Potentially inappropriate prescribing in an Irish elderly population in primary care.

AIMS Screening tools have been formulated to identify potentially inappropriate prescribing (IP) in older people. Beers’ criteria are the most widely used but have disadvantages when used in Europe. New
IP screening tools called Screening Tool of Older Person’s Prescriptions (STOPP) and Screening Tool to Alert doctors to Right Treatment (START) have been developed to identify potential IP and potential prescribing omissions (PPOs). The aim was to measure the prevalence rates of potential IP and PPOs in primary care using Beers’ criteria, STOPP and START.

METHODS
Case records of 1329 patients 65 years old from three general practices in one region of southern Ireland were studied. The mean age SD of the patients was 74.9 6.4 years, 60.9% were female. Patients’current diagnoses and prescription medicines were reviewed and the Beers’ criteria, STOPP and START tools applied.

RESULTS
The total number of medicines prescribed was 6684; median number of medicines per patient was ?ve (range 1–19). Overall, Beers’ criteria identi?ed 286 potentially inappropriate prescriptions in 18.3% (243) of patients, whilst the corresponding IP rate identi?ed by STOPP was 21.4% (284), in respect of 346 potentially inappropriate prescriptions. A total of 333 PPOs were identi?ed in 22.7% (302) of patients using the START tool.

CONCLUSION
Potentially inappropriate drug prescribing and errors of drug omission are highly prevalent among older people living in the community. Prevention strategies should involve primary care doctors and community pharmacists.

Effects of the Interaction Between Reaction Component of Personal Need for Structure and Role Perceptions on Employee Attitudes in Long-Term Care for Elderly People

This study examined the interaction of reaction component of personal need for structure (reaction to lack of structure, RLS) and role perceptions in predicting job satisfaction, job involvement, affective commitment, and occupational identity among employees working in long-term care for elderly people. High-RLS employees experienced more role conflict, had less job satisfaction, and experienced lower levels of occupational identity than did low-RLS employees. We found individual differences in how problems in roles affected employees' job attitudes. High-RLS employees experienced lower levels of job satisfaction, job involvement, and affective commitment, irrespective of role-conflict levels. Low-RLS employees experienced detrimental job attitudes only if role-conflict levels were high. Our results suggest that high-RLS people benefit less from low levels of experienced role conflicts.

Climate Adaptation: The future of extra-care housing for the elderly in the United Kingdom.

This paper describes the result of a project to develop climate adaptation design strategies funded by the UK’s Technology Strategy Board. The aim of the project was to look at the effects of climate change in the distant future (2080) on a vulnerable group such as older people with special needs and see how architectural design strategies and technologies may be used today to help mitigate problems ahead caused by climate change.
Older people are the most vulnerable sector of society and are particularly at risk in extreme weather, either excess cold in winter or continual high temperatures in summer. In the UK it is predicted that average temperatures may rise by as much as 8 degrees in Summer by 2080 and there will be a 20% greater chance of extreme weather events. This will place extreme stress on the building stock which is designed for today’s mild maritime climate.
The project took a current proposal for an extra-care home for the elderly designed to 2010 regulations and developed a road map to 2080 using climate models developed by the UK Meteorological Office. This allowed the current design to be assessed using future climatic data, proposals for improvement of the scheme to be made within existing constraints and also a new scheme to be developed from first principals using this data, and projections of new technologies that will be available. By comparing these schemes, the approach allowed a reassessment of the initial scheme, and allowed a new design to be developed that offered a more flexible solution incorporating future retrofit which allows new renewable technologies for heating, cooling and water storage to be added at a later date.

Substituting home care for hospitalization:The role of a quick response service for the elderly

The purpose of the present study was to examine the role of a rapid access home-based service as a means for the elderly to avoid admission to an acute-care hospital. The setting for the study included emergency departments in three acute care hospitals and a home care program in a mid-size Canadian city. Multiple sources of information were obtained to evaluate the service. Hospital emergency department records and home care records were reviewed. Patients who participated in the service (n=96) and physicians and nurses (n =119) who had involvement with the service were surveyed appraising the service in terms of relevance, access, quality and coordination. Study results revealed that elderly women with multiple health problems who lived alone were the most frequent users of the service. The majority of the patients admitted to the service presented with problems of a functional nature that were the result of a fall or mobility problems. The results indicated that the service did avert hospital admissions and facilitated a process by which patients could avoid the intermediate step of hospitalization before placed in a higher level of care or returning to previous levels of functioning. Economic analysis indicated that the value of the service stemmed from the benefits to patients and caregivers rather than from cost savings offered to acute care hospitals.

Prosthodontic care for elderly patients

For older patients, clinicians should consider maintaining teeth and using functionally-orientated treatment strategies as an alternative to removable prostheses. When the remaining dentition has a poor prognosis, key teeth should be preserved as overdenture abutments and a gradual transition to edentulousness planned. Where complete dentures are provided, these can be retained using dental implants to overcome many of the problems associated with conventional replacement dentures.

CLINICAL RELEVANCE: The elderly population of today is better informed and more demanding of oral healthcare providers than previous generations. Clinicians should be aware of all the prosthodontic treatment options available for older patients.

Addressing Bed Costs for the Elderly: A New Methodology for Modelling Patient Outcomes and Length of Stay

The proportion of elderly in the population has dramatically increased and will continue to do so for at least the next 50 years. Medical resources throughout the world are feeling the added strain of the increasing proportion of elderly in the population. The effective care of elderly patients in hospitals may be enhanced by accurately modelling the length of stay of the patients in hospital and the associated costs involved. This paper examines previously developed models for patient length of stay in hospital and describes the recently developed conditional phase-type distribution (C-Ph) to model patient duration of stay in relation to explanatory patient variables. The Clinics data set was used to demonstrate the C-Ph methodology. The resulting model highlighted a strong relationship between Barthel grade, patient outcome and length of stay showing various groups of patient behaviour. The patients who stay in hospital for a very long time are usually those that consume the largest amount of hospital resources. These have been identified as the patients whose resulting outcome is transfer. Overall, the majority of transfer patients spend a considerably longer period of time in hospital compared to patients who die or are discharged home. The C-Ph model has the potential for considering costs where different costs are attached to the various phases or subgroups of patients and the anticipated cost of care estimated in advance. It is hoped that such a method will lead to the successful identification of the most cost effective case-mix management of the hospital ward.

Pharmaceutical care of patients with congestive heart failure: Interventions and outcomes

We evaluated a structured pharmaceutical care program for elderly patients (> 65 yrs) with congestive heart failure (CHF) based on objective measures of disease control, quality of life, and use of health care facilities in a randomized, controlled, longitudinal, prospective clinical trial. The 42 patients in group A received education from a pharmacist on the disease and its treatment, and lifestyle changes that could help control symptoms. Patients also were encouraged to monitor their symptoms and comply with prescribed drug therapy. If necessary, dosage regimens were simplified in liaison with hospital physicians. The 41 control patients (group B) received standard care. The following outcome measures were assessed in all patients at baseline (before the start of the trial) and at 3, 6, 9, and 12 months: 2-minute walk test, blood pressure, body weight, pulse, forced vital capacity, quality of life [disease-specific (Minnesota Living with Heart Failure questionnaire) and generic (SF-36)], knowledge of symptoms and drugs, compliance with therapy, and use of health care facilities (hospital admissions, visits to emergency room, emergency calls). Patients in group A showed improved compliance with drug therapy, which in turn improved their exercise capacity compared with those in group B; education on management of symptoms, lifestyle changes, and dietary recommendations were also of benefit. Group A patients significantly improved knowledge of their drug therapy over the 12-month study and had fewer hospital admissions compared with group B patients. They also had improved outcomes compared with group B, despite the small samples. An extension of this trial to other sites with pooling of results would provide additional evidence of the value of this structured program in elderly patients with CHF.

The Evaluation of an Interdisciplinary Pain Protocol in Long Term Care

Objectives: To evaluate the effectiveness of (1) dissemination strategies to improve clinical practice behaviors (eg, frequency and documentation of pain assessments, use of pain medication) among health care team members, and (2) the implementation of the pain protocol in reducing pain in long term care (LTC) residents. Design: A controlled before-after design was used to evaluate the effectiveness of the pain protocol, whereas qualitative interviews and focus groups were used to obtain additional context-driven data. Setting: Four LTC facilities in southern Ontario, Canada; 2 for the intervention group and 2 for the control group. Participants: Data were collected from 200 LTC residents; 99 for the intervention and 101 for the control group. Intervention: Implementation of a pain protocol using a multifaceted approach, including a site working group or Pain Team, pain education and skills training, and other quality improvement activities. Measurements: Resident pain was measured using 3 assessment tools: the Pain Assessment Checklist for Seniors with Limited Ability to Communicate, the Pain Assessment in the Communicatively Impaired Elderly, and the Present Pain Intensity Scale. Clinical practice behaviors were measured using a number of process indicators; for example, use of pain assessment tools, documentation about pain management, and use of pain medications. A semistructured interview guide was used to collect qualitative data via focus groups and interviews. Results: Pain increased significantly more for the control group than the intervention group over the 1-year intervention period. There were significantly more positive changes over the intervention period in the intervention group compared with the control group for the following indicators: the use of a standardized pain assessment tool and completed admission/initial pain assessment. Qualitative findings highlight the importance of reminding staff to think about pain as a priority in caring for residents and to be mindful of it during daily activities. Using onsite champions, in this case advanced practice nurses and a Pain Team, were key to successfully implementing the pain protocol. Conclusions: These study findings indicate that the implementation of a pain protocol intervention improved the way pain was managed and provided pain relief for LTC residents.

Characterisation of the frequent exacerbator phenotype in COPD patients in a large UK primary care population

BACKGROUND: The 'frequent exacerbator' is recognised as an important phenotype in COPD. Current understanding about this phenotype comes from prospective longitudinal clinical trials in secondary/tertiary care with little information reported in primary care populations.

AIMS: To characterize the frequent-exacerbator phenotype and identify associated risk factors in a large UK primary care COPD population.

METHODS: Using a large database of primary care patients from 80 UK general practices, patients were categorised using GOLD 2014 criteria into high and low risk groups based on exacerbation history. A multivariate logistic regression model was used to investigate covariates associated with the frequent-exacerbator phenotype and risk of experiencing a severe exacerbation (leading to hospitalisation).

RESULTS: Of the total study population (n = 9219), 2612 (28%) fulfilled the criteria for high risk frequent-exacerbators. Independent risk factors (adjusted odds ratio [95% CI]) for ≥2 exacerbations were: most severely impaired modified Medical Research Council (mMRC) dyspnoea score (mMRC grade 4: 4.37 [2.64-7.23]), lower FEV1 percent predicted (FEV1 <30%: 2.42 [1.61-3.65]), co-morbid cardiovascular disease (1.42 [1.19-1.68]), depression (1.56 [1.22-1.99]) or osteoporosis (1.54 [1.19-2.01]), and female gender (1.20 [1.01-1.43]). Older patients (≥75 years), those with most severe lung impairment (FEV1 <30%), those with highest mMRC score and those with co-morbid osteoporosis were identified as most at risk of experiencing exacerbations requiring hospitalisation.

CONCLUSIONS: Although COPD exacerbations occur across all grades of disease severity, female patients with high dyspnoea scores, more severely impaired lung function and co-morbidities are at greatest risk. Elderly patients, with severely impaired lung function, high mMRC scores and osteoporosis are associated with experience of severe exacerbations requiring hospitalisation.