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To determine whether the rate of falls and associated serious injuries in a hospital aged care setting can be reduced using a multistrategy prevention approach.Three-year quality improvement project comparing data at baseline (2001) and at 2-year follow-up (2003) after interventions to reduce falls. All patients admitted to the Aged Care Services wards at Caulfield General Medical Centre, Melbourne, between January 2001 and December 2003 were included.Multistrategy approach phased in over 3 months from September 2001 and involving data gathering, risk screening with appropriate interventions, work practice changes, environmental and equipment changes, and staff education.Total number of falls; number of falls resulting in serious injuries (fractures, head injuries, death); staff compliance with the risk assessment.Over a 2-year period, there was a 19% reduction in the number of falls per 1000 occupied bed-days (OBDs) (12.5 v 10.1; P = 0.001) and a 77% reduction in the number of falls resulting in serious injuries per 1000 OBDs (0.73 v 0.17; P0.001). Staff compliance with completing the falls risk assessment tool increased from 42% to 70%, and 60% of staff indicated they had changed their work practices to prevent falls.A multistrategy falls prevention program in an aged care hospital setting produced a significant reduction in the number of falls and a marked reduction in serious fall-related injuries. Incorporating a falls prevention program into all levels of an organisation, as part of daily care, is crucial to the success and sustainability of falls prevention.

Severe fecal incontinence remains a disabling condition for the patient and a major therapeutic challenge for the physician. A series of observational studies have indicated that placement of an artificial bowel sphincter is associated with marked improvement of continence and quality of life. We have performed a prospective, randomized, controlled trial to evaluate the effect of placement of an artificial bowel sphincter (Acticon Neosphincter) on continence and quality of life in a group of severely incontinent adults.Fourteen adults (male:female, 1:13; age range, 44-75 years) were randomized to placement of the artificial bowel sphincter or to a program of supportive care and were followed for six months from operation or entry into the study. The principal outcome measure was the level of continence, measured with the Cleveland Continence Score, which provides a scale from 0 to 20, representing perfect control through to total incontinence. Secondary outcome measures were perioperative and late complications in the artificial bowel sphincter group, and the changes in quality of life in both groups.In the control group, the Cleveland Continence Score was not significantly altered, with an initial value of 17.1 +/- 2.3 and a final value of 14.3 +/- 4.6 at six months. The artificial bowel sphincter group showed a highly significant improvement, changing from 19.0 +/- 1.2 before placement to 4.8 +/- 4.0 at six months after placement. One patient in the artificial bowel sphincter group had failure of healing of the perineal wound and explantation of the device (14 percent explantation rate). There were two other significant perioperative events of recurring fecal impaction initially after placement in one patient and additional suturing of the perineal wound in another. There were major improvements in the quality of life for all measures in the artificial bowel sphincter group. There was significant improvement in all eight subscales of the Medical Outcome Study Short Form-36 measures. The American Medical Systems Quality of Life score was raised from 39 +/- 6 to 83 +/- 14 and the Beck Depression Inventory showed reduction from a level of mild depression (10.8 +/- 9.3) to a normal value (6.8 +/- 8.7). No significant changes in any of the quality of life measures occurred for the control group.Through a prospective, randomized trial format, we have shown that placement of an artificial bowel sphincter is safe and effective when compared with supportive care alone. Perioperative and late problems are likely to continue to occur and between 15 percent and 30 percent of patients may require permanent explantation. For the remainder, the device is easy and discrete to use, highly effective in achieving continence, and able to generate a major improvement in the quality of life.

Objective: To evaluate the efficacy of estrogen therapy in the treatment of postmenopausal women with symptoms and signs associated with urogenital atrophy, by meta-analysis of available data. Methods: We searched the literature (Excerpta Medica, Biosis, MEDLINE, and hand search) for studies published between January 1969 and April 1995. Criteria for inclusion were English-language articles, peer-reviewed original publications, and urogenital atrophy assessed by at least one of the following outcomes: patient symptoms, physician report, pH, or cytologic change. Data had to allow comparison between treated and control groups in controlled trials or an estimated change from baseline in uncontrolled series. Meta-analytic methods were applied separately to controlled clinical trials and uncontrolled studies. Results: Of the 77 relevant articles reviewed, nine contained ten randomized controlled trials. Meta-analysis of these using the Stouffer method revealed a statistically significant benefit of estrogen therapy for all outcomes studied. In 54 uncontrolled case series, the patient symptoms were treated by 24 different treatment modalities. All routes of administration appeared to be effective and maximum benefit was obtained between 1 and 3 months after the start of treatment. As expected, the least systemic absorption of estrogen was seen with estriol (administered orally or vaginally), then vaginal estradiol as measured by pretherapy and posttherapy serum estradiol and estrone. Conclusion: Estrogen is efficacious in the treatment of urogenital atrophy and low-dose vaginal estradiol preparations are as effective as systemic estrogen therapy in the treatment of urogenital atrophy in postmenopausal women.

This is an account of the International Continence Society's ContiNet—the web server linking up continence organisations worldwide with provision to upload or download vast data stores of information on continence via e-mail, FTP, mailing lists, and special tools to seek information using “search engines.” Special communication devices using internet voice/phone mail and real-time “text” or “voice” chats permit conversation globally over normal phone lines linked to the Net at local telephone rates. Special features of ContiNet include announcements of upcoming conventions, information for professionals and laypeople, and the capability to conduct research via the net and conduct consultations and discussions via newsgroups. In-built devices requiring special IDs and passwords permit privacy and security for users. Simple instructions are provided on how to get your PC up and running and get connected to fellow members of ICS, link up with national continence societies, or simply surf for professional enrichment and leisure. With the advent of advanced multimedia capabilities, the current poor quality videoconferencing on the Net will be replaced by excellent videophones by 1998. Neurourol. Urodynam. 16:609–616, 1997. © 1997 Wiley-Liss, Inc.

Seventy‐eight community residing patients (63% women) aged 60 years or older attending an outpatient continence clinic were randomised to receive immediate conservative (non‐surgical, non‐pharmacological) management or to a control group in which treatment was deferred for two months. All patients were followed up for 12 months. Outcome was assessed by three day bladder charts (objectively) and by patient questionnaires (subjectively). The average age was 74.8 yean and mean duration of incontinence was 7.3 years with 60% not having had any previous treatment. After four months of active treatment incontinence was cured or improved subjectively in 88% of patients and objectively in 58% of patients. This was sustained through to the 12 month follow‐up. Severity of incontinence was significantly reduced on a range of variables. Conservative management of elderly community‐based patients can be very effective, taking up to four months to see peak benefit which can be sustained over a 12 month period with little additional input. The improvement seen in the control group perhaps reflects the importance of support and destigmatisation of this condition. Copyright © 1994, Wiley Blackwell. All rights reserved

Incontinence is a distressing, complex health problem which disproportionately affects older people. It is commonly endured silently, with many sufferers and carers not receiving appropriate support. In addition, incontinence is generally poorly managed both by families and health-care professionals, and is a major contributing factor in the institutionalization of the elderly. This paper argues that incontinence experienced in later life is often multifactorial in nature, thus health care professionals need to be cognizant of the many causes of incontinence, as well as the impact of lifestyle factors and 'normal' ageing processes. Incontinence in the community-based elderly can be cured or significantly improved in over 60% of cases with conservative management. Unfortunately community and professional attitudes and ignorance remain major barriers to continence.

Parkinson's disease is frequently associated with overt and subclinical swallowing disorders. It is not clear whether these are responsive to levodopa therapy. As levodopa is usually prescribed to be taken after meals, we hypothesised that swallowing at meal time would improve by administration of levodopa one hour prior to meals. Twenty-one subjects with idiopathic Parkinson's disease treated with levodopa were randomised to receive their levodopa for one week at the same time as their meals (A) or one hour before (B). A modified barium swallow (MBS) was then performed at the usual meal time to assess swallowing function. Subjects were crossed over to the other treatment arm and the study repeated a week later. Subjects were then crossed back to the original randomisation and a third study performed. There were improvements in oropharyngeal transit time when subjects were given levodopa one hour prior to meals. This was particularly pronounced with solid food consistencies (mean time for B-12.31 sees, for A = 16.39 sees, P = 0.026 using ANOVA). Aspiration, number of swallows to clear bolus, number of tongue elevations per swallow, place of bolus at initiation of swallow and degree of vallecular pooling were not significantly affected. Some evidence of improved swallowing when levodopa is taken one hour prior to meals was demonstrated.

To evaluate the efficacy of estrogen therapy in the treatment of postmenopausal women with symptoms and signs associated with urogenital atrophy, by meta-analysis of available data.We searched the literature (Excerpta Medica, Biosis, MEDLINE, and hand search) for studies published between January 1969 and April 1995. Criteria for inclusion were English-language articles, peer-reviewed original publications, and urogenital atrophy assessed by at least one of the following outcomes: patient symptoms, physician report, pH, or cytologic change. Data had to allow comparison between treated and control groups in controlled trials or an estimated change from baseline in uncontrolled series. Meta-analytic methods were applied separately to controlled clinical trials and uncontrolled studies.Of the 77 relevant articles reviewed, nine contained ten randomized controlled trials. Meta-analysis of these using the Stouffer method revealed a statistically significant benefit of estrogen therapy for all outcomes studied. In 54 uncontrolled case series, the patient symptoms were treated by 24 different treatment modalities. All routes of administration appeared to be effective and maximum benefit was obtained between 1 and 3 months after the start of treatment. As expected, the least systemic absorption of estrogen was seen with estriol (administered orally or vaginally), then vaginal estradiol as measured by pretherapy and posttherapy serum estradiol and estrone.Estrogen is efficacious in the treatment of urogenital atrophy and low-dose vaginal estradiol preparations are as effective as systemic estrogen therapy in the treatment of urogenital atrophy in postmenopausal women.

We aimed to study the impact of conservative non-pharmacological, non-surgical management on quality of life in elderly incontinent patients. Community-dwelling patients age 60 years or older were randomized to receive immediate or delayed conservative management. A number of questions relating to quality of life were administered at admission and then at 2, 4, 8 and 12 months. By 4 months, incontinence was cured in 25% and improved in 63% of patients. The frequency and severity of incontinence was reduced (p < 0.001), and deferment time was improved (p < 0.01). There were statistically significant improvements in subjective quality of life measures at 4 and 12 months involving depression (p < 0.001), isolation (p < 0.03), embarrassment (p < 0.001), laundry (p < 0.001) and smell (p < 0.02) when comparing these variables with initial assessment. This effect did not appear to be a placebo effect as evidenced by comparison with the delayed intervention group, and was sustained over 12 months. There are significant short- and long-term benefits to the quality of life of older patients with incontinence when treated by conservative measures. Intervention studies should measure and report quality of life as an outcome variable.

We sought to ascertain whether patients with Parkinson's disease without symptoms of dysphagia have abnormalities of swallowing, and to describe the characteristics as seen on clinical examination and videofluoroscopy. Patients with stable Parkinson's disease were interviewed for symptoms of dysphagia and 16 asymptomatic patients were enrolled. Whilst on their usual medication, an examination of facial, tongue and palatopharyngeal musculature was made, and a modified barium swallow performed. All patients had at least one abnormality on videofluoroscopic examination of their swallowing. Three patients showed aspiration and 14 had evidence of vallecular residue considered a risk for aspiration. Oropharyngeal transit time was invariably prolonged as was delay in the initiation of swallow. The majority of patients also demonstrated an increased number of tongue elevations and number of swallows to clear their pharynx of the bolus. Despite having no symptoms of dysphagia, the patients demonstrated widespread abnormalities of swallowing.

There are various circumstances where the traditional face to face setting for multidisciplinary meetings is not practical or possible. This includes departments which have a responsibility covering a large geographic region. This paper describes an inexpensive, cost-effective and novel way of conducting multidisciplinary meetings using the telephone conference facility. Team members based in the community are 'linked' by telephone to other members of the hospital-based Aged and Extended Care Department. These conferences led to a significant increase in the referral rate of community-based patients for fuller multidisciplinary geriatric assessment. It also provided a forum for education, exchange of ideas and development of new policy. Other uses for telelinking are highlighted, particularly its successful applications for linking together isolated and handicapped elderly people in the community.

Urinary incontinence is a common, distressing and costly condition afflicting up to 25% of hospitalized patients and 60% of nursing home patients most of whom are elderly. It is important for nurses and doctors to have a good knowledge base and positive attitudes in order for them to deal optimally with this condition. A survey of 106 nurses and doctors was conducted in a large general acute teaching hospital. The survey assessed both attitudes and knowledge to various aspects of the causes, investigation and management of incontinence. It was found that (1) most staff had little teaching on this subject, (2) most staff had a poor knowledge base as to causes, investigation and management, (3) about 40% of nurses felt urinary incontinence was an attention seeking act, (4) State enrolled nurses who had the greatest contact with such patients had the poorest knowledge base. The results of this survey support the need for more undergraduate and inservice training, and particularly for the appointment of hospital based Clinical Nurse Specialists, with expertise in continence management.