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When Proposition 99 tobacco control program funding to state health departments was reduced in 1993, Contra Costa County developed a strategy to institutionalize its tobacco control programs in other organizations. This effort identified seven funding priorities and three stable, experienced community organizations "adopted" these priorities.
Urinary incontinence among institutionalized elderly were analyzed from clinical and social viewpoints. The patient group included 25 males and 107 females with an average age of 78 years (ranged from 66 to 92). They had neither highly impaired performance status nor severe dementia. Forty-nine of them (37%) underwent urological examination. Urge incontinence was common among male patients, while urge, stress or mixed incontinence were prevalent in female patients. Thirty-six per cent of the patients had to use pads, diapers and others for their incontinence, while other needed no special protection for their incontinence. Incontinence caused limitation of social activity in 30% of the patients. Many causal factors were assumed for incontinence in elderly; weakness of the pelvic muscles, urinary tract infection, cerebrovascular disorders, neurological disorders and prior pelvic surgery. Prostatic carcinoma or urethral stricture caused overflow incontinence in a few patients. Diuretics or tranquilizers appeared to lead incontinence in some patients. Nine of 18 patients undergoing cystometry had overactive detrusor. Majority of the incontinent elderly showed no intention to visit clinics. Therefore, it recommended to keep staffs in elderly institutions as well as elderly themselves informed that incontinence in the elderly should be treated, which in turn improves the quality of life.
Prevalence of micturition problems among 1,023 institutionalized elderly was surveyed by a questionnaire. The reply was obtained from 821 elderly (80.3%) including 276 males and 545 females with ages averaged 77 years (range 61 to 96 years). They had neither highly impaired performance status nor severe dementia. Micturition problems were complained by 38% of male responders, where micturition difficulty was the most common. On the other hand, 23% of female responders answered having micturition problems and urinary frequency was the most common. One hundred and twenty-four of total responders (15%) replied to have urinary incontinence; 8% in men and 19% in women. Over half of patients with marked objective incontinence denied its presence or refused to answer. Seventy-one per cent of the incontinent elderly had no intention to receive medical care. From the above facts, it seems that many elderly have micturition problems and the incidence of urinary incontinence is latently higher than complained at survey.
All federally funded facilities are required to use the Minimum Data Set Plus (MDS+) for functional assessment of their residents. Within the MDS+ there are 18 specific conditions addressed through Resident Assessment Protocols (RAPs). The purpose of this study was to determine if MDS+ items not included in the pressure ulcer RAP correlated with pressure ulcer prevalence in newly institutionalized elderly. Additionally, this study examined whether the addition of nutritional status information to the correlated items increased association with pressure ulcer prevalence. Data were collected through a retrospective chart review of 990 residents over age 65 at eight nursing homes. Pressure ulcer prevalence was 33.2%. Nineteen of 59 non-RAP MDS+ items were correlated with pressure ulcer prevalence. Logistic regression determined that 10 MDS+ items predicted pressure ulcer prevalence in 28.88% of the subjects. Including serum albumin in the logistic model increased the predictability for pressure ulcer prevalence to 36.3%. Results of this study demonstrate the strong association between nutrition and pressure ulcer prevalence and the need to revise the pressure ulcer RAP.
Kimberly presents a case study of the birth and early development of an innovative medical school. When the school opened in 1971, the existing 86 medical schools all offered similar programs: two years of basic science training in lecture halls and laboratories, followed by two years of direct contact with patients in clinical settings. In the new school, students were taught didactically only during the first year. During the second year, each student was assigned to a community physician who acted as an advisor and who discussed with students those patients afflicted with the diseases the student was currently studying. Available evidence indicated that the school's innovative curriculum was favorably received by the students and that they performed as well as their peers on standardized year-end exams. The author found the case of this medical school to be of particular interest from an organizational viewpoint in that: (1) the early development of the school was shaped by the first dean's entrepreneurial activity, ambitions, visions, strengths, and weaknesses; (2) the uncertainty resulting from the school's novelty forced individuals to assume new roles and face unclear performance criteria; and (3) the transition of an innovative school to an institutionalized one was problematic because it modified the decision-making process. The author suggests that those things which lead to an organization's success during its early years are not the same as those that lead to longer-run success. He says that a new organization creates new norms, values, and procedures whereas the elements of an existing organization interact within an established culture. He concludes that organizational birth is a phenomenon about which relatively little is known, but which may be an important constraint on later development. A comparative analysis of the birth, life, and death of organization is advocated.
Services for the non-institutionalized patients with epilepsy have been the subject of a number of government sponsored reports. The recommended expansion in specialized services (for example, the special centres and the hospital-based epilepsy units) has not come about, and, as a result, services for epilepsy in the UK do not conform to the highest international standards. This paper reviews recent US findings with regard to the cost of epilepsy: contrasts recent developments in the US with those in the UK: emphasizes the need for further audit of the hospital facilities in this country: outlines the role of specialized epilepsy services and the structure these services might take in the UK.
The author contrasts the "paternalistic" and the "civil libertarian" views of non-consensual treatment of institutionalized psychiatric patients. Citing court cases and relevant literature, he emphasizes that competent patients have the right to refuse treatment, even when this decision is considered foolish. Involuntary hospitalization need not imply incompetence to refuse treatment, and the determination of such incompetence should be subject to rigorous safeguards. The nature of psychiatric treatment and the institutional setting necessitates procedures to ensure that consent truly is voluntary and informed. For patients judged incompetent, the decision to treat without consent should be influenced by various considerations related to diagnosis, prognosis, and the nature of the proposed treatment.
As a large percentage of the elderly population will spend some time in long-term facilities such as nursing homes, it is important to ensure the best possible conditions for residents and staff of these facilities. The authors describe the application of the eight components of the "normalization principle" to the institutionalized elderly as a valuable, systematic approach to maintaining the quality of life in long-term facilities. They suggest methods of promoting normal daily, weekly, and yearly rhythms, normal life-cycle experiences, and normal social, sexual, economic and environmental conditions within the framework of the long-term facility.
Several factors, such as disability, malnutrition, weight loss, and the interactive effect of diseases and aging have been associated with morbidity and mortality in the elderly population. Nevertheless, the relationship between disability and biological parameters has not been extensively investigated as a primary focus. In a cross sectional survey, 344 institutionalized elderly subjects were evaluated. Disability was measured according to the Katz index, and patients were divided into three groups: low (0-1 lost ADL), mild (2-4 lost ADL), and severe (5-6 lost ADL). Anthropometric, metabolic, and nutritional parameters were assessed; age, gender, number of pathologies, and number of drugs were also recorded. Data were analyzed by multiple comparison of means according to Scheffé, and by multivariate logistic regression analysis. An impairment in functional status was associated with several modifications in biological parameters. Logistic regression analysis showed that severe disability (5-6 lost ADL) was associated with low waist/hip ratio (< 0.9 vs > 0.9, OR: 1.56, CI 95%: 1.08-2.25), high body resistance (> 625 vs < 575 omega, OR: 1.39, CI 95%: 1.38-1.39), low plasma albumin levels (< 3.5 vs > 4.0 g/dL, OR: 6.02, CI 95%: 5.18-6.85), and low plasma transferrin levels (< 200 vs > 250 mg/dL, OR: 5.47, CI 95%: 4.56-4.58) independently of age, gender, comorbidity, and other confounding factors. Our results indicate that severe disability in ADL is strongly associated with anthropometric and biohumoral parameters suggesting the presence of malnutrition. A careful evaluation of the nutritional state appears to be of primary importance, and efforts to improve nutritional status are needed in approaching disabled elderly patients.
Epidemiological studies suggest that at least 1.5 million skin tears occur each year in institutionalized adults. Despite this incidence, very little is known about the management of skin tears in elderly persons. Studies related to wound dressings and healing rates for these skin tears have rarely been reported in the medical literature. A randomized, prospective trial of 37 subjects compared the treatment of skin tears using either an opaque foam dressing or a transparent film dressing. Subjects had either a modified Payne-Martin Category II (25%-75% epidermal loss) or Category III (100% epidermal loss) skin tear. Category I skin tears (linear with no tissue loss) and skin tears greater than 48 hours old were excluded. Mean subject age was 85.1 +/- 9.7 years. Subjects were followed weekly until healed or for up to 21 days. Subjects in the comparison groups did not differ at baseline in age, sex, wound severity score, presence of diabetes, nutrition score, ambulation and mobility score, or mental status score. Complete healing occurred in 94% (16/17) of subjects treated with the foam dressing as opposed to 65% (11/17) of subjects treated with the film dressing (P < 0.05). Complete healing correlated only with dressing type (P < 0.05) and age (P < 0.01). No other factor was associated with the healing outcome. The number of dressing changes was similar in each group, 3.1 +/- 1.2 versus 3.4 +/- 1.1. Based on the results of this study, we conclude that this opaque foam dressing is a superior wound dressing for skin tears.
This study was carried out among 287 institutionalized elderly aged 60 years and above residing in Mangalore. The oral health status was assessed using the modified Oral Health Assessment Form. The most frequently observed periodontal condition was shallow pockets seen in 32.29% of the dentate subjects. None of the subjects were found to have a completely healthy periodontium. The dental caries prevalence was found to be 77.6%. The mean DFT of the dentate subjects was 3.64 with the mean DT and FT being 3.58 and 0.06 respectively. The mean DFT was found to increase with advancing age. Findings also suggest that edentulousness is directly proportional to the period of stay in the old age home and inversely proportional to the mobility of the individual.
Nutritional status and vitamin B6 status were assessed in 18 men and 32 women, average age 84, living in a home for the aged. Average proportion of energy derived from protein was higher than the recommended; fiber intake was very low. Also low were intakes of calcium, magnesium, zinc, copper, vitamins D and E, thiamin, folic acid and vitamin B6. Supplementation with vitamin B6 (10 mg/d) for 28 days in those with the lowest B6 status assessed by B6 intake, activation coefficient of aspartate transaminase and plasma pyridoxamine concentrations led to improved B6 status (marked decrease in activation coefficient) and increased synthesis and decreased degradation of many short-lived neutrophil proteins. Though our elderly enjoy a variety of foods, some have marginal deficiencies that can be improved. Therefore, in the institutionalized elderly, micronutrient supplementation should be administered at a level low enough to be safe (below recommended upper level of intake) but high enough to be effective.
The fight against smallpox epidemics in the Granada at the end of the 18th and beginning of the 19th centuries involved a whole series of actions which demonstrated the new ways of treating the disease. First the application of the innoculation and then the vaccination coincided with a greater general concern for the health of the population. At this time and especially with the arrival of José Celestino Mutis on Latin-American soil science in Colombia embarked upon an institutionalization process which also involved Medicine. José Salvany's proposals of stablishing Central Vaccination Committees were made in this context. The analysis of these proposals and their contribution towards "establishing institutional spaces" are the axes upon which this study is based.
A measure which is used to count kinds of social behavior in more severely mentally retarded residents was described in this study. The measure is an aggregate or sum, and it is referred to as the Sum of Adjusted Behavior. In this study, we determined measures of social adjustment which are useful for obtaining population parameters. Data concerning the relationship between the Sum of Adjusted Behavior and CA to MA, age at time of institutionalization, gender, medical diagnosis, medication, and social behavior were discussed. The relationships between adjustment and adaptive behavior were also defined on the basis of the findings.
BACKGROUND: There is no systemic disease, which so frequently gives rise to disorders of the eye as leprosy does. The study was conducted to determine the prevalence and gravity of ocular complications in institutionalized leprosy patients in NWFP. It is important to provide necessary information to leprosy health workers and general physicians in order to sensitize them to early detection and treatment or referral to appropriate centre. METHODS: A prospective study of ocular complications of leprosy patients was conducted at the leprosy centre of Lady Reading Hospital Peshawar and the Leprosy Hospital Balakot, district Mansehra. The study included a record of the name, age, sex, type, duration of disease and completion of multi-drug therapy (MDT). Classification of the patients was done according to Ridley and Jopling 5-group system. Visual acuity was tested by Snellen chart and those patients having a vision of less than 3/60 were labelled as blind. Ocular adnexa were examined by naked eye and lacrimal sac regurgitation test was done. Slit lamp biomicroscopy was done for anterior segment examination and direct ophthalmoscope was used for fundoscopy. RESULTS: The authors studied 143 patients in the above mentioned leprosy centres. Out of these, 59 had lepromatous leprosy, 39 borderline tuberculoid leprosy, 9 tuberculoid leprosy, 33 borderline lepromatous leprosy, and 33 borderline leprosy. The majority of patients came from the northern districts of NWFP, including Malakand division and district Mansehra. The male to female ratio was 4:1. The age of the patients ranged from 14 to 80 years and the duration of the disease ranged from 1 year to 48 years. Ocular complications were found in 73% of the patients. These complications included loss of eyebrows in 57 patients, loss of eyelashes in 37, corneal changes (including opacity, ulceration, and/or anaesthesia) in 44, iridocyclitis in 31, lagophthalmos in 36, ectropion in 13, and chronic dacryocystitis in 3. Of the total of 15 (11%) patients who went blind from ocular complications, 16 eyes did so due to corneal opacities, 6 eyes due to cataract, 5 eyes due to chronic anterior uveitis and one eye due to corneal ulcer, panophthalmitis and phthisis bulbi each. CONCLUSIONS: A significant number of leprosy patients (73%) have ocular complications. The frequency of ocular complications increases with the increasing age and duration of disease of the patients.
Aging is associated with increased risk of developing anaemia and micronutrient deficiencies. The purpose of this study was to evaluate the daily intake of micronutrient whose deficient in diet could cause anaemia (iron, folic acid, vitamin B12) and vitamin C to establish the prevalence of anaemia in a group of institutionalized of 124 elderly subjects residing in five nursing homes in León (Spain). A precise weighing method was used to conduct the control of food intake covering seven days. Energy, alcohol, iron, folate, vitamin B12, and vitamin C intake were obtained. Weight, and Height also were measured. Serum iron, serum ferritin, haemoglobin and hematocrit were also measured. Average daily iron intake was higher than the 10 mg recommended by the National Academy of Science although significantly higher (p < 0.05) in males (17.0 +/- 7.4 mg) than in females (11.8 +/- 1.5 mg). Moreover, vitamin C intake in all subjects is high (118.8 +/- 43.7 mg) and higher than Spanish RDA (198%). Average intakes of folate and vitamin B12 in the present study exceeded the RDA, (103% and 144%). However, 45.83% of males and 5.97% of females showed deficiencies in vitamin B12 and 53.91% of the subjects showed deficiencies in folic acid. The average haemoglobin concentration (14.28 +/- 1.33 g/dL), hematocrit percentage (43.71 +/- 6.31), ferritin concentration (87.01 +/- 59.74 ng/mL) and serum iron (85.36 +/- 33.98 micrograms/dL) showed similar figures to the results obtained in other studies carried out on elderly populations. It would be necessary to adequately compose the menus given in nursing homes, decreasing energy contribution, and supplying micronutrient rich foods or fortified foods.
The author attempts to describe the different strengths that emerge from the role of the supervisor (clinic) in a community organization in relation to two aspects: the maintaining of the defining characteristics of the notion of "alternative" and the dynamic understanding of the social worker-user relationship. After a review of how a day centre operates, the author describes the individual and collective "defense mechanisms" that are used by social workers to alleviate the impact of the user's baffling behaviour on their personality. The author follows by showing that failure to use these defense mechanisms can lead to burnout for the social worker, while certain forms of collective defense mechanisms can prompt this alternative care system to institutionalize itself from within.
Although Down syndrome children are known to be greatly predisposed to periodontal disease when compared with normal children, the preventive dental health practices of non-institutionalized Down syndrome children have not been well reported. This questionnaire study of 25 Down syndrome children aged 1-14 years compared with 25 normal control children showed that Down syndrome children have poorer dental health practices compared with normal children. Significantly greater numbers of Down syndrome children were weaned from the bottle at greater than 18 months of age (56% vs 24%, p less than 0.05) or had taken a bottle to bed (40% vs 12%, p less than 0.05), indicating their increased risk for the development of nursing bottle caries. In addition, Down syndrome children were receiving less help during tooth brushing (60% vs 84%, p less than 0.05), were older when they first visited the dentist, and less likely to be taking regular fluoride supplements. These results indicate that Down syndrome children are further disadvantaged by poor preventive dental health practices and should be targeted for increased preventive dental care.