Biomedical subjects
S Ebrahim
Publications and source records attributed to S Ebrahim.
Postmarketing surveillance studies.
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Outcome measures should be relevant.
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Is relocation harmful to institutionalized elderly people?
One hundred and one elderly continuing-care residents were relocated, from a hospital which closed, to new or refurbished accommodation at another hospital. Barthel and CAPE scores were used to assess changes in disability. Small improvements in disability over the relocation period were seen compared with changes seen over a subsequent, 2-month control period. The monthly mortality rate in the 6 months after relocation was not statistically different from that in the corresponding 6 months the previous year. Relocation to more appropriate accommodation may have had overall beneficial effects on disability.
Elderly bed-blockers in a Thai teaching hospital: is it a problem?
Elderly patients suffer from a wide range of chronic disabling diseases and social problems. These conditions often lead to increased lengths of hospital stay for acute medical and surgical problems--"bed-blocking". By means of a one-day census of all inpatients at Chulalongkorn Thai Red Cross Hospital the number and reasons for continued hospital stay of all patients, classified by age (less than 60, and 60+ years), were measured. Of 191 medical inpatients surveyed, 34 per cent were 60 years and over. More older than younger patients were still in hospital for non-medical reasons (35% vs 21%, Chi-square = 4.89, p < 0.01). Durations of hospital stay were longer for older patients: median stay 8 and 11 days respectively for those less than 60 and those 60+ years. Early discharge of disabled elderly people to their families was achieved by vigorous social work, thus reducing the extent to which elderly patients become bed-blockers. Further demographic trends, coupled with a breakdown of the extended family structure, will make bed-blocking a very likely problem. The present patterns of care may lead to poor long-term outcomes for the elderly.
Assessing the effects of a health promotion programme for elderly people.
Physical exercise is an increasingly popular health promotion activity for elderly people, although evidence of its effectiveness is limited. We aimed to evaluate the impact of the exercise component of the Look After Yourself (LAY) package promoted by the Health Education Authority in two groups of elderly people attending the 10 weekly sessions which make up the LAY course. Classes 1 and 2 comprised 13 and 18 subjects, aged from 65 to 89 years, and from 58 to 87 years respectively. Class 1 subjects were white with the exception of one Jamaican man, and Class 2 subjects were all Afro-Caribbean. Subjects had measurements of shoulder joint flexibility, grip strength, blood pressure, weight and a self-perceived health questionnaire, the Nottingham Health Profile (NHP) completed at baseline, 10 weeks and at six months. Class 1 showed reductions in grip strength and a deterioration in pain and mobility dimensions of the NHP, whereas Class 2 showed large improvements in shoulder joint flexibility and a small and non-significant trend towards improved self-perceived health. Class 2 subjects felt that they had benefited, and just over half had continued with an exercise programme. These findings suggest that the effect of mild exercise on objective indicators and self-perceived health may depend on the context in which it is done, the type of exercise promoted, and that continued exercise is aided by the provision of further group classes. There is a need for evaluation of the impact of different types of exercise programmes, covering a wider range of indicators of fitness, in larger groups of elderly people.
Long-term institutional residents: does the environment affect outcomes?
Quality in institutional care is frequently questioned, yet there has been little research on the effects of different environments on important outcomes such as disability and quality of life. These outcomes are difficult to measure, and randomised trials difficult to perform. An alternative to formal trials is to assess the effects of 'natural experiments' arising from service reforms. We have studied the relocation of 95 residents from the continuing-care wards of a hospital which closed to two different ward environments: one new and purpose built, the other refurbished maternity wards. Deaths and changes in disability over 12 months from pre-relocation measurements were recorded, using the Barthel Index and Clifton Assessment Procedure for the Elderly (CAPE) Behavioural Rating and Cognitive Assessment Scales. No advantage could be shown for the new wards in terms of changes in disability; in fact, Barthel scores improved more on the refurbished wards (the difference being 2.5 points at 4 months, p less than 0.0005). Changes in CAPE scores did not differ between the wards. Mortality at 1 year was 44%, with no significant difference between the ward types. Logistic regression analysis and multivariate analysis of variance showed this effect to be independent of initial differences between the groups. Efforts to improve quality in long-term care for the elderly are not wholly dependent on the provision of expensive new facilities.
Delirium in newly admitted elderly patients: a prospective study.
The prevalence, associated conditions and outcome of delirium were studied in a consecutive series of 184 patients admitted with acute illness to a department of health care of the elderly. Forty of these elderly subjects (22 per cent) met Diagnostic and Statistical Manual version 3 (revised) criteria for delirium. Screening for delirious patients using the abbreviated mental test on admission gave a high sensitivity (92 per cent). The conditions most commonly associated with delirium were infection and stroke. Onset of acute illness of less than 15 days, a reported history of dementia or recent confusion, and presence of a definite site of infection were much more likely in those with delirium. Serial use of the abbreviated mental test was a sensitive means of distinguishing delirious from other patients and may be useful in both the clinical and research setting. Delirious patients had more serious pre-existing disease than non-delirious patients. They had a higher number of admissions during the 2 years prior to the index admission, a higher mortality rate and a higher rate of transfer to long-stay care than other patients, but no difference in duration of admission. All acutely ill elderly people should undergo an abbreviated mental test on admission, and if abnormal, this should be repeated as it will aid detection of delirium.
The valuation of states of ill-health: the impact of age and disability.
The effects of age and disability on valuations of health states used in deriving QALYs have not been examined. We compared the valuations of seven states of immobility and pain given by 88 subjects aged 20-89 years, and of various degrees of disability. They were asked to score each state, their present health and death, on a range from 'best' to 'worst' health. Only two states of health (no disability but moderate pain, and slight disability and moderate pain) were valued differently by older subjects. Disabled subjects tended to rate most ill-health states more adversely, and to rate death as substantially better than more severe states of ill-health. The development of explicit valuations of survival should take into account differences caused by disability, and examine other dimensions of illness experience.
A randomized controlled trial of nursing home and long-stay geriatric ward care for elderly people.
This paper reports outcome data on mental and physical ability levels, mortality and accident rates, from a randomized controlled trial evaluating health authority funded nursing home and long-stay geriatric ward care in one inner London health district. There were no differences between settings in mortality rates, although respondents randomized to the nursing homes deteriorated more rapidly in overall, mental and functional ability levels. Previous analyses reported that they also experienced a higher accident rate than respondents in the wards. However, observational data from the evaluation clearly indicated that quality of life in the homes was superior to that in the wards. We conclude that the more rapid physical decline and greater risk of accident in the nursing homes have to be balanced against an inferior quality of life in the hospital, and that a judgement is not easy to make on behalf of other people.
The abbreviated mental test: its use and validity.
The validity of the Abbreviated Mental Test was demonstrated by comparison with final clinical diagnoses in a consecutive sample of 168 patients admitted with acute illness to a department of health care of the elderly. Fifty-eight (34%) had abnormal cognition. The best cut-off point was 8, with less than 8 suggesting abnormal cognitive function. A short version (the AMT7) of the AMT was developed. Its validity, internal consistency and coverage of domains was equivalent to the AMT but it had a slightly higher sensitivity (with acceptable specificity) than the original. This new short version may improve performance of junior doctors in clinical practice who appear to have difficulty remembering all 10 items of the AMT.
Prevalence and severity of morbidity among Gujarati Asian elders: a controlled comparison.
Asian elders make relatively heavy use of health services: this may be due to higher levels of morbidity, but controlled comparisons have not been carried out. A comparison of the prevalence and severity of chronic diseases and use of health services of Asian and indigenous elders was made. A sample of 59 Gujarati Asians of mean age 62.9 years and 59 indigenous subjects of mean age 63.9 years of whom 42% (25 in each group) were female drawn from a general practice was studied. Asian subjects had a higher prevalence of diagnosed diseases, with the exception of chronic obstructive airways disease, but lower risk of falls and urinary incontinence. Asian subjects had higher life satisfaction scores and lower prevalence of depressed mood. Asian women were more likely to have had contact with primary care services. Both Asian men and women had more frequent hospital admissions, but similar levels of out-patient attendance. Body mass index, blood pressure and shoulder joint range of movement were similar for both Asians and the indigenous population. Asian subjects had significantly lower peak expiratory flow rates and hand grip strength. Asian elders have a higher risk of chronic diseases, but the impact of disease (indicated by life satisfaction, mood, and common disabilities) is less than among the indigenous population. Lower peak expiratory flow rates and grip strength among Asian elders are of concern since they may lead to premature arrival at age-related thresholds of physical capacity essential for independence in activities of daily living.
Prevalence and diagnosis of chronic respiratory symptoms in adults.
OBJECTIVE: To investigate the prevalence and diagnosis of chronic respiratory disease in adults. DESIGN: Screening questionnaire was sent to all patients aged 40-70 on the register of a group general practice; those responding positively were sent a detailed questionnaire and invited for assessment of respiratory function by forced expiratory volume in one second, forced vital capacity, peak flow rate, and reversibility studies with a beta adrenergic inhaler. SETTING: Group general practice in south west London. RESULTS: Of 2387 patients aged 40-70, 1444 completed a screening questionnaire. Of the 509 patients who reported cough, phlegm, wheeze, or shortness of breath, 324 responded to a detailed questionnaire, 256 of whom had simple respiratory function assessed. Chronic bronchitis affected 106 (17%) men and 58 (7%) women, and wheeze occurring at least once a week affected 60 (9%) men and 20 (3%) women. Only a half to a third of patients had received a diagnostic label of chronic bronchitis or asthma for their symptoms. There was considerable clinical and physiological similarity (including reversibility of the airways) between patients labelled as having asthma and having chronic bronchitis. A label of asthma was used more often for patients of social classes I and II. CONCLUSIONS: Comparison with prevalence surveys carried out in the 1950s showed that respiratory symptoms are as common now as then, but the risk of disabling chronic bronchitis has fallen, more among men than women, probably because of their reduced smoking. Changes in diagnostic fashion, together with increased detection, may have contributed to the upward trend in reported morbidity from asthma over the past 30 years.
Vitamin C status and other nutritional indices in patients with stroke and other acute illnesses: a case-control study.
Sixty-three patients with acute thrombotic stroke were compared with 47 age and sex-matched patients admitted concurrently with acute ischaemic cardiac pain and a further 44 with acute noncardiovascular illnesses. Overall the stroke patients scored highest on a questionnaire designed to estimate mean daily intake of vitamin C before hospital admission. There were problems with this retrospective dietary assessment, however, and the diet scores of the 27 stroke patients able to answer the questionnaire themselves fell between those of the other two groups. There were no significant differences between the three patient groups in plasma ascorbic acid or uric acid levels, but plasma magnesium and albumin levels were higher in the stroke patients. These findings were similar for patients aged over and under 70 but intergroup differences in magnesium and albumin levels were more marked in the elderly. These results do not support the postulated inverse relationship between vitamin C status and the risk of stroke.
Treatment of adult asthma: is the diagnosis relevant?
The diagnosis and management of chronic respiratory symptoms was studied in all adults aged 40-70 years in a group general practice. A respiratory symptoms screening questionnaire was sent to 2387 men and women, of whom 1444 (85% of those who had not moved or died) responded. The 509 subjects reporting symptoms were sent a detailed questionnaire and invited to have their respiratory function tested. Of these, 324 (64%) responded, of whom 256 (79%) had spirometry. A diagnosis of chronic bronchitis was reported by 3.9% of the men and 2.1% of the women, and a diagnosis of asthma by 4.7% of the men and 3.3% of the women. Wheezing in the preceding year was reported by 18% of the men and 15% of the women, and 16.7% of the men and 7.1% of the women satisfied the Medical Research Council criteria for chronic bronchitis. Bronchodilator treatment was being taken by 12% of the patients with symptoms, regular cough linctus by 10%, and regular antibiotics by 5%. After the frequency and severity of respiratory symptoms had been controlled for wheezing patients reporting a diagnosis of asthma were prescribed bronchodilatory drugs three times more often than those labelled as having chronic bronchitis and 12 times more often than those without a diagnostic label. Eleven per cent of general practitioner consultations resulted in a referral to hospital. Referral was unrelated to the diagnosis given, but depended on the degree of respiratory disability and handicap experienced by the patient. Our findings confirm the relevance of the diagnostic label to the drug management of chronic wheezing disorders, but further investigation of the diagnostic process is needed to establish why some patients with severe wheeze remain untreated.
Bacterial resistance to trimethoprim in geriatric medical wards.
Urinary tract infections (UTI) caused by organisms resistant to trimethoprim (TMP), as well as their faecal carriage were studied in two geriatric wards. TMP-resistant UTI was common (26 and 50% of admission and ward-acquired infections, respectively) and was associated with male sex, recurrent and transferred admissions and length of stay. There was a strong relationship between faecal carriage and isolation of TMP-resistant organisms from urine. Antimicrobial exposure was the major determinant of TMP-resistant faecal carriage.
Prevalence, frequency, and duration of hypnotic drug use among the elderly living at home.
Details of consumption of hypnotic drugs derived from a nationally representative sample of elderly people were analysed in terms of the prevalence, duration, and likely frequency of use. Of 1020 randomly selected subjects aged 65 and over 16% (166) reported using (mainly benzodiazepine) hypnotic drugs, and of these 89% reported having taken such a drug the night before the interview. Most of these users (73%) had been taking hypnotic drugs for more than one year, with 25% reporting drug use for more than 10 years. These results suggest that for most elderly users of hypnotic drugs, patterns of consumption encourage the development of cumulative effects and benzodiazepine dependence.
Characteristics of subjective insomnia in the elderly living at home.
Profiles of sleeping habits, subjective sleep quality, and mental and physical well-being were obtained from 1023 elderly individuals randomly sampled from the Nottinghamshire Family Practitioner Committee's records. Subjective insomnia at least 'sometimes' was reported by 37.9% of the sample. Discriminant analysis of selected health and demographic variables indicated that symptoms of anxiety, sex and self-ratings of health were the factors most influential in predicting reports of problem sleep. Thus, respondents classified as subjective insomniacs tended to have significantly higher anxiety scores, to be women, and to rate their health as below average. Relative to the non-insomniac respondents, those complaining of sleep problems also perceived their sleep latency as longer, and their total sleep as shorter. These results emphasize that, in addition to apparently 'normal' age-related changes in the structure of sleep, subjective insomnia in old age may often be mediated by the physical and psychological disorders which can accompany ageing.