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Purpose: This study aims to develop ah in-depth understanding of the issues important to primary care physicians in providing care to cognitively impaired elders. Design and Methods: In-depth interviews were conducted with 20 primary care physicians. Text coded as "cognitive impairment" was retrieved and analyzed by use of grounded theory analysis techniques. Results: A patient's impaired ability to provide an accurate history and to participate in self-care hindered the usual process of care, often resulting in greater medical uncertainty and feelings of inadequacy and frustration for the physician. Shifting the goal of care from "curing" the patient's illness to "caring" for the patient's quality of life was also problematic. The doctor-patient relationship changed dramatically as others became involved in care, often with attendant ethical dilemmas related to patient autonomy and the locus of decision making. Many physicians described a deep sense of loss and grief as the personhood of patients faded. The increased complexity and prominent social and emotional issues were difficult to manage in the context of the current model of practice. Implications: Profound changes occur in the process of care with cognitively impaired patients. The increased complexity mandates an expanded model of care that addresses the prominent psychosocial and ethical aspects of care as well as the medical ones.Key Words: Primary health care, Cognitive impairment, Geriatrics

The Barnes Manuscripts Collection in the William Henry Smith Memorial Library comes from the Detroit Public Library which donated the material to the IHS because of its Indiana focus. The [...]

The Barnes Manuscripts Collection in the William Henry Smith Memorial Library comes from the Detroit Public Library, which donated the material to the IHS because of its Indiana focus. The collection contains general correspondence for several nineteenth-century Hoosiers: Charles J. Finney, Frank Morris, Carrie Thomas, and Senator and Judge D. D. Dykeman, as well as legal correspondence for several state legal firms. It also incorporates legal forms for fifty-four Indiana counties, dated from 1833 to 1925, including warranty deeds, mortgages, bonds, title abstracts, memorandums of agreement, estate inventories, and court proceedings. (1) All Henry, Randolph, and Rush County legal forms were abstracted for this article. They appear below in chronological order by county. Note that the first document abstract for Henry County describes land in Pulaski County, Indiana; the document abstract for Randolph County describes land in Ohio; and the two documents for Rush County describe land in Michigan., Henry County Legal Documents Warranty Deed.John and Mary E. Clark, Henry County, Indiana, conveyed and warranted to Erasmus M. Weaver, Tippe canoe County, Indiana, 120 acres in two sections in [...]

The Barnes Manuscripts Collection in the William Henry Smith Memorial Library comes from the Detroit Public Library which donated the material to the IHS because of its Indiana focus. The [...]

The Barnes Manuscripts Collection in the William Henry Smith Memorial Library comes from the Detroit Public Library, which donated the material to the Indiana Historical Society because of its Indiana [...]

The Barnes Manuscripts Collection in the William Henry Smith Memorial Library comes from the Detroit Public Library, which donated the material to the Indiana Historical Society because of its Indiana [...]

Purpose: Many primary care physicians find caring for elderly patients difficult. The goal of this study was to develop a detailed understanding of why physicians find primary care with elderly patients difficult. Design and Methods: We conducted in-depth interviews with 20 primary care physicians. Using an iterative approach based on grounded theory techniques, a multidisciplinary team analyzed the content of the interviews and developed a conceptual model of the difficulty. Results: Three major domains of difficulty emerged: (i) medical complexity and chronicity, (ii) personal and interpersonal challenges, and (iii) administrative burden. The greatest challenge occurred when difficulty in more than one area was present. Contextual conditions, such as the practice environment and the physician's training and personal values, shaped the experience of providing care and how difficult it seemed. Implications: Much of the difficulty participants experienced could be facilitated by changes in the health care delivery system and in medical education. The voices of these physicians and the model resulting from our analysis can inform such change. Key Words: Primary health care, Health services for the aged

A small percentage of elderly people appear to have a drinking problem and it may not be diagnosed using the standard diagnostic tool, the CAGE questionnaire. The CAGE questionnaire asks people if they have thought about cutting back on drinking, are annoyed when others suggest doing so, feel guilty about drinking or must have a drink upon awakening. A survey of 5,065 elderly patients of 88 primary care physicians found that 9% of men and 2% of women drank more than 21 drinks per week and 15% of men and 12% of women drank more than 14 or 7 drinks per week, respectively. The CAGE questionnaire did not identify half of the heavy drinkers., Objectives.--To describe potentially hazardous alcohol use among elderly patients in the primary care setting and to assess the widely used CAGE questionnaire (cut down, annoyed by criticism, guilty about drinking, eye-opener drinks) as a tool for detecting self-reported heavy and binge drinking among these patients. Design.--Cross-sectional study. Setting.--The offices of 88 primary care physicians at 21 sites in southeastern Wisconsin. Patients,---A total of 5065 consecutive consenting patients older than 60 years. Measures.--A previously validated self-administered questionnaire that included beverage-specific questions about the quantity and frequency of regular drinking in the last 3 months, the number of episodes of binge drinking (->6 drinks per occasion), and the CAGE questionnaire. Results.--Fifteen percent of men and 12% of women regularly drank in excess of limits recommended by the National Institute of Alcohol Abuse and Alcoholism (>7 drinks per week for women and >14 drinks per week for men). Nine percent of men and 2% of women reported regularly consuming more than 21 drinks per week. When we administered the CAGE questionnaire, 9% of men and 3% of women screened positive for alcohol abuse within 3 months. The CAGE performed poorly in detecting heavy or binge drinkers; fewer than half were CAGE positive when the standard cutoff of 2 positive answers was used. Conclusions.--Alcohol consumption in excess of recommended limits is common among elderly outpatients. The CAGE questionnaire alone is insufficient to detect such drinking. Asking questions on the quantity and frequency of drinking in addition to administering the CAGE increases the number of problem drinkers detected. JAMA. 1996;276:1964-1967

Hospitalization for alcohol-related conditions is common among people 65 years old and older. There were 87,147 alcohol-related hospital admissions in 1989. Examination of the 1989 Medicare Provider Analysis and Review Record indicates that total hospital charges were $233,543,500 for admissions where the primary diagnosis was alcohol-related. Alcoholic liver cirrhosis was the diagnosis in 52.4% of these cases. Charges averaged $4,514 per hospitalization, but were more than $39,000 in 466 cases. In Alaska the rate of alcohol-related hospitalizations was 77 per 10,000 population. This was the highest rate in the study. The lowest rate was 18.9 per 10,000 in Arkansas., Objective.--To determine the prevalence, geographic variation, and charges to Medicare of alcohol-related hospitalizations among elderly people in the United States. Design.--A cross-sectional prevalence study using 1989 hospital claims data from the Health Care Financing Administration (HCFA). Rates were determined using (1) hospital claims records from the HCFA's Medicare Provider Analysis and Review Record (MEDPAR) database for all Medicare Part A beneficiaries aged 65 years and older; (2) county population estimates for 1985 from the Bureau of the Census; and (3) per capita consumption of alcohol by state in 1989 as estimated by the US Department of Health and Human Services. Setting.--Data include all hospital inpatient Medicare Part A beneficiaries aged 65 years and older in the United States in 1989. Results.--The prevalence of alcohol-related hospitalizations among people aged 65 years and older nationally in 1989 was 54.7 per 1 0 000 population for men and 14.8 per 1 0 000 for women. Comparison with hospital records showed that MEDPAR data had a sensitivity of 77% to detect alcohol-related hospitalizations. There was considerable geographic variation; prevalence ranged from 18.9 per 10 000 in Arkansas to 77.0 per 1 0 000 in Alaska. A strong correlation existed between alcohol-related hospitalizations and per capita consumption of alcohol by state (Spearman correlation coefficient, .64; P

Objectives: Medications and alcohol are both used commonly by older people. Thus, the potential for adverse drug-alcohol interactions is very high in this population, but data on actual concurrent use of alcohol and medicines likely to interact with alcohol are lacking. The objectives of this study were to determine the frequency of alcohol and medication use and the potential for specific adverse drug-alcohol interactions in residents of retirement communities. Design: Cross-sectional study using a mailed survey. Setting. Three retirement communities in suburban Milwaukee, Wisconsin. Participants: All 454 independently living residents of the communities were surveyed. Of these, 311 residents (68%) returned completed questionnaires. Mean age of respondents was 83 [+ or -] 6 years, 100% were white, 77% were female. Measurements: The questionnaire included alcohol use questions adapted from the Khavari questionnaire and the CAGE questionnaire to screen for alcohol abuse. Respondents were asked to list all prescription and nonprescription medications. Results: Thirty-eight percent of the population reported using both alcohol and a skin risk medication. Six percent had seven or more drinks per week and took a high risk medication. High risk drugs commonly used by drinkers were antihypertensives in 50%, aspirin in 27%, nonsteroidal antiinflammatory drugs in 20%, medication for congestive heart failure in 18%, antacids or blockers in 16%, sedatives in 11%, narcotics in 5%, and warfarin in 5%. Conclusions: Concurrent use of alcohol and medications is common in residents of these retirement communities. Many of the drugs taken by regular drinkers have potential for adverse drug-alcohol interactions even at moderate levels of alcohol use. This represents a strong possibility of adverse outcomes and a need for increased awareness on the part of both the public and physicians of the potential for interactions between drugs and alcohol. (1995;43:1021-1025) Wendy L. Adams, Zabloeld VA Medical Center, 5000 W National Ave, 111P, Milwaukee, WI 53211.