Increased use of emergency services by older people after health screening

Background: evaluation of the 'Keep Well At Home' (KWAH) Project in West London indicated that a programme of screening persons aged 75 and over had not reduced rates of emergency attendances and admissions to hospital. However, coverage of the target population was incomplete. The present analysis addresses 'efficacy'-whether individuals who completed the screening protocol as intended did subsequently use Accident & Emergency (A&E) services less often. Methods: the target population was divided into five groups, depending on whether an individual had completed none, one or both phases of screening, and whether deviations from the protocol related to incomplete coverage or refusal to participate further. We ascertained use of emergency services before screening and for up to 3 years afterwards by linkage of records from KWAH to those of local A&E Departments. Patterns of emergency care were examined as crude races and, via proportional hazards models, after adjustment for available confounders. Results: there was an increase of 51% (95% CI 22-86%) in the crude rate of emergency admissions in the year after first-phase screening compared with the 12 months before assessment. This was most obvious in individuals deemed at high risk who also underwent the second-phase assessment (adjusted hazard ratio relative to individuals not 'at risk'= 2.33; 95% CI 1.59-3.42). Conclusions: the available data do not allow us to distinguish between several possible explanations for the paradoxical increase in use of emergency services. However, what seem to be sensible policies do not necessarily have their intended effects when implemented in practice.

Controlled trial of multidisciplinary care teams for acutely ill medical inpatients: enhanced multidisciplinary care

Background: Acute hospital general medicine services care for ageing complex patients, using the skills of a range of health-care providers. Evidence suggests that comprehensive early assessment and discharge planning may improve efficiency and outcomes of care in older medical patients. Aim: To enhance assessment, communication, care and discharge planning by restructuring consistent, patient-centred multidisciplinary teams in a general medicine service. Methods: Prospective controlled trial enrolling 1538 consecutive medical inpatients. Intervention units with additional allied health staff formed consistent multidisciplinary teams aligned with inpatient admitting units rather than wards; implemented improved communication processes for early information collection and sharing between disciplines; and specified shared explicit discharge goals. Control units continued traditional, referral-based multidisciplinary models with existing staffing levels. Results: Access to allied health services was significantly enhanced. There was a trend to reduced index length of stay in the intervention units (7.3 days vs 7.8 days in control units, P = 0.18), with no change in 6-month readmissions. in-hospital mortality was reduced from 6.4 to 3.9% (P = 0.03); less patients experienced functional decline in hospital (P = 0.04) and patients' ratings of health status improved (P = 0.02). Additional staffing costs were balanced by potential bed-day savings. Conclusion: This model of enhanced multidisciplinary inpatient care has provided sustainable efficiency gains for the hospital and improved patient outcomes.

The effect of depression on balance decline in mature women

Depression has been identified as a risk factor for falls, and a change in balance ability over time has yet to be investigated. This study aimed to identify if, over a 3-year period, balance ability changed in 26 women who were on medication for depression, compared to 26 non-depressed women. The two groups were matched for age, number of co-morbidities, activity level, medications, and height. All participants were simultaneously enrolled in a larger, longitudinal study of ageing. Balance measures included the Functional Reach (FR) test, Lateral Reach (LR) test, Step Test (ST), Timed Up and Go, and the Modified Clinical Test of Sensory Integration and Balance, Unilateral Stance (ULS) and Limit of Stability (LOS) laboratory tests. Results showed a significant difference between the groups on ST, right ULS (eyes closed) and forward end point excursion of the LOS. There was no difference in the number of falls between groups. Analysis of the depressed group alone showed that right FR declined significantly and left and right LR tended towards decline, but not differently between groups. There was no between-group differences for these measures. There was no significant decline in non-depressed women for any measurement. Depressed women have less ability to maintain their balance than non-depressed women, and should be encouraged to participate in appropriate activities known to improve or maintain balance.