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PubMed2004

Sleep-disordered breathing and nocturia in older adults.

OBJECTIVES: To investigate the relationship between sleep-disordered breathing (SDB) and nocturia episodes in community-dwelling older adults. DESIGN: A cross-sectional study. SETTING: Community. PARTICIPANTS: Community-dwelling older adults (N=72) recruited from independent living facilities and adult learning centers in Atlanta, Georgia. MEASUREMENTS: Three-day voiding diary, ambulatory sleep recording, focused physical examination, Epworth Sleepiness Scale, and Geriatric Depression Scale. RESULTS: Fifty-eight of the 72 subjects completed the study. The mean age+/-standard deviation was 77.7+/-6.7; 44 (76%) were female. Of the 58 subjects, 26 (45%) had an apnea-hypopnea index (AHI) of less than 10 per hour of sleep, 21 (36%) had an AHI between 10 and 24 per hour sleep, and 11 (19%) had an AHI of 25 or higher per hour of sleep. The mean nocturia episodes were 1.7+/-1.1, 1.6+/-0.9, and 2.6+/-1.4 for subjects in these groups, respectively (F=3.82; P=.028). Those with an AHI of 25 or higher had more nocturia episodes, higher mean arterial blood pressure, and higher body mass index than those with a lower AHI. CONCLUSION: These results suggest that older adults with severe SDB have a greater number of nocturia episodes. These findings underscore the importance of considering SDB as a differential diagnosis in the evaluation of older patients with nocturia.

Aged↗

PubMed1991

Quality of life after psychiatric rehabilitation: the clients' perspective.

Fifty-five people discharged from inpatient psychiatric rehabilitation programs were interviewed 1 year after leaving hospital using the Client's Quality of Life Instrument. Following long periods of psychiatric hospitalization, these former patients had adapted to living in the larger community with considerable success. Ninety-six percent felt that their quality of life had improved as a consequence of leaving hospital. Most people had the necessary maintenance skills to live in community settings. They showed appropriate behaviors and blended into the larger community without difficulty. They used outreach support services provided by the hospital to help them in the transition to community living.

Activities of Daily Living↗

PubMed2004

Validating the Time and Change test to screen for dementia in elderly Koreans.

BACKGROUND: We assessed the applicability of the T&C test as an accurate and convenient means to screen for dementia in primary care and community settings. METHODS: The study group comprised 59 patients and 405 community participants, all of who were aged 65 years and over. The time component of the T&C test evaluated the ability of a subject to comprehend clock hands that indicated a time of 11:10, while the change component of the T&C test evaluated the ability of a subject to make 1,000 Won from a group of coins with smaller denominations (one 500, seven 100, and seven 50 Won coins). RESULTS: The T&C test had a sensitivity and specificity of 73.0 and 90.9%, respectively, and positive and negative predictive values of 93.1, and 66.7%, respectively. The test-retest and interobserver agreement rates were both 95% (kappa = 0.91) (time interval, 24 hours). The association between the T&C test and K-MMSE test was modest, while significant (r = 0.422, p < 0.001). The T&C test scores were not influenced by educational status. CONCLUSIONS: We conclude that the T&C test is useful as supplemental testing of important domains (e.g., calculation, conceptualization, visuospatial) to traditional measures such as the MMSE. However, because T&C test is simple, rapid, and easy to use, it can be applied conveniently to elderly subjects by non-specialist personnel who receive training.

Aged↗

PubMed2002

Community-acquired methicillin-resistant Staphylococcus aureus in institutionalized adults with developmental disabilities.

Methicillin-resistant Staphylococcus aureus (MRSA) has recently been reported to emerge in the community setting. We describe the investigation and control of a community-acquired outbreak of MRSA skin infections in a closed community of institutionalized adults with developmental disabilities. In a 9-month period in 1997, 20 (71%) of 28 residents had 73 infectious episodes. Of the cultures, 60% and 32% obtained from residents and personnel, respectively, grew S. aureus; 96% and 27% were MRSA. All isolates were genetically related by pulsed-field gel electrophoresis and belonged to a phage type not previously described in the region. No known risk factors for MRSA acquisition were found. However, 58 antibiotic courses had been administered to 16 residents during the preceding 9 months. Infection control measures, antibiotic restriction, and appropriate therapy resulted in successful termination of this outbreak. Selective antibiotic pressure may result in the emergence, persistence, and dissemination of MRSA strains, causing prolonged disease.

Adolescent↗

PubMed1995

Cost-effectiveness of preventing hip fractures in the elderly population using vitamin D and calcium.

Recent evidence suggests that vitamin D and calcium can reduce the incidence of hip fracture amongst elderly women. We estimated the costs of using either parenteral vitamin D alone, or oral vitamin D plus calcium, in a number of treatment strategies. These were: all women in a community setting; women with low body mass index (BMI) in the community; women in nursing homes; women with low BMI in nursing homes. The cost per averted fracture amongst women living in the community through the use of parenteral vitamin D alone was 946 pounds, and the cost per averted hip fracture was 2317 pounds. Inclusion of calcium significantly increased the cost to 14, 240 pounds for any fracture and 22, 379 pounds for hip fractures. However, targeting either treatment on women with the lowest BMI reduced the cost of averting a hip fracture, as did targeting women living in nursing homes. After removing cost savings from treatment costs, savings to the NHS occurred for all parenteral vitamin D strategies but only one of the oral vitamin D and calcium strategies. Preventing fractures with injectable vitamin D is likely to produce savings for the NHS. The addition of calcium will increase costs significantly unless the intervention is targeted on those at high risk.

Administration, Oral↗

PubMed1993

A strategy to enhance skills. Developing intravenous therapy skills for community nursing.

1. Information abounds on teaching clients, partners and relatives about home i.v. therapy, but there is a lack of training for community nurses in this area. 2. Training for IV therapy has been difficult to develop in community settings, but must involve managers, specialists, and practitioners. 3. Community-led IV therapy training requires resources across acute and community sectors, with skills development through contract learning and focusing skills to specific practice contexts. 4. Training and experience in managing central venous access developed by community nurses are transferable to all clients and to other colleagues.

Community Health Nursing↗

PubMed1997

The role of developmental stimulation in nutritional rehabilitation.

OBJECTIVE: To evaluate the role of developmental stimulation and nutritional supplementation in rehabilitation of malnourished children in the hospital and community settings. DESIGN: Prospective follow up study. SETTINGS: (i) Nutrition clinic of a teaching hospital; and (ii) Community Nutrition Project in coastal Kerala. SUBJECTS: (i) Hospital study: 100 children aged 6-24 months with moderate and severe Protein Energy Malnutrition (PEM) constituted the study group. The control group consisted of well nourished children matched for age and sex, 50 from high (Control I) and 50 from low socioeconomic (SE) status (Control II). The study group was randomized into two subgroups to administer the interventions namely composite stimulation package (STIM) or nutritional management (NUT). (ii) COMMUNITY STUDY: A cohort of 332 children aged 6-24 months with varying grades of PEM were studied. As per the area of residence, they were divided into three subgroups; 2 study groups to administer the two interventions namely STIM or NUT and a control group. METHODS: In both the hospital and community studies, environmental parameters, growth and development were assessed initially. After two years, the study groups were reassessed in comparison with the control groups. A final IQ assessment was done in each subgroup by a tester blinded to the grouping. RESULTS: (i) Hospital study: Control children from high SE status (Control I) had the highest overall scores compared to those from low SE status (Control II) as well as the study groups with PEM even after administering either STIM or NUT. Both the interventions produced a significant positive impact on growth and development, but STIM was found superior to NUT. (ii) Community study: There was a high prevalence of PEM in the community, which reduced significantly after the interventions. STIM was found superior in its positive impact on growth and development. In both studies, direct correlation was observed between environmental parameters and anthropometric scores and between anthropometric scores and IQ. CONCLUSIONS: The benefit of developmental stimulation in nutritional rehabilitation and the need for providing better environment for deprived children are brought out in this study.

Analysis of Variance↗

PubMed2005

Comparing diagnostic checklists for pediatric bipolar disorder in academic and community mental health settings.

OBJECTIVES: To compare six promising mania measures, the Parent Mood Disorder Questionnaire (P-MDQ), the Adolescent self-report MDQ, the 10-item short form of the Parent General Behavior Inventory (PGBI-SF10), the 28-item Adolescent General Behavior Inventory (AGBI), the Parent Young Mania Rating Scale (P-YMRS), and the adolescent YMRS, in a demographically diverse outpatient sample. METHODS: Participants were 262 outpatients (including 164 males and 131 African-Americans) presenting to either an academic medical center (n = 153) or a community mental health center (n = 109). Diagnoses were based on semi-structured interviews with the parent and then youth sequentially. RESULTS: Ninety youths (34%) met criteria for a bipolar spectrum disorder. Parent measures yielded Areas Under the Receiver Operating Curve (AUROC) values of 0.81 for the PGBI-SF10 to 0.66 for the P-YMRS. Adolescent report measures performed significantly less well, with AUROCs ranging from 0.65 to 0.50. There were no significant differences in the diagnostic performance of the measures across the sites or by racial groups, although the reliability of measures tended to be lower in the urban community mental health site. The PGBI-SF10 made a significant contribution to logistic regression models examining all combinations of the instruments. The P-MDQ added information in the younger age group, and no measure improved classification of bipolar cases after controlling for the PGBI-SF10 in the older age group. DISCUSSION: Results replicate previous findings that, in decreasing order of efficiency, the PGBI-SF10, P-MDQ, and P-YMRS significantly discriminate bipolar from non-bipolar cases in youths aged 5-18; and they appear robust in a demographically diverse community setting. Adolescent self-report measures are significantly less efficient, sometimes performing no better than chance at detecting bipolar cases.

Academic Medical Centers↗

PubMed2004

Navigating federalwide assurance requirements when conducting research in community-based care settings.

There is an urgent need for research on quality of life and healthcare delivery for older adults living in community-based care settings, yet implementing current federalwide assurance (FWA) requirements can be a challenge in these settings. This paper discusses FWA requirements for engagement in federally funded research as the requirements pertain to community-based care settings. Factors that impede community facilities in achieving FWA approval include lack of organizational structure to provide oversight for the ethical conduct of research, administrator concerns regarding potential liability associated with obtaining the FWA, lack of resources to complete required paperwork, and lack of staff knowledge about human subjects protection and federal requirements for participating in research. Effects of the FWA process on investigators include the burden of extra time needed to support community-based facilities to acquire a FWA and concerns that studies may be limited to only those community facilities with the resources to complete the FWA process. Investigator-initiated strategies for conducting research in community-based settings include considering study designs that are exempt from the FWA process and proactively assisting community-based facilities to acquire FWA status. Investigators need to work with potential research sites and the office for human research protections to ensure that subjects are protected without shifting the burden of protection to ill-prepared community administrators.

Aged↗

PubMed1997

General practitioners use of hospital and community based paediatric out-patient services in Nottingham.

The paper compares and contrasts the referral patterns of general practitioners in Nottingham for paediatric specialist opinion in a hospital and community setting. Data were collected from case notes review and medical activity data returns on 100 consecutive referrals made by GPs to a hospital paediatric consultant out-patient clinical and 100 consecutive referrals to a community based consultant clinic. Multiple diagnoses are more commonly made and recorded by community based paediatricians with a bias towards behavioural, nutrition, growth and neurodevelopmental problems. Hospital clinic staff made more system and disease based diagnoses with more investigations arranged than the community staff [53 cf. 15 (OR 6.39, 95% CI; 3.25-12.55, P = < 0.0001)]. More children under five were seen in the community clinic sample compared to the hospital sample [75 cf. 57 under fives (OR 2.26, 95% CI; 1.24-4.13, P = 0.01)]. Patients are more likely to be discharged from the hospital clinic than the community clinic after the initial visit. [59 cf. 33 (OR 2.92, 95% CI; 1.64-5.20, P = 0.0004)]. Costs per new case consultation were substantially less in the community clinic than the hospital setting. A broadly similar range of clinic problems are referred to both hospital and community based paediatricians in Nottingham. The educational and liaison value of local community paediatric clinics together with relatively easier access by parents and lower per case costs is an advantage. Commissioners of paediatric and child health services need to take into consideration these factors when purchasing out-patient specialist paediatric opinion. Further research is required into the quality and desirability of these developments.

Ambulatory Care↗

PubMed1997

Midwifery education for safe motherhood.

OBJECTIVE: To determine the useability (relevance, clarity and quality of content), applicability (ease of use) and accessibility (structure and form) of a series of new safe motherhood midwifery education modules. DESIGN: Questionnaire survey and focus group discussions, preceded by a two week clinical skills course and an eight day orientation to using the modules. SETTING: Nursing and midwifery education institutions, regional training centres, acute-care hospital facilities and community settings in Ethiopia, Fiji, Lesotho, Mozambique and Nepal. PARTICIPANTS: Thirty-six teachers, 82 midwives, nurse-midwives and auxiliary nurse-midwives from practice settings, and 60 post basic midwifery students. KEY FINDINGS: Overall it was found that the introductory information and the technical content of the modules were easy to understand and use as were the instructions for both teachers and students. The presentation of the material was orderly and easy to follow; the language was comprehensible; and the illustrations were appropriate, clear and facilitated teaching. The teachers found that they were able to use most of the teaching/learning methods, teach most of the skills in the modules, and use the guidelines for assessing competence. The main difficulties encountered included adherence to the recommended time frame for some of the classroom sessions; the limited availability of clinical cases for teaching the specific skills in the modules and time limitations in the clinical area for practising the skills; and the provision of transport for community visits, data to complete community profiles, and time to complete other planned community activities. The students identified the need for a set of learning materials which they could take with them for future reference, and both teachers and students expressed concern about resources to support, and legislation to cover, the application of the skills taught/learned. KEY CONCLUSIONS: The modules have the potential to strengthen and support the education of midwives in developing countries, enabling them to make motherhood safer and contribute to a reduction in maternal mortality by providing better midwifery care.

Adult↗

PubMed1995

Continuity of care: discharge planning and community nurses.

Continuity of patient care between hospital and community is becoming increasingly important with a trend to shorter hospital stays and more care in the community. This paper describes how community nurses determine patient care provision after hospital discharge. The research presented is a component of a larger study exploring the interface of hospital and community nursing services. Semi-focused interviews were conducted with twelve community nurses to elicit their perceptions and experiences of discharge planning. The findings revealed that although discharge planning influenced continuity of care, community nurses make autonomous decisions about the provision of care to patients in the community setting.

Community Health Nursing↗

PubMedDate not supplied

Documentation in nursing practice.

Accurate documentation is essential to maintain continuity and inform health professionals of ongoing care and treatment. It also provides legal evidence. This article highlights the advantages of accurate record keeping and the barriers to effective documentation in the community setting.

Access to Information↗

PubMed1989

Community health nurses. Their most significant ethical decision-making problems.

Community health staff nurses confront a variety of significant ethical problems in practice that require focused attention in nursing education programs and in community nursing agencies. All community health nurses need to learn to identify ethical problems and to learn a process for resolving these problems that incorporates ethical perspectives. This is particularly critical because nursing colleagues depend on one another for help in dealing with ethical problems in practice. To ignore the ethical problems in community health nursing practice and to neglect to teach the knowledge and skills required to deal with them is to fail to provide nurses with essential skills for providing nursing and health care in community settings.

Beneficence↗

PubMed1981

Social-environmental factors as predictors of adjustment of deinstitutionalized mentally retarded adults.

Mentally retarded adults (N = 338) placed from five state institutions were studied 2 to 4 years, after they were placed in either foster family care or community residences. Factors of the social environment that were most predictive of individual adjustment were determined. Adjustment was defined as behavior in five areas of functioning: self-care, behavior control, community-living skills, use of community resources, and social support. Multiple regression analysis revealed that social environmental factors and other characteristics of community settings played an important role in individuals' adjustment. Important features of the social environment were similar across both settings.

Adolescent↗

PubMed1995

Electronic health records as a key to objective health care needs assessment beyond the hospital boundary.

The continuous challenge within all health services--to use finite resources to the best advantage of patient care--is resulting in the need to ensure that the delivery of care most effectively meets the health needs of the population. Three models of identifying health need are outlined. The development of an integrated real time electronic patent record information system providing comprehensive health needs data is described. It enables the planning of the effective delivery of care to meet the needs of the population and, subsequently, to monitor the effectiveness of care provided; this is seen as an essential step in achieving patient focused care within a community setting.

Community Health Services↗

PubMed1999

Measuring instructional quality in community-orientated medical education: looking into the black box.

OBJECTIVES: Decentralizing medical education to community settings has raised issues of instructional quality. The need to evaluate community-based instruction accents the need to adopt a systems perspective, moving beyond factors known to comprise general clinical teaching effectiveness to include factors that focus on instruction as a process. Application of evaluation models using traditional input-output analysis can be flawed. This approach--dubbed the 'black box'--typically examines inputs and outputs, but often ignores throughputs. DESIGN: In this article we open the black box, using theory to examine the underlying processes that define community-based medical education. We first describe the components and processes of an instructional model that is framed by the philosophy of quality and grounded in experiential learning theory. Without examining the critical processes at work inside the black box - i.e. how students come to acquire clinical knowledge and how behaviours are influenced - it is difficult to assess which programme features contribute to success. Tensions created by the absence of consensus on the outcomes of instruction and the challenge of developing adequate measures are highlighted. SETTING: State University of New York at Buffalo. SUBJECTS: Clinician-teachers, learners and patients in the environment. RESULTS AND CONCLUSIONS: We conclude with describing a tool for evaluating community-based instruction that is guided by the context of our model.

Community Medicine↗

PubMedDate not supplied

Enhancing services for offenders: the impact on treatment completion.

Because of high drop out rates, it is important to determine if enhancing standard substance treatment services will impact treatment completion rates among those in need of specialized services who are involved in the criminal justice system. The purpose of this research was to understand the impact of providing mental health services and gender-specific services for women in a modified therapeutic community setting. In the study, those who received mental health services and/or gender-specific treatment services, in additional to the substance abuse services, had similar rates of treatment completion as compared to those who received only substance abuse services. Logistic regression results indicated that controlling for other variables, age and length of time using one's primary drug were the only statistically significant predictors of treatment completion. The results suggest that the treatment model described in this article is a potentially cost-effective method of maximizing existing resources for treating substance abusing criminal offenders in community-based treatment settings.

Adolescent↗