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Background: The management of older chronically ill patients dominates medical practice. We reorganized our Geriatric Ambulatory Practice to enhance their care using the Chronic Care Model. Methods: We established a disease registry for patients with diabetes and/or cardiovascular disease that centralizes patient information; evaluates disease management; measures outcomes; and provides reminders for patient education and preventive care. Results: We enrolled 410 patients >= 60 years of age: 262 with diabetes, 200 with cardiovascular disease, and 58 with both diseases. 62% were female; 63% were African American, 19% were White, and 8% were Hispanic/Latino. Although lipid testing (74%) exceeded that of Boston's elders cared for in other settings, systematic collection of quality indicators identified foot care and pneumovax administration as two important areas for improvement. Conclusion: Promoting more productive and systematic interactions between healthcare providers and patients can enhance quality of care for older chronically ill urban patients.

Risk information for Alzheimer disease (AD) may be communicated through susceptibility gene disclosure, even though this is not currently in clinical use. The REVEAL Study is the first randomized clinical trial of risk assessment for AD with apolipoprotein E (APOE) genotype and numerical risk estimate disclosure. We examined whether APOE genotype and numerical risk disclosure to asymptomatic individuals at high risk for AD alters health behaviors. One hundred sixty-two participants were randomized to either intervention (APOE disclosure) or control (no genotype disclosure) groups. Subjects in both groups received numerical lifetime risk estimates of future AD development based on sex and family history of AD. The intervention group received their APOE genotype. Subjects were informed that no proven preventive measures for AD existed and given an information sheet on preventative therapies under investigation. Participants who learned they were epsilon 4 positive were significantly more likely than epsilon 4 negative participants to report AD-specific health behavior change 1 year after disclosure (adjusted odds ratio: 2.73; 95% confidence interval: 1.14, 6.54; P=0.02). Post hoc analyses revealed similar significant associations between numerical lifetime risk estimates and self-report of AD-specific health behavior change. Despite lack of preventive measures for AD, knowledge of APOE genotype, numerical lifetime risk, or both, influences health behavior. [ABSTRACT FROM AUTHOR]

Objective: To explore perceptions of the impact of erectile dysfunction on men who had undergone definitive treatment for early nonmetastatic prostate cancer.Design: Seven focus groups of men with early prostate cancer. The groups were semistructured to explore men's experiences and quality-of-life concerns associated with prostate cancer and its treatment.Setting: A staff model health maintenance organization, and a Veterans Affairs medical center.Patients: Forty-eight men who had been treated for early prostate cancer 12 to 24 months previously.Results: Men confirmed the substantial effect of sexual dysfunction on the quality of their lives. Four domains of quality of life related to men's sexuality were identified: 1) the qualities of sexual intimacy; 2) everyday interactions with women; 3) sexual imagining and fantasy life; and 4) men's perceptions of their masculinity. Erectile problems were found to affect men in both their intimate and nonintimate lives, including how they saw themselves as sexual beings.Conclusions: Erectile dysfunction, the most common side effect of treatment for early prostate cancer, has far-reaching effects upon men's lives. Assessment of quality of life related to sexual dysfunction should address these broad impacts of erectile function on men's lives. Physicians should consider these effects when advising men regarding treatment options. Physicians caring for patients who have undergone treatment should address these psychosocial issues when counseling men with erectile dysfunction. [ABSTRACT FROM AUTHOR]

Much has been written about the complexities of the doctor-patient relationship and the myriad ways that both parties communicate. When patients become more frail, this relationship must expand to include their family caregivers. This addition of a third person complicates the situation in more than an additive fashion. It requires more time and energy on the part of physicians that are not without costs. Balancing both patient and caregiver needs in a time-driven and increasingly competitive world is not easy. Physicians not only need better preparation to meet the challenges of caring for frail older patients, but they also need changes in reimbursement policies so that they can afford to spend the time needed to manage the complexities inherent in the doctor-patient-family caregiver relationship. Although there is uncertainty about timing of these changes, there is no uncertainty about the complexity of the doctor-patient-family caregiver relationship. To make its management easier, the following rules are worth remembering: 1. Carefully assess problems in all domains of patient function and develop plans for managing and monitoring these problems. 2. Recognize that the effects of patient disabilities cycle between patient and caregiver. 3. Pay attention to the needs and concerns of patients and of their caregivers. 4. Provide caregivers with as much information as possible and educate them about "when to worry." 5. Assure caregivers that you are available to answer questions and help them with handling problems that arise in the care of their elders. [ABSTRACT FROM AUTHOR]

The article comments on a study which aims to determine patterns of referral of older women aged 65 and above with early stage breast cancer to medical oncologists by their treating surgeons conducted by S. S. Thwin et al. It states that comprehensive care is influenced by patient-related factors. It asserts that decisions on whether older women with early stage breast cancer should undergo adjuvant therapy are complex because of the need to balance factors such as estimates of life expectancy.