ElderWeb

Andrew Julien of The Hartford Courant reports that physicians in Connecticut are becoming reluctant to provide care to low-income nursing home patients. The problem is that the doctors only receive 80% of the regular Medicare payment for that visit. Generally, physicians receive the other 20% as a co-payment from the patient, but when the patient is on Medicaid, which most nursing home residents are, doctors are not allowed to bill the patient. The state used to make up the difference, but quit doing so two years ago.

Connecticut's Legislative Program Review and Investigations Committee has recommended that minimum nursing hours required in nursing homes be raised from 1.9 to 2.75 hours per patient per day. They estimate that this increase will cost about $13.7 million for residents covered by Medicaid, half of which would be paid by the state and half by the federal government. The committee noted that many nursing homes are having trouble finding and retaining staff, which may make it difficult for facilities to reach these staffing levels. To counter this problem, they suggest a two year phase in period to allow facilities time to find ways to deal with the staffing problems. The Connecticut Department of Labor provided information used by the committee to conclude that the turnover rate among staff in Connecticut nursing homes was 43% in 1998 and 46% in 1999, but concluded that these high turnover rates would be reduced by raising the minimum ratios in nursing facilities to reduce job burnout by making the work environment less stressful. SB 1173, which would mandate the increase in the minimum staffing hours, has been raised and referred to the Joint Committee on the Program Review and Investigations Committee.

A low dose of estrogen was as effective in reducing bone turnover as higher doses when given to a group of healthy women 65 years and older, according to a study published in the December issue of the Journal of Clinical Endocrinology and Metabolism. This is the first controlled clinical trial to directly compare the effects of different doses of estrogen on bone turnover in older women.

Bone turnover refers to the bone remodeling cycle in which new bone is formed as older bone is dissolved. Osteoporosis develops when more bone is dissolved than is formed, weakening the bones and making them prone to fracture. The risk for developing osteoporosis increases with age.

Decreases in bone turnover among the women who took 0.25 mg of estradiol, a form of estrogen, was quite similar to the decrease among the women who took 1.0 mg of estradiol, according to lead author Karen Prestwood, M.D., of the University of Connecticut (UCONN). The 1.0 mg estrogen dose that women conventionally are prescribed as part of estrogen replacement therapy (ERT) to treat symptoms of menopause, reduce bone turnover, and treat osteoporosis, sometimes results in side effects such as breast tenderness, fluid retention, headaches, and bloating. The group taking 0.25 mg estradiol had no more side effects than the placebo group, according to the study, conducted at UCONN?s Claude D. Pepper Older Americans Independence Center.

Thomas Gill, M.D., associate professor of medicine and geriatrics at the Yale School of Medicine led a study of the causes of falls in older adults published in the December issue of the journal Medical Care. Falls are common among the elderly and often lead to loss of independence or even death. The rate of falls among persons 65 and older is about 30%, and among persons 80 or older, 50%. Of those who do fall, about 10% sustain a serious injury, such as a fracture, joint dislocation, or severe head injury. Falls and fall related injuries also are associated with pain, loss of confidence, functional decline, and placement in a nursing home.

Gill reports that they found very little evidence to link falls to home hazards, and also said the significance of the results is that money spent making homes of the elderly safer probably could be better utilized. A co-author of the study, Mary Tinetti, M.D., professor in the Departments of Internal Medicine, Geriatrics, and Epidemiology and Public Health, completed a study about six years ago showing that a multi-component program targeting primarily muscle weakness, poor balance, vision loss, proper footwear, and monitoring medications, among other precautions, was most effective in preventing falls by the elderly.

Gill and his co-researchers evaluated 1,088 New Haven residents 72 and older and performed home safety assessments to determine whether 13 potential trip or slip hazards were present. These included hazards such as loose throw rugs, obstructed pathways, and slippery bathtubs. They then contacted participants each month for three years asking if they had fallen, and, if they had, what were the circumstances.

Yale researchers have designed a cost-saving program that helps prevent older patients from declining physically and mentally while hospitalized. The problem of functional and mental decline is increasingly important since patients aged 65 and older account for more than 48% of all hospital days, said Sharon Inouye, M.D., associate professor of internal medicine and geriatrics at Yale School of Medicine. She is principal investigator of the study published in the December issue of the Journal of the American Geriatric Society about the new Hospital Elder Life Program.

The Hospital Elder Life Program involves entire hospital units, provides skilled staff and trained volunteers to implement interventions for all patients, and targets interventions to specific risk factors. Under the program, patients 70 and older are screened on admission for six delirium risk factors: cognitive impairment, sleep deprivation, immobility, dehydration, vision or hearing impairment. Targeted interventions for these risk factors are implemented by an interdisciplinary team, which includes a geriatric nurse specialist, elder life specialists, trained volunteers and a geriatrician. All work closely with the primary nurses. Other experts provide consultation at twice-weekly interdisciplinary rounds.

To date, 1,507 patients have been enrolled during 1,716 hospital admissions. The overall intervention adherence rate was 90% for at least partial adherence with all interventions during 37,131 patient days.

Patients In Program vs Not In Program Who Declined 2%+ While in Hospital:

Decline Measured by: Mini-Mental State Examination (MMSE) 8% vs 26%
Decline Measured by: Activities of Daily Living (ADL) 14% vs 33%

Preliminary, unpublished results show that the program reduces overall hospital costs by $1,500 per patient. Start up costs for the program include the equivalent of 1.7 fulltime paid staff and equipment costs estimated to be about $3,000 for one or two hospital units totaling 35 to 70 beds. The figure includes an optional computer expense of $1,500 for patient enrollment, volunteer assignments, and tracking of adherence and program outcomes. The program is effective for delirium prevention and insomnia. Other benefits include providing cost effective care, gaining recognition as a center of excellence, enhancing patient satisfaction, improving community outreach, and serving as an educational site for acute geriatric care.

Co-authors of the paper include Sidney Bogardus, M.D., assistant professor of internal medicine and geriatrics and medical director of the Adler Geriatrics Assessment Center; Dorothy Baker, research scientist in the Department of Epidemiology and Public Health (EPH); Linda Leo-Summers, programmer-analyst, EPH, and Leo Cooney, M.D., professor and section chief, general internal medicine. The study was funded by the National Institute on Aging, The Commonwealth Fund, the Retirement Research Foundation, the Community Foundation for Greater New Haven and the Yale New Haven Hospital Auxiliary.

Older patients hospitalized with pneumonia for an increasingly shorter length of time are more likely to be re-admitted or discharged to a nursing home, a study by a Yale researcher and collaborators shows. This is important because the length of hospital stays is declining nationwide. Pneumonia among older patients is responsible for more than 600,000 hospitalizations nationally and $9 billion in health care costs every year. About 10% of patients older than 64 who are hospitalized with pneumonia die while hospitalized. Many more die within a month of being discharged. Of those patients who do survive, about 12% require placement in a long-term care or rehabilitation facility.

Meehan and his co-researchers looked at patients over 65 who were discharged from Connecticut hospitals between Oct. 1, 1991 to Sept. 30, 1997, after being treated for pneumonia. In that six-year period, the average length of stay for these patients dropped by about 4 days. They found that the mortality rates during the patients' hospital stays declined, because they were there for a much briefer period of time, but:

* The percentage of patients transferred to long term care facilities increased from 30% to 43%.

* The rate of mortality within 30 days after discharge increased from 7% to 9%.

* Re-admissions to the hospital for pneumonia within 30 days of discharge increased from 3% to 4%.

The mean adjusted costs associated with hospitalization for pneumonia declined steadily over the five year period from $9,228 to $6,897. The next study they plan will look at the total cost to the healthcare system when you factor in rates of re-admission and transfer to long term care facilities.

The principal investigator of the study was Mark Metersky, M.D., of the University of Connecticut School of Medicine. Co-authors included Michael Fine, M.D., of the University of Pittsburgh School of Medicine; and Janet Tate, MPH, and Marcia Petrillo, MA, of Qualidigm, a quality improvement organization based in Middletown. Metersky and Meehan also are affiliated with Qualidigm.

The Hartford Financial Services Group, Inc., the MIT Age Lab and Connecticut Community Care, Inc., have developed a guide to Alzheimer's Disease, Dementia and Driving as a tool to help individuals and caregivers determine when it is time to stop driving. The guide points out that many older adults who don't have dementia can assess their driving without family intervention and make gradual changes to the way they drive as they are impacted by problems with eyesight or slower reaction times. It's different for those with Alzheimer's Disease and other dementias. The progression of this disease is usually gradual and somewhat unpredictable. It affects cognitive functions critical to driving, such as judgment, reaction time and problem-solving abilities. It can also cause physical and sensory problems that increase driving risk. With dementia, an individual's capacity to assess his or her driving abilities may also diminish. People with dementia are especially likely to minimize the complexity of driving and overestimate their abilities. As driving and assessment skills decline, the risk of serious loss or injury increases. Caregivers must assume the responsibility for monitoring and regulating the driving of the person with dementia, and this guide is a resource to help them do so.

A study published in the Journal of Gerontology by William T. Gallo of the Yale University School of Public Health reports that negative mental and physical health effects of involuntary job loss are significant for older workers. The researchers noted that workers in the United States save heavily in the years preceding retirement, often relying primarily on personal savings amassed in this period to finance the costs of retirement. Because of that, late-stage job loss has important consequences for the well-being of dislocated U.S. workers. Further supporting their findings, the study indicated that re-employment of the displaced workers was associated with improvements in both physical functioning and mental health.