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Despite evidence that doctor-patient communication affects important patient outcomes, patient expectations are often not met. Communication is especially important in terminal illness, when the appropriate course of action may depend more on patient values than on medical dogma. We sought to describe the issues important to terminally ill patients receiving palliative care and to determine whether patient characteristics influence the needs of these patients. We utilized a multimethod approach, first conducting interviews with 22 terminally ill individuals, then using these data to develop a more structured instrument which was administered to a second population of 56 terminally ill patients. Patient needs and concerns were described and associations between patient characteristics and issues of importance were evaluated. Seven key issues were identified in the initial interviews: change in functional status or activity level; role change; symptoms, especially pain; stress of the illness on family members; loss of control; financial burden and conflict between wanting to know what is going on and fearing bad news. Overall, respondent needs were both disease- and illness-oriented. Few easily identifiable patient characteristics were associated with expressed concerns or needs, suggesting that physicians need to individually assess patient needs. Terminally ill patients receiving palliative care had needs that were broad in scope. Given that few patient characteristics predicted responses, and that the majority opinion may not accurately reflect that of an individual patient, health care providers must be aware of the diverse concerns among this population and individualize assessment of each patient's needs and expectations. [ABSTRACT FROM AUTHOR]

The "graying" of America has resulted in dentists treating increased numbers of elderly patients, 60% of whom are dentate. Since the majority of elderly persons has at least one chronic disease, this chapter addresses critical aspects of history taking and risk assessment for the geriatric dental patient. Self-administered questionnaires have limitations in the geriatric population and the medical history must emphasize functional status, medication use, social support, and financial considerations. Common chronic diseases which potentially increase the risk of adverse events for the geriatric patient undergoing dental care are discussed. Effective dentist-physician communication is pivotal to the successful management of the elderly dental patient.

The ability to limit the trunk flexion associated with an anteriorly directed trip is a determinant of successful recovery of recovering postural stability and is subservient to rapidly detecting and correcting the imposed trunk flexion in the available time. This experiment tested the hypothesis that subjects demonstrating greater eccentric trunk/hip extension strength, faster voluntary reaction times, shorter automatic response latencies, and larger automatic activation amplitudes of the paraspinal muscles, would demonstrate less trunk flexion following a trip. An isokinetic protocol was used to obtain measures of trunk extension strength, response latencies, and activation amplitudes. Motion analysis methods were used to quantify trunk kinematics during the positioning phase of recovery following an induced trip. Statistically significant and functionally meaningful relationships between eccentric strength of the trunk/hip extensors, voluntary-reaction time, automatic reaction time, activation amplitudes and trunk kinematics failed to emerge. Thus, although automatic and voluntary paraspinal muscle responses have the potential to limit trunk flexion during the positioning phase of recovery, the task may be achieved through intersegmental factors or other muscular sources such as the gluteus maximus and hamstrings.

This study examined the validity of the assumption of bilateral lower extremity joint moment symmetry during the sit-to-stand motion for a group of young (n = 7) and a group of elderly (n = 7) female subjects. Two force plates and a motion analysis system were used to determine peak joint moments at the ankles, knees, and hips following liftoff from a chair. Statistically, bilateral asymmetries in peak joint moments were found at the knee joint in the young group [a right to left difference of 0.43% BW x BH (body weight x body height)] and at the hip joint in both subject groups (differences of 0.20% BW x BH and 1.09% BW x BH for the young and elderly subjects, respectively). Subsequent data analysis, using an algorithm that assumed bilateral ground reaction force (GRF) symmetry, was performed to determine whether the bilateral differences were a result of kinematic or GRF asymmetry. It was concluded from these results that both the kinematic and GRF data account for the bilateral asymmetry. The results of the subsequent analysis also showed that the method which assumed bilateral GRF symmetry underestimated the peak joint moments at the ankles, knees, and hips, with the greatest difference between methods being 0.10% BW x BH for the ankle joint. The results of this study suggest that the assumption of bilateral symmetry of lower extremity joint moments during the sit-to-stand is not valid. However, the biomechanical significance of the errors associated with assuming symmetry must also be taken into account.(ABSTRACT TRUNCATED AT 250 WORDS)

Background: Cardiopulmonary resuscitation (CPR) is a dramatic, costly, and often futile intervention whose appropriate use is under scrutiny. Physicians often ask patients and families to make decisions about resuscitation for themselves or loved ones. Clinical variables and personal beliefs may influence physician recommendations about CPR., Methods: Physicians (N = 451) at a tertiary care hospital were surveyed to determine the following: (1) the factors they consider when recommending in-hospital CPR, (2) the conditions under which they discuss CPR with patients, (3) their recent participation in CPR attempts, (4) their perceptions of its effectiveness, (5) their personal wishes regarding their own resuscitation, and (6) their personal and professional characteristics., Results: The patient's self-reported wishes about resuscitation and physician judgment of medical utility were the most important influences on physician recommendations. Most physicians believe that patients with metastatic cancer or late Alzheimer's disease should not be resuscitated. Age alone was not viewed as an important clinical consideration. Guidance from hospital policies and ethics committees had the least influence on physicians. Physicians overestimated the likelihood of survival to hospital discharge after in-hospital CPR by as much as 300% for some clinical situations and predicted an overall success rate of 30%., Conclusion: These findings suggest that most physicians are thoughtful and discriminating in their recommendations to patients about CPR. Patient's wishes are of paramount importance, followed by physician judgment of medical utility. However, physicians do overestimate the efficacy of CPR and may thus misrepresent the potential utility of this therapy to patients and their families.

Background: Injuries most frequently related to accidents in elderly persons are falls during locomotion and stair ascent and descent. Although numerous risk factors have been related to falling behavior, effective strategies to predict and prevent falls have not evolved. The rationale underlying this study was that systematic experimental and analytical investigation of the effects of perturbations during locomotion and the subsequent requisites for recovery could lead to the development of clinically relevant evaluation(s) capable of identifying a predisposition to falling. The present study is the first biomechanical investigation of recovery from an anteriorly directed stumble., Methods: Seven healthy, young males participated in this study. While the subjects walked along a walkway in the laboratory, stumbles were unexpectedly induced using a mechanical obstacle. Videotape records of these trials were analyzed and selected sagittal plane kinematics extracted., Results: The perturbation caused an increase in the maximum trunk flexion angle from 4.3 degrees (control) to 18.3 degrees (p = .057), and this change was significantly associated with preperturbation walking velocity (p = .036). The maximum hip and knee flexion angles increased from 26 to 47 degrees (p = .039) and from 60 to 89 degrees (p = .009), respectively. The increases in maximum hip flexion velocity (79%) and maximum knee extension velocity (36%) were not significant., Conclusions: Identification of the principal elements of control during perturbed locomotion can contribute to understanding the relationship between specific age-related performance deficits and some types of falling behavior. The results suggest that recovery from a stumble is dependent upon lower extremity muscular power and the ability to restore control of the flexing trunk.

Objective: The primary purpose of this preliminary investigation was to determine the functional relationship between selected information processing time and response execution variables and measures of postural stability in elderly women. A secondary purpose was to explore the efficacy of a neuromotor model using selected variables to retrospectively identify subjects with a self-reported history of falling., Design: Descriptive, retrospective, cohort., Setting: General community., Subjects: Convenience sample of 17 community-dwelling females with a mean age of 72.2 years., Main Outcome Measures: Postural stability variables included the amplitude and frequency of postural sway during static vision-aided no-vision conditions. Information processing and response execution variables were collected using a simple-choice reaction time paradigm for an isometric knee extension task., Results: Postural stability and information processing variables were functionally independent. Based upon significant intergroup differences, simple and choice pre-motor reaction time and non-vision aided anterior posterior sway amplitude were selected for inclusion in a discriminant analysis. The resulting discriminant function was significant (P = 0.01), correctly categorizing all of the subjects with a self-reported history of falling and identifying six out of seven of the non-fallers., Conclusions: These preliminary results suggest that it is feasible to identify a predisposition to falling by detecting an inability to respond successfully to a postural disturbance.

Two hundred forty-eight elderly outpatients completed a survey designed to assess knowledge about the procedural aspects and efficacy of in-hospital cardiopulmonary resuscitation. We found that older people overestimate the percentage survival to actual hospital discharge following in-hospital cardiopulmonary resuscitation by nearly 300%. Most older people also have definite opinions about the appropriate application of cardiopulmonary resuscitation for different clinical circumstances. Most believe that patients with advanced Alzheimer's disease or widespread cancer should not be resuscitated, while patients with depression or early Alzheimer's disease should. Inaccurate beliefs about cardiopulmonary resuscitation efficacy can adversely impact on decision making about resuscitation by older patients. Educational efforts for the elderly may lead to more informed decision making and thereby more appropriate use of this technology.

The aging cardiovascular and renal systems put the elderly patient at increased risk of end-organ damage from marked hypertension. Thus, the office-based physician needs to be skilled in making the diagnosis of a hypertensive urgency or emergency based on accurate blood pressure readings and an assessment of the heart, brain, retina, and kidney. Hypertension urgency and emergency are distinguished from each other by the clinical decision of how quickly the blood pressure must be lowered. The clinician has a wide variety of agents from which to choose for pharmacologic treatment, with the goal being a smooth and safe reduction in blood pressure.

Methods of conducting comprehensive geriatric evaluation and management (GEM) are proliferating in a variety of clinical settings. However, rigorous evaluations of efficacy for this new approach to care of older patients have demonstrated a favorable impact on patient outcome in only a few studies. All of these have been controlled single site studies, and replication is needed. If replication studies show similar results, further studies should be undertaken to define the minimum necessary intervention to achieve the desired outcome. Controlled trials are needed to determine if consultative geriatric evaluation and/or primary patient management is effective. Further innovative work is needed in model development for geriatric assessment and management in outpatient settings. Finally, studies of geriatric evaluation and management in other environments, such as home care or the nursing home, are recommended.

Non-valvular atrial fibrillation is associated with a markedly increased risk of embolic stroke in elderly persons. Evidence is accumulating that anticoagulation with warfarin or aspirin may be effective in reducing this risk.

The Denver Veterans Administration Medical Center (DVAMC) established a mobile internal medicine clinic (MediVAn) to provide access to primary care for veterans living more than fifty miles from the center and to study the costs of such an outreach program. A fully equipped van staffed by an internist visited four Colorado cities weekly for scheduled appointments. In the first two years of operation there were 4,655 visits by 766 veterans with a mean age of 56 years, with 3.9 diagnoses, and receiving 3.0 medicines. The cost per MediVAn visit was $68, compared with $67 per outpatient visit at DVAMC. We conclude that a mobile medical clinic is a convenient method of delivering primary care over distances and is comparable in cost to outpatient hospital visits.

Little information exists on the use of mechanical restraints among nonpsychiatric inpatients. This prospective study evaluates their use among consecutive medical and surgical admissions to an acute care hospital. Daily direct observation of patients and hospital record review provided data on potential predictors of restraint, reasons for their application, complications, and outcome. Cox regression analysis was used to calculate relative risk of restraint while adjusting for duration of hospitalization as well as other variables. Restraints were applied to 37 (17%) of the 222 study patients. Restrained patients were eight times more likely to die during hospitalization (24% v 3%; P less than 0.01). Abnormal mental status exam, diagnosis of dementia, surgery, and presence of monitoring and support devices (eg, intravenous lines) were statistically significant independent predictors of restraint. Mechanical restraint is a common occurrence among nonpsychiatric inpatients particularly those with impaired mentation, requirement for surgery, or intensive medical intervention. Identification of medical and surgical patients at risk for restraint may reduce the use of these devices by concentrating surveillance and prevention on this group.

A hospice program (HP) was established on the medical service at the Denver Veterans Administration Medical Center (DVAMC) for the care of the terminally ill cancer patients and to integrate such care into house staff training. A two-bed inpatient unit was managed by an intern, a resident, and the attending physician with the aid of a multidisciplinary team. During the program's first year, 29 patients were cared for with an average inpatient stay of 26 days. Twenty-nine out of a possible 33 house officers returned questionnaires evaluating their hospice experience. Twenty-eight respondents felt that the hospice program was appropriate in a teaching hospital. Over half indicated improved awareness of the psychological problems of their patients and families. Two-thirds of the house staff members felt that the HP changed their approach to pain control and made them more comfortable in dealing with terminally ill patients. From this study, it can be concluded that a hospice program can be successfully integrated into an active medical teaching service.

The relationship of nutritional status, self-perceived chewing ability, dental status, and social isolation was examined. Seventy-three ambulatory, elderly (means = 86 years) veterans were studied. Parameters of nutritional status included intakes of protein, carbohydrate, fat, and total calories, and hemoglobin, serum albumin, total lymphocyte count, and height/weight ratio were determined. Dental status was measured, and self-perceived chewing problems and social isolation were assessed by interview. Results showed a significant correlation between perceived chewing problems and diminished protein and total caloric intake and increased carbohydrate intake. No association was found between measured dental status and nutritional status. Social isolation was weakly correlated with greater protein and calorie intake. These results support the contention that the presence of self-perceived chewing problems are more reliable than the quality of the dentition itself as an indicator of altered nutritional status.

In a prospective study, 46 patients discharged from a teaching hospital to a "teaching unit" nursing home, where primary medical care was provided by faculty geriatricians, medical students, and medical housestaff, were compared with 78 similar patients discharged to one of five community nursing homes without a teaching affiliation. At the time of hospital discharge, patients were determined to have a terminal, rehabilitative, or long stay prognosis based on a review of hospital discharge summaries using specific criteria. Among 34 study and 55 control patients with a long stay prognosis, ten of the study group compared with seven of the control group returned home (P = .03). Seven of 34 long stay patients in the study group were rehospitalized, while 15 of a matched control group of 34 required hospitalization (P = .04). There was no increase in mortality or emergency service use in the study population. Patients considered to be terminal or rehabilitative showed no difference in ultimate outcome or hospital use. In the study group patients experienced an average reduction in total medications prescribed from 6.2 to 5.3, while patients in the control group had an increase from 5.4 medications prescribed to 7.6 (P less than .001). Of 16 study patients discharged from the teaching unit nursing home, all remained home at least three months after discharge; only 12 of 18 control group patients discharged from the nursing home remained at home at three months (P less than .01). Long-term care by geriatric faculty, students, and housestaff appeared to have favorably influenced patient outcomes.

While the need for regular oral examinations increases in the aged, edentulous elderly persons generally see their dentists rarely, while most see their physicians relatively frequently. If these patients cannot be convinced to see a dentist, the physician should perform regular oral screening examinations. A technique is described for accomplishing this.

The percentage of elderly persons retaining natural teeth is increasing. Although many of these individuals cannot be convinced to see a dentist regularly, they are generally seen by a physician or nurse relatively frequently. The physician or nurse can provide a vital service for these patients by performing oral screening examinations. A technique is described for accomplishing this.

Eight methods for estimating creatinine clearance (CLcr) were compared in 65 men with serum creatinine concentrations (SCr) less than or equal to 1.5 mg/dL (group 1) and 65 men with SCr greater than 1.5 mg/dL (group 2). All patients had SCr values that did not fluctuate by more than +/- 10% for two weeks before and two weeks after measurement of CLcr. For each patient, predictions of CLcr by each of eight currently used formulas were compared with measured CLcr values; both regression analysis and predictive error analysis were used. Group 1 patients ranged in age from 32 to 64 years (mean, 53), weighed from 48 to 105 kg (mean, 73), and were from 63 to 79 inches in height (mean, 69). Group 2 patients ranged from 26 to 63 years of age (mean, 53), weighed from 34 to 141 kg (mean, 80), and were from 63 to 76 inches in height (mean, 70). Measured CLcr values ranged from 29.8 to 197 mL/min in group 1 and from 2.8 to 118 mL/min in group 2. Ranges of SCr values were 0.7-1.5 mg/dL (mean, 1.1) in group 1 and 1.6-7.1 mg/dL (mean, 2.8) in group 2; the formula of Cockcroft and Gault, which uses age, body weight, and SCr, had the highest correlation and the greatest accuracy in group 1, whereas the formula of Jelliffe, which uses body surface area and SCr, had the highest correlation and the greatest accuracy in group 2. Estimation of creatinine clearance can be improved by identification and use of the formula that is best suited to a specific patient population.

Recent reports have suggested that the antibody response of elderly persons to standard doses of influenza vaccine is depressed. We examined the effect of an additional threefold dose of influenza B vaccine on the antibody response in elderly, ambulatory veterans. One hundred thirty-one male subjects aged 70 years and older were randomized to receive one of three influenza vaccine regimens: Group I received standard trivalent influenza vaccine containing 15 micrograms of B/USSR/100/83 in one arm and placebo in the other; Group II received standard trivalent vaccine in one arm and a supplemental dose of 45 micrograms of B/USSR in the other; Group III received the same dose as group II combined in one arm with a placebo in the other. Antibody levels were measured at baseline, 1 month, and 5 months. Nearly 80% of the participants achieved levels of antibody to B/USSR considered protective; seroconversion rates varied from 40% to 61%. No significant differences in antibody response to B/USSR occurred among the vaccine groups, and there were more side effects at higher doses. The higher dose groups did, however, achieve greater antibody levels to the drifted influenza B virus which circulated during the year of the study. Response to the influenza A components of the vaccine, however, may have been blunted in Group III which received a large dose of A and B antigens all at one site.

Use of pneumococcal vaccine remains controversial. To further study this question, 89 patients hospitalized at the Denver Veterans Administration Medical Center with pneumococcal bacteremia were chosen as the case group for a case-control study. The control group was made up of patients matched on the basis of age, date of admission, and comorbid conditions. Vaccination status in the bacteremic patients and control patients was determined, as were pneumococcal serotypes among the bacteremic patients. If the vaccine were protective, vaccination rates should be higher among the control patients, and serotype distribution should be different in vaccinated and nonvaccinated bacteremic patients. There were no differences between vaccination rates among bacteremic patients (29 percent) and control patients (24 percent). Furthermore, 65 percent of the blood isolates from nonvaccinated bacteremic patients were serotypes included in the vaccine, as compared with 69 percent of the isolates in vaccinated bacteremic patients. Pneumococcal vaccine did not appear to be protective in this high-risk population.

Information derived from the relationship of the primary care physician with an older patient provides the best possible way to eliminate or minimize many ethical conflicts that arise in the care of the very old. The conscientious physician can seek information regarding the patient's personal value scheme and his or her expectations and utilize the breadth of available technology to best serve the patient. Many of the issues raised in this article are discussed in much greater detail in subsequent articles. The discussions of the issues they encompass are intended to inform and to stimulate. There is legitimate reason for optimism that, with education and thoughtful review, physicians will be able to improve the manner in which we care for older individuals.