A pilot study on the development and testing of an instrument for assessment of dependency needs of older persons in South Africa

Bibliographical references.With the advent of the new government and the end of the apartheid era, the Department of Welfare investigated methods whereby the demand for equitable access to state subsidised homes for the aged might be met. It was decided to develop an instrument to assess dependency needs of older persons that might warrant admission to homes for the aged. Financial constraints dictated that only 2% of those over the age of 65 years could be institutionalised in state subsidised homes. An instrument with high specificity and sensitivity and good face and construct validity was required in order not to exclude the needy or include the undeserving in subsidised institutional care. The instrument formerly used in South Africa was designed to assess dependency needs of urban-living individuals and assumed relative affluence in contrast to the reality of the situation of the bulk of the South African population. The instrument was deficient in that it assessed only mental and physical disabilities. It did not take into account the wide disparities relating to primary needs (such as water, food, sanitation and security) that exist among communities with widely disparate socio-economic status. Since South Africa is a developing country, a significant component of the elderly population live in extreme poverty, often in rural subsistence-economy conditions. Instruments used in other countries, which assume a certain level affluence, are thus not applicable to the majority of the South African population

Prevalence of and risk factors for falls in older people in an urban community in South Africa

Includes abstract. Includes bibliographical references

Predictors of good outcome in upper gastrointestinal bleeding (UGIB)

Background and literature review: Introduction: Acute upper gastrointestinal bleeding is a common cause of emergency hospital admission. It is also not uncommon in patients already in hospital. The bulk of severe morbidity and mortality occurs in patients with recurrent bleeding or significant comorbid illness. The use non-steroidal anti-inflammatory drugs (NSAID), which is more common in the elderly, more than doubles the mortality associated with peptic ulcer complications. Endoscopy and endotherapy have improved outcome in patients with continued or recurrent bleeding. Clinical Predictors of Outcome: Despite improved technology in the management of upper gastrointestinal bleeding (UGIB), mortality has remained high. This has been attributed to the increase in the population of elderly people who tend to have other underlying diseases leading to the high mortality rate. From international literature, mortality varies from 4-10%. Most of the reports reflect mortality around 8%. A local retrospective study by Van Stiegmann et. al. (1983) on patients with bleeding peptic ulcer had an overall mortality of 5.4 %, and mortality of 9.8% in those treated surgically. Ideally to avoid waste of resources and time, emergency endoscopy should primarily be considered in relatively few patients at risk of further haemorrhage. In this class of patients, endoscopy is used not only for diagnosis but also for endoscopic treatment to control massive ulcer bleeding. This approach is worthy of consideration in a "resource poor" environment. Most previous studies have employed endoscopic criteria for identifying patients at high risk of poor outcome. These data are not available at the time of admission. This is therefore not helpful in the triage of patients prior to endoscopy. Groote Schuur Hospital (location for the current study) has experienced a significant staff cutback over the past 5 years. Few of our regional hospitals and none of our primary health care facilities have endoscopy facilities and endoscopic expertise is similarly limited. Given the pressures on the limited endoscopy services, there is a need for guidelines for the referral of patients to centres with these facilities. There is a possibility that the number of potential referrals of patients with upper gastrointestinal bleeding (UGIB) will increase as the primary health care services improve, a rational review of criteria for referral appeared timely. There would be need to triage patients into: i). those who must have endoscopy urgently and ii). those who could be safely referred for elective endoscopy. Most previous studies have looked at predictors of adverse outcome. To our knowledge no study has been done in South Africa to determine clinical predictors of good outcome prior to endoscopy, that would help determine patients who would recover uneventfully without urgent endoscopy. Study Rationale: Given the scarcity of both endoscopy resources and of information for the triage of patients who would recover uneventfully following UGIB without urgent endoscopy in our setting, this study set out to answer the question: Is it possible to identify clinical criteria that will predict patients with UGIB in whom endoscopy could be safely deferred? OBJECTIVES: 1. To identify clinical criteria that predict uneventful recovery. 2. To determine the accuracy of individual symptoms and signs or combinations. of symptoms or signs at the time of presentation in predicting uneventful recovery. Study population and Methods: Study design and study setting: The design was a prospective, descriptive, cross sectional study with an analytical component. The study was conducted at Groote Schuur Hospital (GSH), which is a tertiary referral teaching hospital with 14 70 beds. It is affiliated to the University of Cape Town

The burden and risk factors for adverse drug events in older patients - a prospective cross-sectional study

Objective. To determine the burden and risk factors for adverse drug events (ADEs) in older patients. Design. A prospective cross-sectional study. Methods. Patients (65 years and older) presenting to the tertiary Emergency Unit of Groote Schuur Hospital, Cape Town, between February and May 2005, were assessed for wellestablished ADEs, as defined by the South African Medicines Formulary. Logistic regression models were fitted to determine drugs and other factors associated with the likelihood of developing ADEs. Results. ADEs were identified in 104 of the 517 (20%) presentations. The most frequently involved drug classes were cardiovascular (34%), anticoagulant (27%), analgesic (19%) and antidiabetic (9%). Patients who developed ADEs were more likely to have five or more prescription drugs (p < 0.0001), more than three clinical problems (p = 0.001), require admission (p = 0.04), and report compliance with medication (p = 0.02) than those who did not. Drugs shown to independently confer increased risk of ADEs were angiotensin-converting enzyme inhibitors (RR = 2.6, 95% CI: 1.3 - 5.2, p = 0.009), non-steroidal anti-inflammatory drugs (RR = 4.1, 95% CI: 2.1 - 8.0, p < 0.0001) and warfarin (RR = 3.1, 95% CI: 1.6 - 6.3, p = 0.0014). Conclusion. ADEs contribute significantly to the burden of elderly care in the Emergency Unit. In a setting such as ours, increased pill burden and certain drug classes are likely to result in increased risk of ADEs in the older population group

HIV and AIDS prevention: knowledge, attitudes, practices and health literacy of older persons in the Western Cape and KwaZulu‑Natal Provinces, South Africa and in Lesotho

Background Population ageing and access to anti-retroviral therapies in South Africa have resulted in ageing of the HIV/AIDS epidemic, which has implications for policy, planning and practice. Impactful interventions on HIV/ AIDS for older persons require knowledge on effects of the pandemic on this population. A study was undertaken to assess knowledge, attitudes, and practices (KAP) of HIV/AIDS, as well as health literacy (HL) level of a population aged ≥ 50 years. Methods A cross-sectional survey was conducted at three sites in South Africa and two sites in Lesotho with an educational intervention at the South African sites. At baseline, data were collected for assessment of KAP of HIV/AIDS and HL levels. The pre- and post-intervention comprised participants at South African sites being familiarised with the contents of a specially constructed HIV/AIDS educational booklet. Participants’ KAP was reassessed six weeks later. A composite score of ≥ 75% was considered adequate KAP and an adequate HL level. Results The baseline survey comprised 1163 participants. The median age was 63 years (range 50–98 years); 70% were female, and 69% had ≤ 8 years’ education. HL was inadequate in 56% and the KAP score was inadequate in 64%. A high KAP score was associated with female gender (AOR = 1.6, 95% CI = 1.2–2.1), age < 65 years (AOR = 1.9, 95% CI = 1.5–2.5) and education level (Primary school: AOR = 2.2; 95% CI = 1.4–3.4); (High school: AOR = 4.4; 95% CI = 2.7–7.0); (University/college: AOR = 9.6; 95% CI = 4.7–19.7). HL was positively associated with education but no association with age or gender. The educational intervention comprised 614 (69%) participants. KAP scores increased post intervention: 65.2% of participants had adequate knowledge, versus 36% pre-intervention. Overall, younger age, being female and higher education level were associated with having adequate knowledge about HIV/AIDS, both pre- and post-intervention. Conclusions The study population had low HL, and KAP scores regarding HIV/AIDS were poor but improved following an educational intervention. A tailored educational programme can place older people centrally in the fight against the epidemic, even in the presence of low HL. Policy and educational programmes are indicated to meet the information needs of older persons, which are commensurate with the low HL level of a large section of that population

Management of older patients presenting after a fall - an accident and emergency department audit

Background. It is common for older patients to present to accident and emergency (AE) departments after a fall. Management should include assessment and treatment of the injuries and assessment and correction of underlying risk factors in order to prevent recurrent falls. Objectives. To determine management of older patients presenting after a fall to the AE department of Groote Schuur Hospital in Cape Town, South Africa. Method. Hospital records were reviewed for a random sample of 100 patients aged 65 years and older presenting to the AE department after a fall, between December 2001 and May 2002. Results. The mean age of the sample was 78.6 years (range 65 - 98 years); 72% of subjects were female. History of a previous fall, and history of drug or alcohol intake, were recorded in less than 20% of cases. Blood pressure and pulse rate were recorded in approximately 90% of cases, and pulse rhythm and postural blood pressure in 2%. Examination of the musculoskeletal system was done in 86% of cases and that of other systems in less than 50%; cognitive assessment was conducted in less than 30%. Radiological investigations were performed in 89% of cases, glucose and haemoglobin in 32%, renal profile and electrocardiogram in 5%, and urinalysis in 4%. Three-quarters of the patients were referred for further management: 52% to orthopaedic surgery, 12% to other surgical subspecialties, 6% to the general medical department, and 6% to other hospitals and clinics. No referrals were made to geriatric medicine, physiotherapy or occupational therapy. Conclusions. In managing elderly patients after a fall, the AE department focused on injuries sustained. Little effort was made to establish and manage risk factors, hence to prevent recurrent falls. Guidelines are needed for the management of such patients in AE departments. South African Medical Journal Vol. 96(8) 2006: 718-72

Methodological challenges in a study on falls in an older population of Cape Town, South Africa

Background: Falls are a major cause of disability, morbidity and mortality in older persons, but have been under researched in developing countries. .Objective: To describe challenges encountered in a community-based study on falls in a multi-ethnic population aged ≥65 years in a low-income setting.Methods: The study was conducted in four stages: A pilot study (n=105) to establish a sample size for the survey. An equipment validation study (n=118) to use for fall risk determination. A cross-sectional baseline (n=837) and a 12-month follow-up survey (n=632) to establish prevalence and risk factors for falls.Results: Prevalence rate of 26.4% (95% CI 23.5-29.5%) and risk factors for recurrent falls: previous falls, self-reported poor mobility and dizziness were established. Adaptations to the gold standard prospective fall research study design were employed: 1) to gain access to the study population in three selected suburbs, 2) to perform assessments in a non-standardised setting, 3) to address subjects’ poverty and low literacy levels, and high attrition of subjects and field workers.Conclusion: Studies on falls in the older population of low- to middle-income countries have methodological challenges. Adaptive strategies used in the Cape Town study and the research experience reported may be instructive for investigators planning similar studies in such settings.Keywords: Falls, older people, community-based research, low and middle income countries, methodology, study desig

Methodological challenges in a study on falls in an older population of Cape Town, South Africa.

Background: Falls are a major cause of disability, morbidity and mortality in older persons, but have been under researched in developing countries. . Objective: To describe challenges encountered in a community-based study on falls in a multi-ethnic population aged 6565 years in a low-income setting. Methods: The study was conducted in four stages: A pilot study (n=105) to establish a sample size for the survey. An equipment validation study (n=118) to use for fall risk determination. A cross-sectional baseline (n=837) and a 12-month follow-up survey (n=632) to establish prevalence and risk factors for falls. Results: Prevalence rate of 26.4% (95% CI 23.5-29.5%) and risk factors for recurrent falls: previous falls, self-reported poor mobility and dizziness were established. Adaptations to the gold standard prospective fall research study design were employed: 1) to gain access to the study population in three selected suburbs, 2) to perform assessments in a non-standardised setting, 3) to address subjects\u2019 poverty and low literacy levels, and high attrition of subjects and field workers. Conclusion: Studies on falls in the older population of low- to middle-income countries have methodological challenges. Adaptive strategies used in the Cape Town study and the research experience reported may be instructive for investigators planning similar studies in such settings