Effect of home-based light treatment on persons with dementia and their caregivers

Sleep disorders are problematic for persons with dementia and their family caregivers. This randomized controlled trial with crossover evaluated the effects of an innovative blue-white light therapy on 17 pairs of home-dwelling persons with dementia and their caregivers. Subjects with dementia received blue-white light and control ('red-yellow' light) for six weeks separated by a four-week washout. Neither actigraphic nor most self-reported sleep measures significantly differed for subjects with dementia. For caregivers, both sleep and role strain improved. No evidence of retinal light toxicity was observed. Six weeks of modest doses of blue-white light appear to improve sleep in caregivers but not in persons with dementia. Greater or prolonged circadian stimulation may be needed to determine if light is an effective treatment for persons with dementia.

Dizziness: state of the science

Dizziness is prevalent in all adult populations, causing considerable morbidity and utilization of health services. In the community, the prevalence of dizziness ranges from 1.8% in young adults to more than 30% in the elderly. In the primary care setting, dizziness increases in frequency as a presenting complaint; as many as 7% of elderly patients present with this symptom. Classification of dizziness by subtype (vertigo, presyncope, disequilibrium, and other) assists in the differential diagnosis. Various disease entities may cause dizziness, and the reported frequency of specific diagnoses varies widely, depending on setting, patient age, and investigator bias. Life-threatening illnesses are rare in patients with dizziness, but many have serious functional impairment. Dizziness can be difficult to diagnose, particularly in elderly persons, in whom it often represents dysfunction in more than one body system. Given the relatively underdeveloped state of the empirical literature on dizziness, investigators would benefit from use of consistent criteria to describe dizziness symptoms and establish diagnoses. Investigation of the effects of testing and treatment should focus on diagnoses that are life threatening or lead to significant morbidity. In the elderly, a function-oriented approach should be studied and compared with current diagnosis-focused strategies. Alternative therapies for chronic and recurrent dizziness also merit investigation.

Low bone mineral density and risk of fracture in white female nursing home residents

CONTEXT

Low bone mineral density (BMD) is a strong risk factor for fracture in community-dwelling white women, but the relationship in white female nursing home residents, for whom fracture rates are highest, is less clear.

OBJECTIVE

To assess the relative contribution of low BMD to fracture risk in nursing home residents.

DESIGN

Prospective cohort study with baseline data collected April 1995 to June 1997, with 18 months of follow-up.

SETTING

Forty-seven randomly selected nursing homes in Maryland.

PATIENTS

A total of 1427 white female nursing home residents aged 65 years or older.

MAIN OUTCOME MEASURE

Documented osteoporotic fracture occurring during follow-up as a function of baseline BMD measurements higher vs lower than the median, and after controlling for demographic, functional, cognitive, psychosocial, and medical factors.

RESULTS

A total of 223 osteoporotic fractures occurred among 180 women. Low BMD and transfer independence were significant independent risk factors for fracture in this nursing home sample (P<.001) and the 2 factors acted synergistically (P =.06) to further increase fracture risk. Compared with women whose BMD was higher than the median (0. 296 g/cm(2)), those whose BMD was lower than the median had an unadjusted hazard ratio for risk of fracture of 2.1 (95% confidence interval [CI], 1.5-2.8); women who were independent in transfer had a hazard ratio of 1.6 (95% CI, 1.2-2.2) compared with women dependent in transfer. Among residents independent in transfer, those with BMD below the median had a more than 3-fold increase in fracture risk compared with those with higher BMD (unadjusted hazard ratio, 3.1; 95% CI, 2.2-4.4). Among residents dependent in transfer, those with BMD below the median had a 60% increase in fracture risk (unadjusted hazard ratio, 1.6; 95% CI, 1.1-2.3). Adjustment for covariates did not alter the BMD-fracture relationship.

CONCLUSIONS

Our data indicate that low BMD and independence in transfer are significant predictors of osteoporotic fracture in white female nursing home residents. JAMA. 2000;284:972-977

Specialized dementia programs in residential care settings

The authors conducted a telephone survey in 7 states to determine the prevalence of residential care specialized dementia programs (RC-SDPs) and to identify a sample of homes (n = 56) for more detailed study. The 56 homes were site visited, and data were gathered on facility administration, therapeutic environment, and characteristics of 259 randomly selected residents. Comparison data from 138 nursing home Special Care Units (NH-SCUs) and 1,340 of their residents were obtained from 4 studies conducted in the same 7 states. RC-SDPs were smaller, provided a more homelike environment, and had a higher proportion of residents paying privately, compared with NH-SCUs. Mean levels of cognitive and physical impairment among residents were higher in NH-SCUs; prevalences of psychotropic medication use and problem behaviors were similar. Among RC facilities, small homes were more homelike, provided fewer structured activities, and charged less than larger facilities. RC-SDPs include 5 types: small, independently operated homes; multiple small homes with joint administration; larger, all-dementia facilities; SDPs operated within larger, exclusively RC facilities; and RC-SDPs in multilevel facilities.

Use of physical restraints and psychotropic medications in Alzheimer special care units in nursing homes

OBJECTIVES

This study analyzed the use of mechanical restraints and psychotropic medication in Alzheimer special care units (SCUs) in nursing homes.

METHODS

We analyzed 1993 data for more than 71,000 nursing home residents in 4 states, including more than 1,100 residents in 48 SCUs. The dependent variable in multinomial logistic regression was use of physical restraints or psychotropic medication. Models contained covariates representing facility and resident characteristics, and multivariate matching strategies were used to protect against selection bias.

RESULTS

Residents in SCUs did not differ from similar residents in traditional units in their likelihood of being physically restrained. Residents in SCUs were more likely to receive psychotropic medication.

CONCLUSIONS

With regard to the measures used in this research, the findings indicate that residents in the SCUs in the 4 study states did not receive quality of care superior to that provided to similar residents in traditional units. In fact, the results related to drug use raise the question of whether some may have received poorer care.

Severe disruptive vocalizers

OBJECTIVES

To describe the most severe disruptive vocalizers in nursing facilities, in regard to their clinical and behavioral characteristics, staff responses, and treatments used, and to report on their prognosis over 6 months.

DESIGN

A longitudinal cohort study.

SETTING

One hundred seven skilled nursing facilities.

PARTICIPANTS

The 203 residents who were among the two most disruptive vocalizers in their respective facilities and who vocalized at least 2 hours a day.

MEASUREMENTS

Telephone interviews of licensed nursing staff who cared for the subjects, conducted at baseline, 2, 4, and 6 months. Data gathered included subject demographics, physical function, diagnoses, medication and restraint use, behavioral problems, vocalization characteristics, treatments used, and status at follow-up.

RESULTS

Subjects tended to have dementia, to be dependent in most activities of daily living, to have multiple medical problems, to be physically restrained (48%), and to be taking psychotropic medication (76%). Nearly all (95%) were audible at least 50 feet away, with loudness associated with more severe cognitive impairment (OR 4.90, P = .001). When subjects who primarily made nonverbal noises ("screamers") were compared with those whose predominant expressions were words ("talkers"), hearing impairment, severe cognitive impairment, and greater dependency in activities of daily living characterized the screamers. Staff reported trying a variety of treatments with all subjects, often with little success. Two months after enrollment, 66% of surviving subjects vocalized fewer hours than at baseline, and 45% were rated as improved. Independent predictors of improvement included greater ADL independence, hearing and vision problems, shorter length of stay, urinary incontinence, and use of a treatment other than one-on-one interventions. Nearly one-quarter of subjects (23.4%) died within 6 months. Baseline factors associated independently with a higher probability of death included age, use of activity intervention, physical abusiveness, and absence of wandering.

CONCLUSION

Severe disruptive vocalization is associated with severe cognitive and physical impairment and with a high probability of mortality within 6 months. Subcategorization of severe vocalizers by vocalization type or other associated factors may be useful for prognostic and treatment purposes.

The prevalence of osteoporosis in nursing home residents

This study describes the prevalence of osteoporosis in a statewide sample of nursing home residents. Composite forearm bone mineral density (BMD) (including the distal radius and the distal ulna) of 1475 residents aged 65 years and older from 34 randomly selected, stratified nursing homes was assessed. BMD was expressed with reference to World Health Organization diagnostic criteria. Trends with age, gender and race were consistent with other populations. However, prevalence estimates were higher than community-based age-specific rates. The prevalence of osteoporosis for white female residents increased from 63.5% for women aged 65-74 years to 85.8% for women over 85 years of age. Only 3% had composite forearm BMD within 1 standard deviation of the young adult mean. The significance of the high prevalence of low BMD in nursing home residents is the increased fracture risk it may confer. In community cohorts of white women, the risk of hip fracture increases approximately 50% for every 1 standard deviation decrease in bone mass. However, the degree to which BMD contributes to fracture risk in this population has not been well established.

Advances in the treatment of Alzheimer's disease

Management of the most common type of dementia--Alzheimer's disease--is becoming increasingly sophisticated. Differentiation of Alzheimer's disease from vascular dementia has become therapeutically important, since the choice of treatments depends on the diagnosis. Two cholinesterase inhibitors, donepezil and tacrine, are labeled for use in patients with Alzheimer's disease. Other therapies, such as estrogen, nonsteroidal anti-inflammatory drugs and vitamin E, are sometimes used and show promise in delaying the progression of this dementia. Behavior problems, which often accompany the disease, can be managed using environmental modification, alterations in caregiving and medication. In the terminal phase of the illness, quality care involves implementing advance directives, communicating with the family, individualizing care and attending to patient comfort.

Environmental correlates of resident agitation in Alzheimer's disease special care units

OBJECTIVE

To determine the point prevalence of agitated behaviors in a representative sample of Alzheimer's disease Special Care Units, and to determine the extent to which agitation is associated with aspects of the treatment environment.

DESIGN

A cross-sectional study in which nonparticipant observers recorded 3723 observations of resident behaviors in 53 Alzheimer's disease Special Care Units. Observational data were gathered on the physical environment and staff treatment in these settings, and resident characteristics were extracted from a data base developed in the study states by the Health Care Financing Agency. Analyses studied the association between aspects of the staff and physical environment and resident agitation levels, controlling for resident cognitive and functional status.

SETTING

Special Care Units in nursing homes in Kansas, Maine, Mississippi, and South Dakota.

PARTICIPANTS

All residents and staff of the participating units.

MAIN OUTCOME MEASURES

Eight specific agitated behaviors and two indexes of resident agitation were measured by direct observation by research assistants on three to four data collection walk-throughs in each of the study facilities.

RESULTS

The most common agitated behaviors noted were repetitive mannerisms (4.5% of resident observations) and non-loud verbal excess (3.8%). Wandering, which frequently reflects agitation, was noted in 6.5% of resident observations. The proportion of residents exhibiting an agitated behavior varied from none in some units to 38% in one unit. Independent correlates of low unit agitation levels included favorable scores on measures of the physical environment and of staff treatment activities, low rates of physical restraint use, a high proportion of residents in bed during the day, small unit size, low levels of resident functional dependency, and fewer numbers of comorbid conditions.

CONCLUSIONS

While the prevalence of agitation tends to increase as Alzheimer's disease progresses, modifiable treatment factors appear to have a strong influence on the prevalence of agitation. Both physical design and staff treatment appear to influence agitation rates, as do some measures consistent with a low stimulus approach to Alzheimer's care.

Effects of residence in Alzheimer disease special care units on functional outcomes

CONTEXT

Alzheimer disease special care units (SCUs) in nursing homes are increasingly prevalent, but little is known about their effects on residents' outcomes.

OBJECTIVE

To analyze the effect of SCU residence on the rates at which residents decline in functional status.

DESIGN

A cohort of nursing home residents assessed at multiple points during about 1 year. Facility staff completed all assessments using the Minimum Data Set for Nursing Home Resident Assessment and Care Screening (MDS).

SETTING

Medicare- or Medicaid-certified nursing facilities.

PATIENTS OR OTHER PARTICIPANTS

All nursing home residents in 1993 and early 1994 in Kansas, Maine, Mississippi, and South Dakota. Serial MDS assessments of 77337 residents in more than 800 facilities, including 1228 residents in 48 facilities with SCUs.

MAIN OUTCOME MEASURES

Decline in locomotion, transferring, toileting, eating, dressing, and a summary activities of daily living index; decline in urinary and bowel continence; and significant weight loss.

RESULTS

No statistically significant difference was observed in the speed of decline for residents in SCUs and traditional units in any of the 9 outcomes. Residents were matched on a variety of characteristics, and subgroup analyses were performed. In none did we observe a pattern of better outcomes among SCU residents.

CONCLUSIONS

Although SCUs may have provided unmeasured benefits to families and residents, it does not appear that those benefits included any slowing in the rates of functional decline experienced by individuals with dementia.

Management of the patient with disruptive vocalization

Disruptive vocalization (DV) is a common problem in the management of cognitively and physically impaired older people. This article reports the results of a consensus meeting convened to provide guidelines for clinicians and recommendations for researchers in this difficult and little-studied behavioral problem. DV arises largely in people with cognitive impairment and generally reflects an underlying need or discomfort. A variety of factors can precipitate and aggravate DV; the key to management is appropriate identification of all possible factors and development of an individualized treatment plan.

Evaluation and management of dizziness in the older patient

The increased prevalence of dizziness with advancing age is the result of specific disease processes superimposed on normal aging physiology. The first step in evaluating dizziness in older persons is a careful clinical history, focusing on the type, temporal pattern, onset, associated symptoms, and the patient's overall physical health. Common dizziness problems in this age group are postural dizziness without postural hypotension, positional vertigo, cerebrovascular disease, a variety of acute and recurrent labyrinthine problems, neck problems, physical deconditioning, and medications. Often, multiple problems coexist, and secondary psychologic disability results. Treatment should aim at identifying and managing remediable problems.

Nursing home survey deficiencies for physical restraint use

New federal regulations, implemented in 1990, severely restrict the use of physical restraints in nursing homes nationwide. This study evaluated the impact of these regulations on North Carolina nursing homes during 1991. An average of 32.6% of facility residents were restrained during that year, and 29.2% of facilities were cited for violation of the restraint regulations. Annual health department surveys of a sample of 195 North Carolina nursing homes were analyzed. The facility proportion of restrained residents was modeled using estimated weighted least-squares regression. A probit model was used to predict if the facility received a deficiency for restraint use. Facility-level factors associated with overall restraint use were the ratio of licensed vocational nurse/nursing assistant staff to residents in the facility, and the overall facility disability level. Factors associated with the receipt of a restraint violation were facility size, direct costs per patient day, the proportion of restrained patients, use of bladder training in less than 3% of residents, and the proportion of residents with organic brain syndrome; variables that were of borderline significance included proprietary affiliation, the proportion of intubated residents, the facility disability level, and the proportion of residents on psychotropic medication. These findings indicate that, despite implementation of these regulations, nearly one third of North Carolina nursing home residents remained physically restrained. The characteristics associated with restraint use and with restraints violations can be used to identify facilities most likely to benefit from assistance and education in reducing physical restraints.

Bathing persons with dementia

In the care of persons with Alzheimer's disease and related disorders, bathing frequently poses a formidable challenge for caregivers. This article reports the results of a consensus conference on techniques to reduce disruptive behaviors during bathing, and to make the process less stressful for persons with dementia.

Predictors of fear of falling in dizzy and nondizzy elderly

Fear of falling may constitute an independent risk factor for disability, leading older people to unnecessarily restrict their activity. Sixty older adults with chronic dizziness and 66 healthy controls were studied to help clarify the interrelationships among demographic factors, psychological status, physical health, and fear of falling. Chronic dizziness was strongly associated with fear of falling; among dizzy patients, nearly half (47%) expressed fear of falling, in comparison with 3% of controls. In participants with dizziness, 3 factors predicted fear of falling: an activity of daily living score, the revised Symptom Checklist 90 Depression (Derogatis, 1983) score, and stability when standing with feet together. These results support the concept that fear of falling is multiply determined and that psychological factors play a major role in influencing the symptoms and responses in many older patients with dizziness.

Validation of the Minimum Data Set Cognitive Performance Scale: agreement with the Mini-Mental State Examination

BACKGROUND

Almost all nursing homes in the United States are required by the 1987 Omnibus Budget Reconciliation Act to assess each resident's functional, medical, psychosocial, and cognitive status using a standard instrument known as the Minimum Data Set (MDS). We report a validation study to show that the MDS Cognitive Performance Scale (CPS), a cognitive measure generated from 5 MDS items (comatose status, decision making, short-term memory, making self understood, and eating) can be used to detect cognitive impairment as defined by the Mini-Mental State Examination (MMSE).

METHODS

Two hundred subjects were randomly recruited from 8 nursing home facilities in North Carolina. Two medical students administered the MMSE, while a geriatric research nurse was responsible for collecting MDS cognitive items, which included the 5 items required for generating CPS scores. Cognitive impairment was defined by MMSE scores adjusted for education. Agreement between the CPS and the MMSE in identifying cognitively impaired subjects was then evaluated.

RESULTS

The CPS showed substantial agreement with the MMSE in the identification of cognitive impairment; the sensitivity was .94 (95% confidence interval [CI]: .90, .98), the specificity was .94 (95% CI: .87, .96), and the diagnostic accuracy as measured by the area under the receiver operating characteristics (ROC) curve was .96 (95% CI: .88, 1.0).

CONCLUSIONS

The MDS Cognitive Performance Scale, when performed by a trained research nurse using recommended protocols, provides a valid measure of cognitive status in nursing home residents.

Predictors of fear of falling in dizzy and nondizzy elderly

Fear of falling may constitute an independent risk factor for disability, leading older people to unnecessarily restrict their activity. Sixty older adults with chronic dizziness and 66 healthy controls were studied to help clarify the interrelationships among demographic factors, psychological status, physical health, and fear of falling. Chronic dizziness was strongly associated with fear of falling; among dizzy patients, nearly half (47%) expressed fear of falling, in comparison with 3% of controls. In participants with dizziness, 3 factors predicted fear of falling: an activity of daily living score, the revised Symptom Checklist 90 Depression (Derogatis, 1983) score, and stability when standing with feet together. These results support the concept that fear of falling is multiply determined and that psychological factors play a major role in influencing the symptoms and responses in many older patients with dizziness.

Evaluating Alzheimer's special care units: reviewing the evidence and identifying potential sources of study bias

Special Care Units (SCUs) for Alzheimer's disease have been proliferating in long-term care, but their effectiveness remains unproven. This review summarizes the published studies, presents and discusses the many potential sources of bias that pose special problems for SCU research, and proposes strategies for conducting and interpreting future outcome studies in this difficult research setting.

The MDS Cognition Scale: a valid instrument for identifying and staging nursing home residents with dementia using the minimum data set

OBJECTIVE

We report the development and validation of an MDS-based cognitive index, the MDS Cognition Scale (MDS-COGS), by evaluating it against two popular dementia rating scales, the Global Deterioration Scale (GDS) and the Mini-Mental State Examination (MMSE).

DESIGN

A Cross-sectional study.

PARTICIPANTS

Two hundred nursing home residents.

MEASUREMENTS

Each study participant was assessed on the GDS and the MMSE by trained medical students. At the same time, but independent of the medical students, a geriatric nurse completed the Minimum Data Set (MDS) instrument on each participant.

MAIN RESULTS

The Cognitive Performance Scale (CPS), a categorical measure of cognition that uses MDS items, was compared with the GDS in 133 subjects, using a split-sample technique. The GDS was found to be more appropriate as a 4-stage than a 7-stage scale, with GDS stages 1-4 acting as a single stage. The CPS showed very poor percent agreement with GDS stages 5 and 7 (50% or less) and, therefore, was revised by adding other MDS predictors. The new instrument, designated MDS-COGS, is a 0-10 point scale generated from eight MDS cognitive items. The MDS-COGS was then validated against the 4-stage GDS and MMSE in the remaining 67 nursing home residents. Chance-corrected agreement (kappa) between the MDS-COGS and GDS in the 67 subjects was 0.80 (95% CI = 0.70, 0.88), and percent agreement with GDS stages 5 and 7 was 60% and 85%, respectively. The MDS-COGS was also demonstrated to be a valid measure of cognitive impairment as defined by the MMSE, with sensitivity, specificity, chance-corrected agreement (kappa), and area under the ROC curve, all above 0.80.

CONCLUSIONS

The MDS Cognition Scale, the MDS-COGS, provides a valid measure of the presence and severity of cognitive impairment in nursing home residents using items from the Minimum Data Set.

Psychological factors associated with chronic dizziness in patients aged 60 and older

OBJECTIVE

To identify the prevalence and character of psychological disorders accompanying chronic dizziness in older patients.

DESIGN

Case series of patients from a geriatric dizziness clinic, with comparison data from age- and sex-matched healthy community controls. Both cases and controls received screening psychological testing; all cases were evaluated by a clinical psychologist as part of the dizziness clinic evaluation.

SETTING

Multidisciplinary Geriatric Dizziness Clinic.

PARTICIPANTS

Fifty six consecutive patients with chronic dizziness, evaluated by a multidisciplinary Geriatric Dizziness Clinic, and 68 healthy volunteers whose age and sex distribution matched that of the dizziness clinic patients.

MEASUREMENTS

Standardized questionnaire for medical, functional, and demographic data; the anxiety, depression, somatization, and phobic anxiety subscales of the Symptom/Checklist-90 (SCL-90-R); the Tinetti gait and motor screen; a physical therapy evaluation; selected laboratory tests; evaluation by a geriatrician; and a formal evaluation by a clinical psychologist, including a semistructured interview. Psychological diagnoses were assigned based on DSM-III-R criteria.

MAIN RESULTS

Of these patients with chronic dizziness, 37.5 percent had a psychological diagnosis causing or contributing to their dizziness problem. Of these, only 3 were felt to have a primary psychological cause of their dizziness, and 18 had secondary psychological diagnoses. Anxiety disorders, depression, and adjustment reactions were the most common diagnoses. On multivariate analysis, factors predicting a psychological diagnosis were a positive response to hyperventilation testing, a high score on the SCL-90 anxiety subscale, and fatigue as a precipitant of dizziness. In addition, dizziness clinic patients scored significantly higher (P < 0.001) on all 4 subscales of the SCL-90 when compared with the healthy elderly, suggesting a greater degree of psychological distress among these elderly with chronic dizziness.

CONCLUSIONS

Psychological disorders are rare as primary causes but are common as contributing or modulating factors in older persons with dizziness.

ED length-of-stay and illness severity in dizzy and chest-pain patients

Emergency department (ED) length of stay, illness severity, and patterns of ED-based testing can be used to compare different ED patient populations. To assess the relative significance of ED patients with dizziness and chest pain in emergency medicine practice, the investigators formed a retrospective chart review of 3,864 adults (age > or = 16 years) seen at the University of North Carolina Hospitals' ED during May and June of 1991. Patients were eligible if they had any complaint of dizziness (n = 259), nontraumatic chest pain (n = 168), or both (n = 18). ED length of stay and illness severity, as measured by Acute Physiology and Chronic Health Evaluation (APACHE) II score, were not significantly different between the two groups. Dizzy and chest-pain patients were both high users of ED-based testing, but management patterns were different. Chest-pain patients were more likely to undergo electrocardiogram and x-ray testing, whereas dizzy patients more often received testing such as brain computed tomography scanning (10.8% v 3.6%, P = .01). ED patients with dizziness and chest pain were similar with regard to ED length of stay. Given their overall similarities to the chest-pain group, dizzy patients appear to represent a significant population of ED patients and may warrant more clinical study.

Management of dizziness in primary care

BACKGROUND

We sought to determine the types of dizziness problems that are commonly seen in primary care practices, and to bring to light clinical and demographic factors that predict management decisions.

METHODS

We undertook a prospective cohort study with a 6-month follow-up using data gathered in nine primary care practices in two North Carolina counties. Subjects were 144 dizziness patients examined by primary care physicians. Data collected included demographic characteristics, a standardized dizziness history, physician estimation of symptom severity and diagnostic certainty, and physician "worry" about arrhythmia, transient ischemic attack, and brain tumor. Physicians reported their management decisions and diagnosis (or differential diagnosis) by responding to a questionnaire after completing the patient encounter. A 6-month follow-up chart review and physician interview were completed on 140 patients (97.2 percent); information obtained included changes in diagnosis and patient mortality.

RESULTS

The most common diagnoses were labyrinthitis, otitis media, benign positional vertigo, unspecified presyncope, sinusitis, and transient ischemic attack. The initial diagnosis changed during the 6-month follow-up period in 34 (24.3 percent) of patients. The overall course of these patients was benign, however, with only one death occurring during the 6-month follow-up period. Patients' dizziness tended to be managed using a combination of strategies, including office laboratory testing (33.6 percent), advanced testing (11.4 percent), referral to a specialist (9.3 percent), medication (61.3 percent), observation (71.8 percent), reassurance (41.6 percent), and behavioral recommendations (15.0 percent). Office laboratory testing was associated with younger patient age, a suspected metabolic or endocrine disorder, and physician worry about a cardiac arrhythmia; advanced laboratory testing was associated with suspected cardiovascular or neurologic disorders. Medication tended to be prescribed for vertigo and severe symptoms and avoided when physicians were worried about a cardiac arrhythmia. Referral to a specialist was associated with suspected neurologic disease. Observation, behavior change, and reassurance were avoided in patients with poorly defined dizziness and tended to be used in older patients. The management approaches employed by the 4 physicians who referred the most subjects to the study varied considerably.

CONCLUSIONS

Dizziness in primary care represents an extremely broad spectrum of diagnoses. The generally conservative management approach of primary care physicians in this study is consistent with basic clinical and epidemiologic principles, and patient mortality with this approach is low.

Collaborating with nonphysician professionals in practice-based research. Dizziness Research Group

Although much has been written about the importance of collaboration among physicians in practice-based research, the relationship between the clinical investigator and nonphysician professionals in this setting has received less attention. Nurses, physician assistants, and other office support staff can provide valuable insights pertinent to research design and project implementation. Because nonphysician professionals frequently play a large part in implementing a research project, how well the investigator collaborates with them often determines the success or failure of the project. We suggest the following guidelines: 1. Consider the research interests of the nonphysician collaborators. 2. Adapt the project to office routine. 3. Limit the demands on staff. 4. Use detailed protocols. 5. Orient all collaborators. 6. Be available and visible. 7. Provide feedback and reward to all collaborators.

Which primary care patients with dizziness will develop persistent impairment?

OBJECTIVE

To determine which factors identifiable during an office visit for dizziness predict chronic impairment from dizziness 3 months later.

DESIGN

A prospective cohort study with 3-month telephone follow-up.

SETTING

Nine primary care office practices in North Carolina.

SUBJECTS

117 adults who presented to primary care practices because of dizziness.

OUTCOME MEASURES

Our outcome of interest, restriction of daily activities due to dizziness 3 months after the enrollment visit, was characterized using three different but correlated self-reported measures. Independent analytic models tested the relationship between demographic variables, health status, psychological state, and dizziness characteristics at baseline and our three measures of activity restriction due to dizziness.

RESULTS

A two-stage logistic regression analysis identified the following baseline characteristics to be independent predictors in one or more models of activity-limiting dizziness at 3 months: dependency in instrumental activities of daily living (odds ratio [OR] = 11.1, P = .002); a high anxiety score (OR = 5.7, P = .003); self-rating of health as fair or poor (OR = 3.2, P = .042); the presence of three or more chronic conditions (OR = 1.9, P = .022); interference from chronic conditions (OR = 1.7, P = .012); dizziness duration of greater than 1 year (OR = 20.9, P < .001); frequent dizziness (OR = 4.3, P = .016); subjective imbalance (OR = 4.7, P = .012); and activity limitation due to dizziness (OR = 11.7, P < .001).

CONCLUSION

To estimate the prognosis and clinical significance of dizziness complaints, primary care physicians should take into account not only the characteristics of the patient's dizziness but also the patient's baseline health status and psychological state.

Left-sided leg edema of the elderly: a common variant of the iliac compression syndrome

BACKGROUND

Anatomically, the right common iliac artery crosses the left iliac vein and its accompanying lymphatics. We hypothesized that this situation could lead to a predominance of edema, telangiectasis, and venous varicosities on the left lower extremities of older persons.

METHODS

To test this hypothesis, a research assistant who was blinded to the study goals examined 215 predominantly elderly residents of North Carolina homes for the aged and disabled.

RESULTS

Among these subjects, 17.7 percent had predominantly left-sided edema, and 5.7 percent had predominantly right-sided edema (P < 0.001). When the 88 subjects with pitting edema greater than 3 mm were studied, 34.5 percent showed a left-sided predominance, and 6.9 percent showed a right-sided predominance (P < 0.001). In contrast, no significant difference was found in the lateralization of venous varicosities or of telangiectasis.

CONCLUSIONS

Asymmetric edema is common and is usually left-sided in older persons. Compression of the left common iliac vein and its accompanying lymphatics by the right iliac artery, rather than overt clinical disease, might explain the majority of asymmetric edema seen in clinical practice.

Alternatives to physical and pharmacologic restraints in long-term care

The most effective programs for reducing the use of restraints involve facility policy initiatives that are strongly supported by the medical director, the administrator and the director of nursing. The physician and nursing home staff must recognize that physical and pharmacologic restraints have different purposes. Implementing alternatives to restraints requires a careful examination of the source of the problem behavior and an individualized approach. Alternatives to medication should be stressed. When a medication is necessary, it should be prescribed for a limited time, with a definite date for discontinuation. Family physicians can actively participate in restraint reduction programs, whether by initiating the process or by providing support and counseling to staff.

A comparison of eye problems in primary care and ophthalmology practices

This study compares the most frequent presenting complaints and diagnoses of eye problems in primary care physician and ophthalmologist offices sampled by the 1985 National Ambulatory Medical Care Survey. The data show that primary care patients (seen by family/general physicians, internists, and pediatricians) with eye complaints constitute 2% of all patient visits and are predominantly for minor inflammatory (58%), traumatic conditions and foreign bodies (8.4%), visual disturbances (15.5%), and eyelid problems (3.9%). Conjunctivitis and corneal abrasion accounted for 54.4% of these diagnoses. Patients see ophthalmologists predominantly for vision problems (35.5%), eye exams (24.1%), and inflammatory conditions (24%). Refractive errors, cataracts, and glaucoma constituted 52.7% of ophthalmologist diagnoses. This study provides significant implications for curricular development. Medical schools, primary care residencies, and continuing medical education settings for primary care should emphasize in-depth knowledge of minor ocular inflammatory conditions, eye trauma, visual disturbances, and eyelid problems, as these areas encompass more than 85% of the eye problems seen by primary care physicians.

Special care units: a typology of care settings for memory-impaired older adults

After rating 55 nursing homes in five states, we created a typology of care settings that included eight distinct types of units designed to care for memory-impaired older adults. SCUs appeared to be associated with higher quality care than were traditional units, although quality of SCU care was not uniformly outstanding. This typology provides guidelines that can be used in preresidential analysis of prospective care units for demented older adults.

Clinical significance of a dizziness history in medical patients with syncope

To determine the implications of dizziness as a symptom in patients with syncope, we analyzed responses to a standardized battery of questions about dizziness in 121 consecutive patients referred for evaluation of syncope. Associations were sought between final diagnosis (dependent variable) and clinical predictor variables. Dizziness was found in 70% of the patients with syncope. Dizzy patients were younger (mean ages, 47 vs 56 years, respectively), more often female (75% vs 42%), and more likely to be assigned a psychiatric diagnosis. Multivariable logistic regression analysis identified young age and rotatory dizziness (vertigo) to be associated with a psychiatric diagnosis. Dizziness and syncope frequently coexist and in many cases may represent the same pathophysiologic process. A careful dizziness history may guide the initial evaluation of syncope patients in clinical practice.

Physical and pharmacologic restraint of nursing home patients with dementia. Impact of specialized units

This case-control study of 31 specialized dementia units and 32 traditional units in five states investigated use of physical and pharmacologic restraints among 625 patients with the diagnosis of dementia. Physical restraints were observed in use on 18.1% of dementia unit patients and on 51.6% of comparison unit patients who were out of bed during the day (adjusted odds ratio, 0.283;95% confidence interval, 0.129 to 0.619). Pharmacologic restraints were routinely given to 45.3% of dementia unit patients and 43.4% of comparison unit patients (adjusted odds ratio, 0.950; 95% confidence interval, 0.611 to 1.477). We used multivariate logistic regression to identify residence in a nonspecialized nursing home unit, nonambulatory status, transfer dependency, mental status impairment, hip fracture history, and a high nursing staff-to-patient ratio, which we found to be independent predictors of physical restraint use. Physically abusive behavior, severe mental status impairment, and frequent family visitation were found to be significant predictors of pharmacologic restraint use, while advanced patient age, large nursing home size, and patient nonambulatory status were protective against such use. These results support the conclusion that physical and pharmacologic restraint constitute separate treatment modalities with different risk factors for use, and indicate that specialized dementia units are successful in reducing the use of physical but not pharmacologic restraints.

An assessment and care planning strategy for nursing home residents with dementia

Dementia is extremely common among nursing home patients, and it takes many forms. Accurate assessment by staff is crucial in providing appropriate care to these patients. Equally important is the ability to establish care priorities. Current staging models are so general, however, that their usefulness is limited. Thus, this paper proposes a strategy that, using basic assessment data, categorizes dementia residents according to four key determinants of care needs: activities of daily living status, behavioral problems, communication abilities, and physical transition.

Changes in ambulatory care with patient age: is geriatric care qualitatively different?

Approximately 25,000 recorded visits between primary care physicians and adults aged 25 and older in the 1985 National Ambulatory Medical Care Survey were analyzed to study the relationship between patient age and selected process measures of the physician-patient encounter. Multiple presenting complaints and visit diagnoses both rose with age. In spite of this evidence of increased complexity of elderly patients, mean visit length for cough, dizziness, diabetes, and general medical examinations failed to rise, with longest visits tending to be among middle-aged patients. Performance of blood pressure examinations, rectal examinations, breast examinations, pelvic examinations, and Papanicolaou (Pap) smears on patients presenting for general medical examinations tended to decline beyond age 65. These results suggest that individual office visits for older patients may be less comprehensive than those for younger adults.

Quantitative vestibular function testing in elderly patients with dizziness

Electronystagmography was used to examine 103 elderly patients complaining of dizziness. This series of tests included tests for pathologic nystagmus, saccades, smooth pursuit, and optokinetic nystagmus, as well as bithermal caloric testing and rotational testing. One or more specific diagnoses were identified in 100 patients (86.2%), with the two most common diagnoses being benign positional vertigo (30 patients, or 25.9%) and cerebrovascular disorders (25 patients, or 21.6%). An abnormality was found on ENG in 75 (65%) of the patients tested, the most common of these being a unilateral hypoexcitability to caloric stimulation. In most cases, the ENG data was used to support a presumptive diagnosis that was based on the patient's history and examination, although in 4 cases ENG provided the critical diagnostic information by identifying decreased caloric and rotational responses in patients with nonspecific dizziness and dysequilibrium.

The vestibular system in the elderly: clinical implications

Cell loss, changes in synapse morphology, electrophysiologic alterations, and changes in the supporting microenvironment have all been noted in portions of the vestibular systems of aged animals and humans. Increased variability with age is also a prominent finding in many studies. Quantitative vestibular testing in humans has shown alterations with age as well, but decline with aging is not a prominent feature of all measures, and many reported studies are methodogically flawed. The connection between these observed aging changes and the increased incidence of dizziness and falls in the elderly is unproven, however, and clinicians should search carefully for specific disease processes in their elderly patients who present with vestibular symptoms.

Persistent dizziness in geriatric patients

Among the 116 consecutive patients aged 70 and older who were evaluated for dizziness in the UCLA neurotology clinic, the mean duration of symptoms was 36.2 months. One or more specific diagnoses were identified in 100 patients (86.2%), with the most common diagnoses being benign positional vertigo (25.9% of patients) and cerebrovascular disorders (21.6%). Benign positional vertigo was characterized by brief episodes of positional vertigo, a positive Hallpike maneuver, and lack of focal signs on neurologic examination and electronystagmography. Cerebrovascular disease presented as two entities, infarction and transient ischemic attacks, each of which had a distinct clinical picture. Patients who could not be definitively diagnosed frequently described presyncopal lightheadedness provoked by upright posture, and usually had normal physical examinations and electronystagmography. The clinical history, particularly the description and temporal nature of the patient's symptoms, provided the key diagnostic data in 69.0% of cases.

Models of adult day care: findings from a national survey

We examined a nationally representative sample of 60 adult day care centers to describe the state of this evolving care modality after a decade's growth. Results indicate that day care centers can be categorized into three models of care, each of which serves a distinctive subpopulation. Model appropriateness was tested with analysis of variance of differences in participant characteristics. Services, staffing, costs, and other program features are contrasted among the three models.

Palpable purpura in leukocytoclastic vasculitis

Palpable purpura is a clinical finding that represents antigen-antibody deposition along small cutaneous vessels, resulting in extravasation of blood cells into the interstitium. The most common cause of palpable purpura is leukocytoclastic vasculitis, a disease involving cutaneous postcapillary venules. Although often idiopathic, leukocytoclastic vasculitis has been associated with numerous infections, drugs, rheumatic diseases and malignancies.

Custodial nursing home care. Setting realistic goals

Despite concerted effort to rehabilitate and return patients to their homes, the majority of nursing home patients are destined to spend the remainder of their days in institutional settings. These custodial care patients are elderly, have many functional disabilities, and are often demented. The traditional medical approach to care, which emphasizes diagnosis and treatment of specific diseases, is often not appropriate for these patients. Instead, physicians should focus their attention on functional assessment and treatment, nontechnologic management of acute problems, humane terminal care, and the development of an efficient caregiving system within the nursing home.

Nursing home candidates: hospital inpatient trial to identify those appropriately assignable to less intensive care

Primary care physicians are often confronted with demands that elderly patients be institutionalized. Patients who appear to have no new medical problems present a therapeutic dilemma. Should they be admitted to a general hospital or should they be placed directly in a nursing home? This longitudinal prospective study involved 29 consecutive elderly patients judged to be in need of nursing home placement but who were without medical indications for admission. They were assessed and treated in a 30-bed ward of a general hospital. The mean length of stay was 19 days. Of the 29 patients, 8 (24 percent) benefited from the hospitalization; the outcome was placement and retention at a level of care less intensive than that in a nursing home. On admission to this special ward, the presence of 2 of the following 3 characteristics identified the patients who would benefit from this preplacement hospitalization (with 75 percent sensitivity and 86 percent specificity): 1) a score of A or B (Katz Scale) for activities of daily living; 2) a score of 3 or fewer errors on the mental status scale (Pfeiffer); and 3) the presence of family members willing to care for the patient, although unable to do so at the time of admission. These 3 factors constitute a screening tool to differentiate elderly patients who will benefit most under a regimen of intensive rehabilitation from those who will be inevitable recipients of long-term care.