Journal of the American Geriatrics Society
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Comparative Study
Depression in a long-term care facility: clinical features and discordance between nursing assessment and patient interviews.
Nurses commonly observe more depression than is diagnosed and treated in nursing homes. Accordingly, we aimed to describe the clinical features of untreated nursing home residents whom nurses identify as depressed and to compare nurse ratings of depressed nursing home residents with ratings from direct interviews and patient self-reports. ⋯ Nurses frequently observed symptoms of depression in a long-term care setting, and many symptomatic patients were not being treated with antidepressants. In these patients, nurse-derived symptom ratings did not vary across DSM-III-R diagnostic categories and correlated poorly with ratings from direct patient interviews. These findings suggest that nurse caregivers may contribute important diagnostic information about non-major depression and raise questions about the application of standard diagnostic categories to late-life depression in the nursing home.
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Frail older adults are especially vulnerable in a health system that is fragmented and fails to focus on preservation or restoration of function. The School of Nursing at the University of Pennsylvania, together with the School of Medicine and the Hospital of the University of Pennsylvania, established the Collaborative Assessment and Rehabilitation for Elders (CARE) Program to meet the needs of this population. We used the British Day Hospital as a model because it provides a comprehensive approach to care and a bridge between acute, home-based, and institutional long-term care. We have designed our program to provide innovative, interdisciplinary care as well as to be reimbursable under current and future payment structures. This nurse-managed, collaborative practice seeks to maximize independent functioning, promote health, and enhance quality of life for chronically ill, frail older adults living in the community whose needs are left unmet by existing services. The program was certified as a Comprehensive Outpatient Rehabilitation Facility (CORF) in December 1993 to maximize reimbursement of services through Medicare and other third party payers. With a Gerontological Nurse Practitioner as care manager, clients receive an intensive, individualized, time-limited program of nursing, rehabilitation, mental health, social, and medical services in one setting several days each week. Additional geriatric services, such as primary care, are available in the same location when needed. ⋯ Under existing Medicare and third party reimbursement policies, it is feasible to establish a nurse-managed comprehensive outpatient rehabilitation program designed to meet the needs of frail older persons. Preliminary data support the beneficial effects of the program as well as the economic feasibility of this approach.
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To determine nursing home medical directors' knowledge about cardiopulmonary resuscitation outcome and their support of treatment limitation requests and policies. ⋯ Health care professionals who are responsible for educating patients about the efficacy of cardiopulmonary resuscitation in nursing homes overestimate its benefit and may benefit from further education about its outcome. Although mandatory Do-Not-Resuscitate orders were favored for terminal or vegetative patients, medical directors are not supportive of such orders across the board. Medical directors are more willing to honor requests for treatment limitation by terminal patients than others.
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Caring for older patients who need surgery presents challenging medical situations. The clinical paradigm involves identifying coexisting disease, defining the urgency of the intervention, and predicting postoperative complications based on the type of surgery planned. The prime function of the medical consultant is searching for correctable medical conditions. ⋯ Non-body cavity surgery, with the exception of hip fracture repair, is usually tolerated well. Age is a risk factor for surgery, but coexisting disease is more important than age alone. The net effect of improvements in surgical outcome advances the age at which surgical risk becomes prohibitive.