catheterization (RR = 9.2, 5.4 and 1.0, respectively). Combined data showed that each successively older age of injury cohort was at 23% greater risk for loss of normal compliance than the preceding cohort. Low compliance was statistically associated with vesicoureteral reflux, radiographic upper tract abnormality, pyelonephritis and upper tract stones (p<0.01, <0.01, 0.04 and <0.01, respectively). CONCLUSIONS Clean intermittent catheterization protects bladder compliance in spinal cord injured patients regardless of the level or completeness of injury and helps to prevent low compliance with time. Also, in the population studied low compliance was associated with upper tract complications. Therefore, clean intermittent catheterization is the superior method for preserving bladder compliance and preventing the upper tract complications associated with low compliance.

Interdisciplinary geriatric primary care evaluation and management: two-year outcomes.

BACKGROUND: The long‐term efficacy of interdisciplinary outpatient primary care Geriatric Evaluation and Management (GEM) has not been proven. This article focuses on results obtained during the 2 years of the study.

The Cost-Effectiveness of a Behavior Intervention with Caregivers of Patients with Alzheimer's Disease

OBJECTIVES: To examine the cost‐effectiveness of a randomized, clinical trial of a home‐based intervention for caregivers of people with dementia.

Translation of a Dementia Caregiver Support Program in a Health Care System—REACH VA

BACKGROUND Based on the National Institute on Aging/National Institute of Nursing Research Resources for Enhancing Alzheimers Caregiver Health (REACH) randomized controlled trial (REACH II), REACH VA (Department of Veterans Affairs) was the first national clinical translation of a proven behavioral intervention for dementia caregivers, running from September 2007 through August 2009. This article describes the population and outcomes of the REACH VA translation of REACH II into the VA. METHODS Clinical staff members from 24 VA Medical Center Home-Based Primary Care programs in 15 states delivered the intervention to stressed caregivers of patients with dementia. Like REACH II, the 6-month REACH VA intervention, structured through a protocol and individualized through a risk assessment, targeted education, support, and skills training to address caregiving risk areas of safety, social support, problem behaviors, depression, and health through 12 individual in-home and telephone sessions and 5 telephone support group sessions. Staff members of the Memphis VA Medical Center, Memphis, Tennessee, collected data on burden, depression, health and healthy behaviors, caregiving frustrations, social support, dementia-related behaviors, and time spent providing care and on duty. RESULTS From baseline to 6 months, caregivers reported significantly decreased burden, depression, impact of depression on daily life, caregiving frustrations, and number of troubling dementia-related behaviors. A 2-hour decrease in hours per day on duty approached significance. Caregivers (96%) believed that the program should be provided by the VA to caregivers. CONCLUSIONS This clinical translation achieved outcomes similar to the REACH II randomized controlled trial, providing clinically significant benefits for caregivers of a veteran with a progressive dementing disease. This model of caregiver support can inform public policy in providing assistance to caregivers.

Clinical significance of detrusor sphincter dyssynergia type in patients with post-traumatic spinal cord injury

OBJECTIVES To investigate the significance of categorizing detrusor sphincter dyssynergia (DSD) by type in patients with chronic spinal cord injury. METHODS A retrospective review of the charts, video-urodynamic studies, and upper tract radiographic studies of 269 patients with post-traumatic, suprasacral spinal cord injuries was performed. The patients were categorized according to the DSD type (intermittent or continuous), level and completeness of injury, intravesical pressure at leak, upper tract complications, and interval since injury. RESULTS Of the 269 patients, 20 (7.4%), 216 (80.3%), and 33 (12.3%) had no DSD, intermittent DSD, and continuous DSD, respectively. No significant association between the specific level of injury and the DSD type was found (P = 0.71). The presence of DSD was associated with complete injuries, elevated intravesical pressures, and upper tract complications (P <0.01); these associations were more prominent with continuous DSD than with intermittent DSD. The proportion of patients with no DSD, intermittent DSD, and continuous DSD was unchanged during the chronic follow-up period. CONCLUSIONS The clinical significance of DSD type is not crucial, since patients with both intermittent and continuous DSD require urodynamic surveillance and expedient treatment to minimize urologic complications. However, the presence of continuous DSD is one of several factors that may require earlier urodynamic follow-up.

Variation in utilization of cardiac procedures in the Department of Veterans Affairs health care system: Effect of race

OBJECTIVES Utilization rates for cardiac catheterization and cardiac surgery in the Department of Veterans Affairs (VA) health care system were studied to determine whether racial differences existed in a delivery plan in which access is not determined by patient finances. BACKGROUND Prior studies have demonstrated significant differences in utilization of cardiac diagnostic and therapeutic resources by white and black patients. Reasons for the reduced utilization by black patients include socioeconomic, biologic and sociocultural effects. METHODS Computerized discharge records of 30,300 patients with coronary artery disease and 1,335 patients with valvular heart disease who were discharged from any of 172 VA Medical Centers between October 1, 1990 and September 30, 1991 were studied. RESULTS For patients with coronary artery disease, utilization rates of cardiac catheterization were significantly greater for white patients (503.4 procedures/1,000 patients) than for black patients (433.2/1,000 patients), with a relative odds ratio of 1.33. Rates for surgery (179.0 vs. 124.5/1,000 patients) were also greater for whites than for blacks, with a relative odds ratio of 1.53. For the subset with valve disease, the catheterization rate was significantly greater for whites than for blacks (575.4 vs. 432.6 procedures/1,000 patients), with a relative odds ratio of 1.78. Surgical rates were not significantly different (423.8 vs. 354.6 operations/1,000 patients). Racial differences for both catheterization and surgery varied widely as a function of geographic region and the level of complexity of the local VA facility. CONCLUSIONS Racial differences in resource utilization exist in a health care system in which economic influences are minimized. The pattern of these differences depends on numerous variables and suggests both biologic and sociocultural factors as underlying causes.

The Experience of Living-Dying in a Nursing Home: Self-Reports of Black and White Older Adults

PURPOSE: The purpose of this study was to describe and compare the experiences, needs, priorities, and concerns reported by black and white nursing home residents during the living‐dying interval. The living‐dying interval is defined as the time between the knowledge of ones impending death and death itself.

Trends in burnout and related measures of organizational stress among leaders of Department of Veterans Affairs medical centers.

Psychological burnout significantly and detrimentally affects individuals and the organizations for which they work. Leaders with burnout often display characteristics that are the opposite of those required to implement major organizational change. This study was undertaken to assess the level of psychological burnout of leaders of the Department of Veterans Affairs (VA) medical centers during a period of rapid change. The objective was to quantify trends in the level of burnout and associated measures of psychological stress. Surveys of medical center directors, associate medical center directors, and chiefs of staff of each VA medical center were conducted in 1989, 1992, and 1997 to evaluate burnout, role characteristics, and job satisfaction. Burnout was measured using the Maslach Burnout Inventory and scored using the phase model of burnout. Findings demonstrated higher prevalences of more advanced levels of burnout in the 1992 and 1997 surveys than in the 1989 survey. Role clarity, perceived adequacy of resources to complete assigned tasks, and several measures of job satisfaction were lower in the 1997 survey compared to the earlier survey data. Therefore, psychological burnout and other indicators of stress increased during the 1989 to 1997 study period. These findings suggest cause for concern as the largest integrated healthcare system in the United States undertakes major organizational change to meet present and future challenges.

The Reciprocal Relationship Between Disability and Depression

n important question for both clinical research and pracA tice is whether favorable psychological attributes slow the progression of disability in older people, or conversely, whether adverse psychological attributes speed disability’s progress. Cross-sectional research has established associations between affective data and disability in older people,’ and longitudinal analysis has documented both the significant predictive value of initial depression for subsequent physical performance declines and synchrony between depression and disability self-reports in changes over time.2’3 A seminal article by Turner and Noh used path analysis of 4-year panel data to document that increased disability was a significant factor explaining increased symptoms of depression4 However, without contradicting any reciprocal causal elements in the relationship between disability and depression, the particular importance of depression in regard to functional health has been emphasized repeatedly by Ormel and colleagues3, including Kempen and whose data reliably support the conclusion that traditional ADL and IADL functional health self-report data are highly susceptible to the effects of depression. Other research has established that the associations between depression and disability are even stronger than those seemingly inevitable associations between disability and the presence of major chronic medical conditions that cause physical deteri~ration.~,’ In this issue of the Journal, Oslin et al. report further research on associations between disability and depression in older adults.’ Comparing admission data with 3-month postdischarge data following inpatient hospitalization for treatment of depression, the investigators found substantially decreased depressive symptoms and overall increased instrumental ADL and health-related quality of life. These findings are as expected for patients receiving effective treatment for depression, and they provide an important research context for further examination of within-subject longitudinal relationships between changes in disability and change in depression. The article’s inferential data analysis, estimating the magnitudes and reproducibility of these longitudinal relationships, documented significant associations between changes in depression symptoms and changes in ADL, IADL, and in most health-related quality of life data. Thus, regarding the primary research hypothesis of the study, associations between improvement in depression and improvements in disability data were both statistically reliable and, particularly when examined in observedcollateral contact data usually from spouse or children also documented clinically significant effect sizes showing parallel changes in relief from both depression and disability. There were similar findings for all eight non-ADL healthrelated quality of life indicators in relation to depression in the study. All eight improved quality of life findings were unequivocally statistically reliable and clinically substantial. Included here were findings of improvements in health perception, physical health, mental health, role emotional functioning, role physical functioning, pain, social functioning, and energy/fatigue data, all paralleling improvement in depression. Indeed, some of the improvements in health-related quality of life in association with decreased depression were even stronger than the improvements reported for the ADL and IADL data. For example, partial correlation analysis found that changes in depression accounted for a surprisingly large 12% of variance in changes in observer-reported health perception of patients, after controlling for the patient’s age, comorbidities, gender, and cognitive ability.