Carol Winograd
Associate Professor of Medicine, Emerita
All Publications
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Residence and quality of life determinants for adults with tetraplegia of traumatic spinal cord injury etiology
SPINAL CORD
2008; 46 (10): 684-689
Abstract
Cross-sectional analysis of individual interviews with a convenience sample of persons living with tetraplegia.To describe patterns of residence among persons living with tetraplegia following discharge from initial acute medical care after spinal cord injury, decision-making process for each residence move and quality of life determinants at different residence types.California and Minnesota, United States.A total of 22 adults with traumatic spinal cord injury tetraplegia were interviewed about their residence histories, the residence decision-making process for each move, and positive and negative features at each residence at which they had lived.Information, money, insurance, accessibility, intimate relationships and personal assistants had the strongest influence over residence location, with insufficient information and finances demonstrating particularly strong influences. Participants frequently viewed parents' homes as an 'only option,' 'place of refuge' or 'stunting' environment. They viewed own homes as 'only options' or ways to achieve quality of life improvements, and other institutions as 'only options' or 'stepping-stones' to independent living.Further research is needed to examine decision-making across multiple moves over the course of the lives of persons living with tetraplegia, particularly examining the roles of inadequate information and finances as inhibitors of freedom of choice.
View details for DOI 10.1038/sc.2008.15
View details for Web of Science ID 000259722700007
View details for PubMedID 18317485
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Physical therapists' nonverbal communication predicts geriatric patients' health outcomes
PSYCHOLOGY AND AGING
2002; 17 (3): 443-452
Abstract
Two studies explored the link between health care providers' patterns of nonverbal communication and therapeutic efficacy. In Study 1, physical therapists were videotaped during a session with a client. Brief samples of therapists' nonverbal behavior were rated by naive judges. Judges' ratings were then correlated with clients' physical, cognitive, and psychological functioning at admission, at discharge, and at 3 months following discharge. Therapists' distancing behavior was strongly correlated with short- and long-term decreases in their clients' physical and cognitive functioning. Distancing was expressed through a pattern of not smiling and looking away from the client. In contrast, facial expressiveness, as revealed through smiling, nodding, and frowning, was associated with short- and long-term improvements in functioning. In Study 2, elderly subjects perceived distancing behaviors of therapists more negatively than positive behaviors.
View details for DOI 10.1037//0882-7974.17.3.443
View details for Web of Science ID 000177991800008
View details for PubMedID 12243386
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Identifying hospitalized older patients at varying risk for physical performance decline: A new approach
52nd Annual Meeting of the American-Geriatrics-Society
WILLIAMS & WILKINS. 1997: 604–9
Abstract
A classification tree analysis identifies patient groups at varying risk for decline in physical performance 1 year after hospitalization.Prospective cohort study.Tertiary care VAMC.A total of 507 acutely ill hospitalized male veterans aged 65 years and older.Eighteen admission characteristics were considered as potential predictors: demographic data, medical diagnoses, functional status (e.g., ADL and IADL), geriatric conditions (e.g., incontinence, vision impairment, weight change), mental status, depression, and physical functioning (measured by self-report (MOS-PFR) and the Physical Performance and Mobility Examination (PPME)). Outcome measure was change in PPME status at 12-months post-admission.Patients with the greatest risk for decline had both high baseline physical performance (PPME > or = 9) and at least moderate self-report limitations on physical functioning (MOS-PFR < or = 36, mean = 30.8). Patients with the lowest risk of decline had impaired baseline physical performance (PPME < or = 8) but fewer self-report limitations on physical functioning (MOS-PFR > or = 31, mean = 37.4) and two or less geriatric conditions.The predictive role of self-report functioning suggests that perception of the impact of health on one's own physical functioning is associated with future performance. The number of geriatric conditions is also an important predictor of physical performance change. By identifying patient risk groups based on geriatric conditions, physical performance, and self-report physical functioning, future targeting strategies may improve physical performance outcomes for hospitalized older adults.
View details for Web of Science ID A1997WZ00900011
View details for PubMedID 9158583
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Geriatric targeting criteria as predictors of survival and health care utilization
JOURNAL OF THE AMERICAN GERIATRICS SOCIETY
1996; 44 (8): 914-921
Abstract
To assess the utility of geriatric targeting criteria in predicting survival and health care utilization in a cohort of hospitalized older veterans.A prospective cohort study assessing geriatric targeting criteria, e.g., polypharmacy, falls, or confusion, with respect to adverse outcomes at 12 months.A Tertiary Care VA Medical Center.507 acutely hospitalized male veterans aged 65 years or more.Survival status, nursing home placement, and total hospital days during 12 months following hospital admission.Patients who had a higher number of targeting criteria at admission showed a significantly increasing trend toward death (P < or = .001), nursing home placement (P < or = .01), and longer hospital stays (P < or = .01) at 12 months. In univariate analyses, weight loss (relative hazard 3.8, 95% CI 2.4, 5.9), appetite loss (relative hazard 3.3, 95% CI 1.9, 5.8), depression (relative hazard 2.5, 95% CI 1.4, 4.5), falls (relative hazard 2.2, 95% CI 1.2, 4.1), confusion (relative hazard 2.2, 95% CI 1.2, 4.0), and socioeconomic problems (relative hazard 1.6, 95% CI 1.0, 2.5) predicted death. Polypharmacy (OR 3.4, 95% CI 1.3, 8.8), confusion (OR 4.4, 95% CI 1.5, 13.0), and prolonged bedrest (OR 7.6, 95% CI 1.5, 39.3) predicted nursing home placement. Confusion (Beta 12.0, 95% CI 2.9, 21.3), falls (Beta 14.2, 95% CI 4.2, 24.3), and prolonged bedrest (Beta 22.4, 95% CI 3.9, 41.0) predicted total hospital days. In multivariate analyses, weight loss, depression, and socioeconomic problems predicted death; confusion and polypharmacy predicted nursing home placements; and falls predicted total hospital days.This prospective cohort study of hospitalized older veterans demonstrated geriatric targeting criteria as predictors of adverse hospital outcomes. Our findings suggest screening acutely hospitalized patients using chart abstracted geriatric targeting criteria is useful in identifying patients at risk for adverse outcomes of hospitalization.
View details for Web of Science ID A1996VA56300004
View details for PubMedID 8708300
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Functional outcomes of acute medical illness and hospitalization in older persons
ARCHIVES OF INTERNAL MEDICINE
1996; 156 (6): 645-652
Abstract
Short-stay hospitalization in older patients is frequently associated with a loss of function, which can lead to a need for postdischarge assistance and longer-term institutionalization. Because little is known about this adverse outcome of hospitalization, this study was conducted to (1) determine the discharge and 3-month postdischarge functional outcomes for a large cohort of older persons hospitalized for medical illness, (2) determine the extent to which patients were able to recover to preadmission levels of functioning after hospital discharge, and (3) identify the patient factors associated with an increased risk of developing disability associated with acute illness and hospitalization.A total of 1279 community-dwelling patients, aged 70 years and older, hospitalized for acute medical illness were enrolled in this multicenter, prospective cohort study. Functional measurements obtained at discharge (Activities of Daily Living) and at 3 months after discharge (Activities of Daily Living and Instrumental Activities of Daily Living) were compared with a preadmission baseline level of functioning to document loss and recovery of functioning.At discharge, 59% of the study population reported no change, 10% improved, and 31% declined in Activities of Daily Living when compared with the preadmission baseline. At the 3-month follow-up, 51% of the original study population, for whom postdischarge data were available (n=1206), were found to have died (11%) or to report new Activities of Daily Living and/or Instrumental Activities of Daily Living disabilities (40%) when compared with the preadmission baseline. Among survivors, 19% reported a new Activities of Daily Living and 40% reported a new Instrumental Activities of Daily Living disability at follow-up. The 3-month outcomes were the result of the loss of function during the index hospitalization, the failure of many patients to recover after discharge, and the development of new postdischarge disabilities. Patients at greatest risk of adverse functional outcomes at follow-up were older, had preadmission Instrumental Activities of Daily Living disabilities and lower mental status scores on admission, and had been rehospitalized.This study documents a high incidence of functional decline after hospitalization for acute medial illness. Although there are several potential explanations for these findings, this study suggests a need to reexamine current inpatient and postdischarge practices that might influence the functioning of older patients.
View details for Web of Science ID A1996UB00100006
View details for PubMedID 8629876
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Hospital admission risk profile (HARP): Identifying older patients at risk for functional decline following acute medical illness and hospitalization
JOURNAL OF THE AMERICAN GERIATRICS SOCIETY
1996; 44 (3): 251-257
Abstract
To develop and validate an instrument for stratifying older patients at the time of hospital admission according to their risk of developing new disabilities in activities of daily living (ADL) following acute medical illness and hospitalization.Multi-center prospective cohort study.Four university and two private non-federal acute care hospitals.The development cohort consists of 448 patients and the validation cohort consists of 379 patients who were aged 70 and older and who were hospitalized for acute medical illness between 1989 and 1992.All patients were evaluated on hospital admission to identify baseline demographic and functional characteristics and were then assessed at discharge and 3 months after discharge to determine decline in ADL functioning.Logistic regression analysis identified three patient characteristics that were independent predictors of functional decline in the development cohort: increasing age, lower admission Mini-Mental Status Exam scores, and lower preadmission IADL function. A scoring system was developed for each predictor variable and patients were assigned to low, intermediate, and high risk categories. The rates of ADL decline at discharge for the low, intermediate, and high risk categories were 17%, 28%, and 56% in the development cohort and 19%, 31%, and 55% in the validation cohort, respectively. Patients in the low risk category were significantly more likely to recover ADL function and to avoid nursing home placement during the 3 months after discharge.Hospital Admission Risk Profile (HARP) is a simple instrument that can be used to identify patients at risk of functional decline following hospitalization. HARP can be used to identify patients who might benefit from comprehensive discharge planning, specialized geriatric care, and experimental interventions designed to prevent/reduce the development of disability in hospitalized older populations.
View details for Web of Science ID A1996TZ89300004
View details for PubMedID 8600192
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PSYCHOACTIVE MEDICATIONS IN THE LONG-TERM-CARE SETTING - DIFFERING PERSPECTIVES AMONG PHYSICIANS, NURSING STAFF, AND PATIENTS
JOURNAL OF GERIATRIC PSYCHIATRY AND NEUROLOGY
1994; 7 (3): 176-183
Abstract
Differences in perceptions among nursing home patients, nursing staff, and physicians were compared in this preliminary study regarding nighttime disorders and psychoactive medications. Nighttime disorders, including both insomnia and behavior problems, are prevalent among institutionalized elderly and are frequently managed with psychoactive medications. All nursing home patients receiving psychoactive medications, the nursing staff, and the physicians involved in their care were interviewed regarding the description, etiology, management, and impact of the nighttime disorder including side effects of the prescribed medications. Overall, the differences in responses among the three groups ranged from 47% to 63%. While both physicians and nurses reported problems more often than did the patients, nurses reported problems more frequently than did physicians. This preliminary study suggests that patients, nursing staff, and physicians perceive nighttime disorders and their management differently. These differences point to the need for improved methods of communication and education to mutually identify the targeted disorder and develop appropriate management.
View details for Web of Science ID A1994PK90300009
View details for PubMedID 7916942
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DEVELOPMENT OF A PHYSICAL PERFORMANCE AND MOBILITY EXAMINATION
JOURNAL OF THE AMERICAN GERIATRICS SOCIETY
1994; 42 (7): 743-749
Abstract
To develop and validate the Physical Performance and Mobility Examination (PPME), an observer-administered, performance-based instrument assessing 6 domains of physical functioning and mobility for hospitalized elderly.Development of a pass-fail and 3-level scoring system and training manuals for the PPME instrument for use in both clinical and research settings. Two patient samples were used to assess construct validity and interrater reliability of the PPME. A third sample was selected to assess the test-retest reliability of the instrument.(1) 146 subjects > or = 65 years of age with impaired mobility admitted to Medical Units of Stanford University Hospital. (2) 352 subjects > or = 65 admitted to acute Medical and Surgical Services of the Palo Alto VA Medical Center. Patient samples were obtained during hospitalization and followed until 3 months post-discharge. To study test-retest reliability, 50 additional patients, whose clinical condition was stable, were selected from both settings.An expert panel selected 6 mobility tasks integral to daily life: bed mobility, transfer skills, multiple stands from chair, standing balance, step-up, and ambulation. Tasks were piloted with frail hospitalized subjects for appropriateness and safety. Test-retest and interrater reliability and construct validity were evaluated. Construct validity was tested using the Folstein Mini-Mental State Examination, Activities of Daily Living (ADL), Instrumental Activities of Daily Living (IADL), Geriatric Depression Scale, and modified Medical Outcomes Study Measure of Physical Functioning (MOS-PFR). Two scoring schema were developed for each task: (1) dichotomous pass-fail and (2) 3-level high pass, low pass, and fail. A summary scale was developed for each method of scoring.High interrater reliability and intrarater reliability were demonstrated for individual tasks. The mean percent agreement (interrater) for each pass/fail task ranged from 96 to 100% and from 90 to 100% for the 3 pairs of raters for each task using the 3-level scoring. Kappas for individual pairs of raters ranged from .80 to 1.0 for pass-fail scoring and from .75 to 1.0 for 3-level scoring (all P < 0.01). Intraclass correlation coefficients for 3-level scoring by pairs of raters ranged from .66 to 1.0. For summary scales, the mean intraclass correlation was .99 for both scoring schema. Test-retest reliability for summary scales using kappa coefficients was .99 for both pass-fail and 3-level scoring, and .99 and .98, respectively, using Pearson Product Moment Correlation. Correlations of PPME with other instruments (construct validity) suggest that the PPME adds a unique dimension of mobility beyond that measured by self-reported ADLS and physical functioning, and it is not greatly influenced by mood or mental status (r = 0.70 (ADL), r = 0.43 (IADL), r = 0.36 (MMSE), r = 0.71 (MOS-PFR), r = 0.23 (GDS)). The 3-level summary scale was sensitive to the variability in the patient population and exhibited neither ceiling nor floor effects.The PPME is a reliable and valid performance-based instrument measuring physical functioning and mobility in hospitalized and frail elderly.
View details for Web of Science ID A1994NW33900010
View details for PubMedID 8014350
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A NEGATIVE TRIAL OF INPATIENT GERIATRIC CONSULTATION - LESSONS LEARNED AND RECOMMENDATIONS FOR FUTURE-RESEARCH
ARCHIVES OF INTERNAL MEDICINE
1993; 153 (17): 2017-2023
Abstract
To determine the effectiveness of inpatient interdisciplinary geriatric consultation provided during hospitalization to frail, elderly subjects. SUBJECTS AND SITE: Admission cohort of 197 men admitted from 1985 through 1989, aged 65 years or more, meeting proxy criteria for frailty, living within follow-up area, without terminal illness, and without prolonged nursing home residence.Randomized controlled trial of inpatient geriatric consultation at a tertiary care Veterans Affairs hospital. Differences were determined between groups in the Physical Self-Maintenance Scale, Instrumental Activities of Daily Living, Mini-Mental State Examination, Morale Scale, and nursing home and health care utilization.No differences were seen between groups in any measure after the intervention or during 1 year of follow-up. Intervention implementation may have been incomplete due to compliance and resource availability.This trial is not definitive in determining whether geriatric consultation is effective or ineffective. Lessons learned from this research indicate that future studies should target frail subjects, include intervention-specific measures, and be conducted with direct control of comprehensive resources.
View details for Web of Science ID A1993LY51300008
View details for PubMedID 8357287
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GERIATRIC-MEDICINE
JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION
1993; 270 (2): 213-216
View details for Web of Science ID A1993LL36800022
View details for PubMedID 8315736
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GERIATRIC-MEDICINE - HOW WE WILL FARE WITH THE MEDICARE FEE SCHEDULE
JOURNAL OF THE AMERICAN GERIATRICS SOCIETY
1992; 40 (12): 1272-1280
View details for Web of Science ID A1992KA80900015
View details for PubMedID 1447447
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FLUOXETINE IN ELDERLY PATIENTS - IS THERE CAUSE FOR CONCERN
JOURNAL OF THE AMERICAN GERIATRICS SOCIETY
1992; 40 (9): 902-905
Abstract
To assess whether fluoxetine use is associated with significant weight loss or other side effects in depressed elderly patients with concomitant medical illness.A retrospective chart review.A tertiary care VA hospital.Five groups of outpatients were studied: (1) patients greater than 75 years old receiving fluoxetine (n = 15); (2) patients 60 to 71 years old receiving fluoxetine (n = 20); (3) patients greater than 75 years old receiving nortryptiline or desipramine (n = 20); (4) patients greater than 75 years old with a history of depression but on no antidepressant medication (n = 20); and (5) patients greater than 75 years old with no history of depression (n = 28).Mortality, change in weight, reports of anorexia or nausea, and serum sodium and glucose measurements.Patients greater than 75 years of age taking fluoxetine experienced significantly greater weight loss (average 4.6 kilograms, P = 0.0062) than the other groups. Both groups of patients taking fluoxetine were significantly more likely to report nausea (P = 0.0095) and anorexia (P = 0.0009). No significant differences were noted in mortality or the frequency of hypoglycemia or hyponatremia between groups.The frequency and degree of weight loss noted here in medically ill elderly receiving fluoxetine warrants further investigation.
View details for Web of Science ID A1992JM86900008
View details for PubMedID 1512386
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CLINIC-BASED PRIMARY CARE OF FRAIL OLDER PATIENTS IN CALIFORNIA
WESTERN JOURNAL OF MEDICINE
1992; 156 (4): 385-391
Abstract
We surveyed medical directors of primary care clinics in California to learn how those clinics cared for their frail older patients. Of 143 questionnaires sent, 127 (89%) were returned. A median of 30% of all patient encounters were with persons aged 65 or older, and a median of 20% of older patients were considered frail. A total of 20% of the clinics routinely provided house calls to homebound elderly patients. Of clinics involved in training medical students of physicians (teaching clinics), 70% had at least one physician with an interest in geriatrics, compared with 42% of nonteaching clinics (P less than .005). For frail patients, 40% of the clinics routinely performed functional assessment, while 20% routinely did an interdisciplinary evaluation. Continuing education in geriatrics emerged as a significant independent correlate of both functional assessment and interdisciplinary evaluation. Among the 94 clinics with a standard appointment length for the history and physical examination, only 11 (12%) allotted more than 60 minutes for frail patients. The data suggest that certain geriatric approaches are being incorporated into clinic-based primary care in California but do not provide insight into their content or clinical effects.
View details for Web of Science ID A1992HN72100004
View details for PubMedID 1574881
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NUTRITIONAL INTAKE IN PATIENTS WITH SENILE DEMENTIA OF THE ALZHEIMER TYPE
ALZHEIMER DISEASE & ASSOCIATED DISORDERS
1991; 5 (3): 173-180
Abstract
The dietary intake of 29 healthy controls was compared with that of 35 community-dwelling patients with probable or definite senile dementia of the Alzheimer type (SDAT), based on NINCDS-ADRDA criteria. The control subject or the caregiver of the SDAT patient completed a 3-day estimated-dietary-intake record. Foods offered to patients were chosen, for the most part, by caregivers, but SDAT patients were allowed to eat ad libitum from those choices, and food consumed was recorded. Dietary intake was evaluated against the 1989 Recommended Dietary Allowances (RDA). Dietary intakes did not differ significantly between control and SDAT patients for any of the 32 nutrients analyzed. The controls and SDAT patients met the RDA guidelines for intake of total energy, protein, and micronutrients, with the exception of female SDAT patients, who did not consume a minimum of two thirds of the RDA for vitamin D. All biochemical indices of nutritional status were within normal limits for the SDAT patients. In addition, cognitive function did not correlate with intake of any nutrient studied. We conclude that moderately impaired, community-dwelling patients with SDAT do not differ from healthy controls in nutritional status or nutrient intake. Neither general nor nutrient-specific malnutrition was present in this population. Based on this cross-sectional study, malnutrition does not appear to be a major contributor to the pathogenesis of Alzheimer disease. However, this investigation examined only a single point in time, when patients were being fed by caregivers, so that the role of malnutrition at the beginning of the disease was not addressed.
View details for Web of Science ID A1991GU43100003
View details for PubMedID 1772637
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BLOOD-GLUCOSE AND INSULIN-RESPONSE IN PATIENTS WITH SENILE DEMENTIA OF THE ALZHEIMERS TYPE
BIOLOGICAL PSYCHIATRY
1991; 30 (5): 507-511
View details for Web of Science ID A1991GE87200011
View details for PubMedID 1932397
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MEDICARE REIMBURSEMENT FOR GERIATRIC ASSESSMENT - REPORT OF THE AMERICAN-GERIATRICS-SOCIETY AD HOC COMMITTEE ON GERIATRICS ASSESSMENT
JOURNAL OF THE AMERICAN GERIATRICS SOCIETY
1991; 39 (9): 926-931
Abstract
This ad hoc committee report from the American Geriatrics Society proposes the prompt initiation of Medicare reimbursement for geriatric assessment (GA) services (also termed comprehensive geriatric assessment or geriatric evaluation and management services). Despite an extensive body of literature documenting the effectiveness of GA for improving health care outcomes in many settings for identifiable groups of frail elderly patients, no explicit Medicare reimbursement mechanisms currently exist to cover GA services provided by either hospital or physician. We believe that new physician reimbursement codes specific for geriatric assessment should be established in the Current Procedural Technology (CPT-4) manual and that reimbursement for GA should be specifically provided under Part B of Medicare. Further, we believe that hospital reimbursement within the Medicare prospective payment system should be modified to encourage GA during inpatient stays for appropriate patients. This paper summarizes the background for these recommendations. It defines the major content of GA at three levels of intensity--screening, intermediate, and comprehensive. It describes the major sites for conducting GA--hospital, office, home, nursing home. Finally, it proposes criteria for targeting patients most likely to benefit from GA.
View details for Web of Science ID A1991GE24300013
View details for PubMedID 1885868
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DURABLE POWER OF ATTORNEY FOR HEALTH-CARE - ARE WE READY FOR IT
WESTERN JOURNAL OF MEDICINE
1991; 155 (3): 263-268
Abstract
Health care professionals need to be well informed about advance directives for medical care in the event a patient becomes incapacitated. The Patient Self-Determination Act requires that all patients be advised of their options at the time of hospital admission. Hospitals and health care professionals will need to work together to plan for implementing this law. We surveyed 215 physicians, nurses, and social workers at a Veterans Affairs Medical Center about the California advance directive, the Durable Power of Attorney for Health Care. Attitudes were generally positive. All of the social workers had heard of the durable power of attorney directive, but 36% of physicians and nurses had never heard of it and an additional 20% had no experience with one. For respondents who had heard of the directive, the mean knowledge score was 6.35 of a possible 10 (5 predicted by chance). Respondents brought up the issue of durable power of attorney with patients before a crisis only 19% of the time and determined whether one had been signed for only 16% of older patients in hospital. The most commonly cited reasons for failure to discuss this with patients were lack of proper forms, pamphlets, or a place to refer a patient. Of those who had ever seen such a document in use, 42% were aware of a problem with it at some time. Whereas attitudes toward advance directives are positive, many physicians and nurses had little knowledge of the Durable Power of Attorney for Health Care and were poorly equipped to discuss it with patients. We encourage educating hospital staff to prepare for the enactment of the Patient Self-Determination Act. We also recommend that the concerns raised by professionals about the use of a durable power of attorney be addressed.
View details for Web of Science ID A1991GF77400005
View details for PubMedID 1949773
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SCREENING FOR FRAILTY - CRITERIA AND PREDICTORS OF OUTCOMES
JOURNAL OF THE AMERICAN GERIATRICS SOCIETY
1991; 39 (8): 778-784
Abstract
To determine the reliability of rapid screening by clinically derived geriatric criteria in predicting outcomes of elderly hospitalized patients.Prospective cohort study of 985 patients screened at the time of hospital admission and followed for 1 year with respect to the outcomes of mortality, hospital readmission, and nursing home utilization.Palo Alto Veterans Affairs Medical Center, a tertiary care teaching hospital.Male patients 65 years of age and older admitted to the Medical and Surgical services during the period from October 1, 1985 through September 30, 1986.Patients were grouped by specific screening criteria into three groups of increasing frailty: Independent, Frail, and Severely Impaired. Each criterion focused on a geriatric condition and was designed to serve as a marker for frailty. Increasing frailty was significantly correlated with increasing length of hospital stay (P less than 0.0001), nursing home utilization (P less than 0.0001), and mortality (P less than 0.0001). Multivariate analyses revealed that the clinical groups were more predictive of mortality and nursing home utilization than were age or Diagnosis-Related Groups (DRGs). Rehospitalization was unrelated to age, clinical group, or DRG, suggesting that utilization may not be driven by the clinical factors measured in this study.Rapid clinical screening using specific geriatric criteria is effective in identifying frail older subjects at risk for mortality and nursing home utilization. Our findings suggest that geriatric syndromes are more predictive of adverse outcomes than diagnosis per se. This well operationalized screening process is inexpensive as well as effective and could easily be introduced into other hospital settings.
View details for Web of Science ID A1991GA27300006
View details for PubMedID 1906492
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OBRA 87 - A COMMENTARY
JOURNAL OF THE AMERICAN GERIATRICS SOCIETY
1991; 39 (7): 724-726
View details for Web of Science ID A1991FU96900014
View details for PubMedID 2061540
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AGGRESSIVE ORAL REFEEDING IN HOSPITALIZED-PATIENTS
AMERICAN JOURNAL OF CLINICAL NUTRITION
1990; 52 (6): 967-968
Abstract
Malnutrition is an important clinical condition leading to increased morbidity and mortality. This report describes an aggressive oral refeeding program of high-caloric foods, which was instituted in severely anorectic patients because of their refusal to eat meals or supplements. After ascertaining a patient's favorite sweet, hospital personnel and family collaborated in providing the food. Frequently, sweets were the patient's only intake for weeks. We saw a gradual return of appetite, inclusion of other foods in the diet, and overall clinical improvement in comorbid conditions. These cases suggest that aggressive oral refeeding with high-caloric foods is an underutilized therapy for multiply impaired elderly patients.
View details for Web of Science ID A1990EK40600003
View details for PubMedID 2239794
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THE NATURAL-HISTORY OF FUNCTIONAL MORBIDITY IN HOSPITALIZED OLDER PATIENTS
JOURNAL OF THE AMERICAN GERIATRICS SOCIETY
1990; 38 (12): 1296-1303
Abstract
This study provides data on changes in the functional status of older patients that are associated with acute hospitalization. Seventy-one patients over the age of 74 admitted to the medical service of Stanford University Hospital between February and May 1987 received functional assessments covering seven domains: mobility, transfer, toileting, incontinence, feeding, grooming, and mental status. Assessments were obtained by report from the patient's caregiver (or the patient when he or she lived alone) for 2 weeks before admission; from the patient's nurse on day 2 of hospitalization and on the day before discharge; and again from the caregiver (or patient) 1 week after discharge. The sample had a mean age of 84, covered 37 Diagnostic Related Groups, and had a median length of stay of 8 days. Between baseline and day 2, statistically significant deteriorations occurred for the overall functional score and for the individual scores for mobility, transfer, toileting, feeding, and grooming. None of these scores improved significantly by discharge. In the case of mobility, 65% of the patients experienced a decline in score between baseline and day 2. Between day 2 and discharge, 67% showed no improvement, and another 10% deteriorated further. These data suggest that older patients may experience a burden of new and worsened functional impairment during hospitalization that improves at a much slower rate than the acute illness. An awareness of delayed functional recovery should influence discharge planning for older patients. Greater efforts to prevent functional decline in the hospitalized older patient may be warranted.
View details for Web of Science ID A1990EQ38000004
View details for PubMedID 2123911
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PROSPECTIVE PAYMENT AND THE UTILIZATION OF PHYSICAL THERAPY SERVICE IN THE HOSPITALIZED ELDERLY
AMERICAN JOURNAL OF PUBLIC HEALTH
1990; 80 (12): 1491-1494
Abstract
We studied the effect, in a university teaching hospital, of the prospective payment system (PPS) on utilization of physical therapy (PT), a non-reimbursable service; subjects were hospitalized patients aged 75 or older with non-PT-related diagnoses (myocardial infarction, pneumonia, congestive heart failure, and colectomy) and PT-related diagnoses (cerebrovascular accident and hip fracture). The proportion of patients referred for PT increased from 68 percent pre-PPS to 85 percent post-PPS for those with PT-related diagnoses and from 13 percent pre-PPS to 19 percent post-PPS for those with non-PT-related diagnoses. The mean number of sessions of PT decreased slightly for both groups: from 8.5 to 7.6 sessions for those with PT-related diagnoses and from 5.2 to 4.5 for those with non-PT-related diagnoses. In patients with PT-related diagnoses whose ambulatory status worsened during hospitalization, referrals for PT increased from 76 percent pre-PPS to 98 percent post-PPS. Referrals of comparable patients with non-PT-related diagnoses did not increase. Changes in provider education and efforts to reduce length of stay may account for these findings.
View details for Web of Science ID A1990EJ98000016
View details for PubMedID 2240337
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INPATIENT GERIATRIC CONSULTATION - CHALLENGES AND BENEFITS
JOURNAL OF THE AMERICAN GERIATRICS SOCIETY
1990; 38 (8): 926-932
View details for Web of Science ID A1990DW50100014
View details for PubMedID 2201716
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FECAL INCONTINENCE IN AN ELDERLY MAN - STANFORD-UNIVERSITY GERIATRICS CASE CONFERENCE
JOURNAL OF THE AMERICAN GERIATRICS SOCIETY
1989; 37 (10): 991-1002
View details for Web of Science ID A1989AV89600012
View details for PubMedID 2794323
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TARGETING THE HOSPITALIZED ELDERLY FOR GERIATRIC CONSULTATION
JOURNAL OF THE AMERICAN GERIATRICS SOCIETY
1988; 36 (12): 1113-1119
Abstract
This empirical study reports the proportion of hospitalized elderly patients who were identified as frail. As a part of a randomized controlled trial, standardized criteria were developed to target the frail hospitalized elderly for geriatric consultation. Twelve-hundred patients aged 65 years and older admitted to the medical and surgical services at the Palo Alto Veterans Administration Medical Center were screened. Because of administrative exclusions of the randomized controlled trial (eg, short stay, lived too far away), 749 (62%) were excluded from the clinical screening process. The remaining 451 patients received clinical screening. Of these patients, almost two thirds (64%) were considered "too independent" to benefit from geriatric consultation (ie, independent in activities of daily living with short term illness), while 12% were judged "too impaired" to benefit (ie, had severe dementia or terminal cancer). Only 24% of those clinically screened (9% of the entire sample) were considered appropriate for geriatric consultation. Strikingly, over 42% of those patients aged 76 or older, were judged "too independent." These data suggest that a large majority of the hospitalized elderly may be too well to benefit from geriatric consultation, thus making targeting by age alone inefficient. A realistic estimate of the percentage of hospitalized patients appropriate for geriatric intervention lies somewhere between 18% (the combined percentage of those found appropriate and those already enrolled in geriatric programs) and 24% (the proportion of the clinically evaluated group found appropriate). Targeting of subjects may be accomplished inexpensively using the authors' explicit criteria. Such targeting may help focus the use of interdisciplinary geriatric expertise on those most in need.(ABSTRACT TRUNCATED AT 250 WORDS)
View details for Web of Science ID A1988R165000005
View details for PubMedID 3192889
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PUBLIC FINANCING OF MEDICARE
JOURNAL OF THE AMERICAN GERIATRICS SOCIETY
1988; 36 (11): 1061-1066
View details for Web of Science ID A1988Q803500016
View details for PubMedID 3049752
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ASSESSMENT OF DEPRESSION IN GERIATRIC MEDICAL OUTPATIENTS - THE VALIDITY OF 2 SCREENING MEASURES
JOURNAL OF THE AMERICAN GERIATRICS SOCIETY
1987; 35 (11): 989-995
Abstract
The validity of two screening measures for depression was assessed in a geriatric medical outpatient population. Sixty-eight patients completed both questionnaires; 31 also completed a clinical interview allowing for accurate diagnosis. Both screening measures were found to accurately identify those who were depressed. Clinical and research applications are discussed, including the complementary use of these screening measures with the physician's diagnosis.
View details for Web of Science ID A1987K748600002
View details for PubMedID 3668142
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PHYSICIAN MANAGEMENT OF THE DEMENTED PATIENT
JOURNAL OF THE AMERICAN GERIATRICS SOCIETY
1986; 34 (4): 295-308
View details for Web of Science ID A1986A536800007
View details for PubMedID 3512674
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MENTAL STATUS TESTS AND THE CAPACITY FOR SELF-CARE
JOURNAL OF THE AMERICAN GERIATRICS SOCIETY
1984; 32 (1): 49-55
Abstract
To test the hypothesis that self-care capacity can be predicted by tests of mental functioning, the performances of patients in a long-term care institution on a Self-Care Scale were compared with their scores on the Short Portable Mental Status Questionnaire (SPMSQ) and a Mental Competence Scale. The Self-Care Scale measures ability to perform activities of daily living; the SPMSQ assesses memory, orientation, and calculation; and the Mental Competence Scale measures ability to respond sensibly to interview questions and to judge the environment. Many people who had poor scores on the SPMSQ were able to perform activities of daily living in the nursing home setting, but none whose scores on the Mental Competence Scale were fair or poor were independent in activities of daily living. Despite the fact that both the Self-Care Scale and the Mental Competence Scale are still in the developmental stages, the author concludes that the SPMSQ is not an adequate predictor of capacity for self-care. Moreover, the ability to respond appropriately to an interview may be more relevant for daily functioning than are tests of mental status. The three methods of assessment used in this study measure distinct yet complementary components of functioning that need to be considered in evaluating a mentally impaired elderly person.
View details for Web of Science ID A1984SA71600011
View details for PubMedID 6690576