The impact of a new geriatric program in a hospital for the chronically ill J.E. SCHUMAN,* BA, MD, FRCP[C], M Sc; E.J. BEATTIE,* RN; D.A. STEED,* RN; J.E. GIBsoN,* BA, MD, CM; G.M. MERRY,* BS, MD; W.D. CAMPBELL,* MD, CM, CRCP; A.S. KRAUS,t BS, MS, SC D

Reports of the rapidly increasing proportion of persons aged 65 years and more in Canada and the resultant need for changes in the country's health care system prompted experimental changes in the operation and training procedures at St. Mary's of the Lake Hospital, Kingston, Ont. Aimed at better patient care and at better education of medical house staff in geriatrics and long-term care, the revised program is permeated with the philosophy of rehabilitation. It includes full-time staff, a geriatric outpatient clinic, a day hospital, a team approach to patient care (with regular team audits), problem-oriented medical records, a formal physical medicine section with a distinct inpatient unit, and an intensive inservice education program. After the first year of the program patient outcome had improved and more efficient use was being made of continuing care beds because of larger numbers of petients being discharged home after shorter stays. This may be one avenue for deceleration of our country's dismal rate of institutionalization. Des rapports signalant l'augmentation rapide du pourcentage des personnes Agees de 65 ans et plus au Canada, et le besoin qul en resulte de changer le systeme national des soins de sant6, ont incit6 Ia mise a l'essai de changements dans le fonctionnement et les methodes de formation au St. Mary's of the Lake Hospital, de Kingston, Out. Destine a ameliorer les soins aux patients et Ia formation du personnel m6dical consacr6 a Ia geriatrie et aux soins A long terme, ce programme revise s impregne de Ia philosophie de Ia readaptation. II met en oeuvre un personnel & temps plein, une clinique externe pour patients g6riatriques, un hApital de jour, un abord d'6quipe aux soins des patients (avec verification multidisciplinaire reguliAre), des dossieurs m.dicaux destines A identifier les problemes, une section de physiatrie ayant une unite distincte pour patients hospitalises, et un programme intensif de formation dans le service. AprAs Ia premiere ann6e de fonctionnement, From the departments of 6geriatsic and continuing care medicine and tcommunity health and epidemiology, Queen's University, Kingston Reprint requests to: Dr. I.E. Schuman, St. Mary's of the Lake Hospital, P0 Box 3600, 340 Union St., Kingston, Ont. K7L 5A2

le sort des patients s'etait am6liore et ii se faisait une utilisation plus efficace des lits consacres aux soins continus, un plus grand nombre de patients etant retournes A domicile apres une hospitalisation plus courte. Ceci peut Atre un moyen de freiner le triste taux de placement en etablissement de sante atteint dans notre pays. At the present time 8% of Canadians are over 65 years of age. This group accounts for 35% of all patient-days in general and allied special hospitals.1 Furthermore, population projections suggest that over the next 60 years the number of people over the age of 65 will triple.2 Accordingly, it is essential that we plan for the treatment of these elderly people. Currently, a major solution for their care is institutionalization. For example, in 1962 and 1963, 7.7% of Canadians 65 years of age and over were residing in some form of institution. From 1971 to 1973, the figure for Ontario was 9.2%, 50 that the rate is increasing and is much higher than in Great Britain or the United States.3 As well as producing a financial drain on the health care system, institutionalization has many adverse effects on patients.4 According to Spasoff and colleagues5'6 these include depression, low activity, loss of interest in the outside world, and extensive use of psychoactive drugs. On Apr. 1, 1975, a new program was initiated at St. Mary's of the Lake Hospital, a 210-bed chronic-care hospital in Kingston, Ont. Its aims were to provide better patient care and education in geriatrics and chronic care for medical house staff. The philosophy of rehabilitation permeates this program. It is based on the belief that patients will acquire a greater sense of achievement, satisfaction and self-esteem, and experience an increased enjoyment of life if they are encouraged to function at the maximum of their ability. One would expect that the achievement of greater independence would lead to a lower rate of institutionalization. This paper describes the program at St. Mary's of the Lake Hospital and presents some of its effects. The program at St. Mary's of the Lake Hospital The major components of the program consisted of full-time medical

and house staff, a formal section for physical medicine, a team approach with team audit, problem-oriented medical records, intensive inservice teaching, a geriatric outpatient department and a day hospital. Five full-time physicians were employed on a salary rather than a fee-for-service basis. This recognized their roles in administration, establishing new programs, and instituting a teaching program, in addition to patient care. Two of the physicians began their service on Apr. 1, 1975; a third did so in August 1975. One physiatrist began his practice Jan. 1, 1975; the second began a year later. The full-time staff provides care for 75 geriatric and continuing care (0CC) patients and 35 rehabilitation patients. Previously six physicians provided the care for 210 patients and four associate staff physicians have continued to provide care for 100 patients. In both instances remuneration was on a feefor-service basis. A full-time house staff began its duties July 1, 1975. The house staff comprised two medical residents in their first or second year on 3-month rotations and two medical interns on 2-month rotations. The department of medicine recognized their service to this program as similar to their other rotations. No specific selection process governed the choice of the trainees, Accordingly, almost every medical trainee whose core training was in Kingston was exposed to geriatric and continuing care. In consequence their attitudes appear to have changed and their knowledge has increased in these areas. Certainly trainees from this program initiated fewer inappropriate referrals for placement and took a more active approach to their geriatric patients when they returned to their other rotations. However, the purpose of this study was to assess the effect of the new program on patient care and not on medical education. There has always been someone available on whom the nurses could call with less hesitation than they would call an attending physician. Moreover, as each new group of interns began their period of service they looked afresh at the institution with the critical eyes of young medical graduates. They have provided constant peer review for the practice of medicine in this hospital. A formal physical medicine section was established with a distinct inpatient

CMA JOURNAL/MARCH 18, 1978/VOL. 118

639

unit. This section was administratively to admission and for their follow-up separate from the rest of the hospital. following discharge. It also initiated If a patient was transferred from the measures in the elderly to prevent geriatrics department to the physical excessive disability and institutionalizamedicine section or vice versa, this tion. There were 1323 clinic visits counted as a discharge and readmis- in the first year following the program sion to the hospital. Physiatric consulta- change. tion was made readily available to the The day hospital provided a full entire institution. Moreover, this situa- range of therapeutic programs as an tion provided relatively short-term re- alternative to institutionalization and habilitation to patients who were likely as an intermediate step allowing earlier to benefit from such a process. It con- discharge. These programs have been centrated on musculoskeletal problems described elsewhere.7'8 In the first year, and those consequent to cerebrovas- two patients were referred from the cular disease. GCC service and one from the rehabiliThe team approach was adopted tation service in order to speed patient throughout the hospital. When each discharge. A further three patients were patient was admitted, the entire group referred from the rehabilitation clinic of individuals who would be caring for as an alternative to hospitalization. the patient reviewed the problems, asIn summary, a series of changes has sessed the goals of treatment, decided been made, many of them based on on their respective roles in achieving the philosophy of rehabilitation. There those goals and tried to make a prog- is a genuine attempt to encourage each nosis. The full-time physicians took a patient to function at the highest level leadership role in these conferences and of his ability and to prevent any avoidencouraged participation by all mem- able disability. bers of the team and closer integration Patient selection of the treatment measures. A team audit was conducted of the Patients were selected for admission progress of the patient. The case of according to the usual criteria for adeach patient was reviewed at least mission to a chronic-care hospital in monthly by the team to decide whether Ontario.9 Accordingly, patients in one the original goals had been reached. or more of the following categories The review was conducted more fre- were admitted: (a) patients requiring quently if any problems arose. If the subacute medical care (indefinite stay), goals were not being attained the team which can only be provided in a hosconsidered whether these were unrealis- pital setting; (b) patients suffering from tic or whether the treatment required terminal disease; or (c) patients in need modification. of rehabilitative services. The problem-oriented medical record The criteria for admission to the hoswas adopted. The problem list on the pital did not change during the study front of the chart gave assurance that period. Unfortunately, physicians. views afflictions in patients who had multiple concerning the rehabilitative potential diagnoses would not be overlooked. or likely terminal course of their paAlso, it allowed every member of the tients were not recorded in every inteam to write on the chart and to com- stance in the charts. It was not possible municate in writing with other mem- to assign all patients specifically to one bers of the team. of the above categories. In all cases An intensive inservice education pro- the basic reason for admission was that gram was established. This was aimed the patient suffered from a disabling at upgrading mainly the quality of condition to the extent that he was no nursing in the hospital. It made the longer able to function outside a hosnurses more aware of modern nurs- pital setting. Selection for treatment by ing techniques. In addition, it demon- the rehabilitation service was the only strated that the administrators and the indication given in the chart that the physicians who gave the courses (in- patient might be expected to improve cluding house staff) were concerned with rehabilitative measures. Neverabout the quality of nursing and recog- theless, the referral pattern was unnized its importance to the institution. changed and the patients in the year Although the numbers of nursing staff before and the year after the adoption have not increased, the nurses are now of the new program were essentially taking an active part in rehabilitation in comparable with respect to the severity addition to fulfilling their former role of their disability and the expectation of supplying supportive care. This of improvement. Within the hospital there were few means the nurses have a heavier workload but they have responded gener- changes in the way in which patients were selected for the various services. ously. The geriatric outpatient clinic repre- Patients believed by the physiatrists to sented an attempt to care for patients have a good prospect of rehabilitation outside an institutional setting. It pro- were admitted to the rehabilitation vided for assessment of patients prior service. When the GCC service was 640 CMA JOURNAL/MARCH 18, 1978/VOL. 118

initiated, patients were assigned to the associate staff simply on the basis of who had been their previous attending physician and what had been their location in the hospital, without regard for their rehabilitation potential. Similarly, when new patients were admitted, they were assigned to the care of the physician (with either GCC service or associate staff service) who had the fewest number of patients at that time. This policy did not change until the beginning of the last trimester of this study, after which all new patients were admitted to either the rehabilitation or GCC service. Virtually none of the patients admitted according to this new policy were discharged in the period under study. Accordingly, we believe the following comparisons are valid: all patients discharged prior to, with those discharged subsequent to, the program change; GCC patients with associate staff patients; GC'C patients with all patients discharged prior to the program change; and associate staff patients with all patients discharged prior to the program change. Only the last two comparisons are biased in so far as patients with the best likelihood of rehabilitation were admitted to the rehabilitation service following the program change and included in the general group of patients prior to the program change. This bias has a slight negative effect on the results observed on both the GCC service and the associate staff service. Assessment methodology The program has been assessed by two methods. First, an analysis was performed of discharge statistics from the charts for 3-month periods for all patients discharged during the year prior to the program change and for 1 year following it. Since many discharges from this institution represented discharges to an acute-care hospital for treatment of an intercurrent illness, holiday discharges or technical discharges (transfer from one service to another), and since the charts failed to reveal the actual type of discharge, only patients who were not readmitted for at least 3 months were considered as true discharges and are discussed in this paper. The charts of the two local acute-care hospitals were searched for admissions of patients within 1 year of their discharge from St. Mary's of the Lake Hospital. Patients' names and birth dates were used to link the records. Second, a prospective study was carned out to determine the effect on patient outcome of the various geriatric programs in this area. Patients were seen and examined at the time of referral to the GCC or rehabilitation service for assessment. They were re-

examined 3 months and 1 year later to determine what, if any, changes had occurred in their level of independence in the activities of daily living, mood, dementia, range of motion at joints and satisfaction with their care. Certain other physical and psychosocial data were collected to determine predictors of improvement among patients treated in the various programs. This study is ongoing and the full results will be reported elsewhere. However, the mode of assessment of independence in the activities of daily living is relevant to this report. The activities rated were eating, transferring, ambulating, climbing stairs, toileting and bathing. Independence in each activity was scored on a 6-point scale, from complete dependence on others to complete independence. The level of independence in the activities of daily living was the sum of these scores. The status of each patient at the time of referral to the geriatrician or physiatrist was compared with that 3 months later. All data were keypunched and analysed with the use of the Statistical Package for the Social Sciences.10

year progressed. The changes were greatest on the GCC service. After the house staff and a third full-time physician joined the program in the second quarter the discharge rates showed substantial increases. The mean length of stay according to service and age is portrayed in Table II. The shortest mean stay was among patients on the rehabilitation service. Patients over the age of 65 also experienced a dramatic shortening of their stay, from a mean of 480.2 days to one of 183.4 days when treated on the GCC service. On the other hand, patients under the age of 65 had a longer stay on both continuing care services. With more readily available medical care, life may be prolonged in the chronically ill when they obtain prompt treatment of any intercurrent illnesses. It must be recognized that patients under the age of 65 referred to this type of institution tend to lack the potential for discharge, so that with in-

creased medical care an increased length of stay is likely. These distributions are highly skewed. During the first year of the program many patients remained who had been admitted many years previously. This resulted in a distinct population of patients who died or were discharged after extremely long stays, which prolonged the mean length of stay. Accordingly, the length of stay of 50% of the patients on each service (the median) provided a more sensitive index of the effects of the program change. Prior to the program change the median length of stay was 164 days. After the program change, the median length of stay was 70.5 days on the GCC service, 65.0 days on the rehabilitation service, and 175 days on the associate staff service, or 83.5 days for all services combined. While the number of patients who died (62 before the program change and 74 after) or moved to other hos-

Results

Prior to the program change the number of patients discharged per quarter was relatively constant at approximately 43 (Fig. 1). Following the program change, the number immediately rose to 60, and the upward trend has continued to the present. This difference is significant at the 5% level (t4 = 3.39).

Following the program change the mean length of stay of all patients fell from 469 to 310 days (Table I). This difference is significant at the 5% level (z = 2.25). The program change brought about an immediate rise in the number of patients discharged and a fall in the mean length of stay. These changes became more marked as the

P R 0 G R A M

c

H A N G E JAN.

APR JUL. ocr JAN

APR JUL. OCT

JUN. SEP DEC. MAR

JUN. SEP DEC. MAR.

K-1974-.4K--- 1975 -.-]I-.re FIG. 1-Number of true patient discharges each quarter before and after program change.

CMA JOURNAL/MARCH 18, 1978/VOL. 118 641

pitals (13 before, 15 after) or institutions (47 before, 54 after) rose slightly, the number of patients who returned home increased notably (from 49 to 117). This increase in the number discharged home when compared with other types of discharge is significant at the 0.5% level (y.= 11.64). The greatest increase in number discharged home was from the rehabilitation service, but the GCC service also discharged an increased proportion of patients home (Table III). On the other hand, the associate staff (the part-time physicians) discharged a somewhat smaller percentage of patients home than they had done previously. Some preliminary results from the prospective study concerning patients' independence in the activities of daily living are presented in Table IV. This includes all patients referred to the geriatricians or physiatrist for assessment. Some of these patients were admitted to the GCC service at St. Mary's of the Lake Hospital and some to the hospital's rehabilitation service, and some were not admitted because of the possibility of going elsewhere. With the rehabilitation service 80% of the patients improved; with the G.C service 78% improved; and of those not admitted 53 % improved or were normal. Three months after referral for assessment, 10 of the 15 rehabilitation patients had been discharged while 7 of the 36 GCC patients had been discharged. Admissions to an acute-care hospital within 1 year following discharge from this hospital are analysed in Table V. Following the program change 23% of the patients required such admission

and had a mean length of stay of 21.07 ± 2.43 days compared with 15% previously with a mean length of stay of 20.42 ± 4.47 days. In each year 8.8% of the patients required readmission. None of these changes were significant. Discussion Our data demonstrate that an active team approach to the treatment of the geriatric patient with significant disability can produce positive results. The majority of patients improve their ability to undertake the activities of daily living. Moreover, there is greater efficiency in the use of beds and a higher turnover rate owing to the larger number of patients being discharged home after a shorter overall stay. Since the new program involved several changes being made at the same time, it is not possible to attribute to any particular one the change in outcome. The employment of a full-time staff does appear important. These patients have a complex interacting network of diseases that requires considerable attention. They often receive many drugs that may interact. The physician in this institution has a key role in presenting problems to the team, establishing goals of treatment, auditing the results, and promoting maximum interaction and assertiveness of the team members. The effectiveness of full-time physicians and house staff is reflected in the decreased length of stay and increased patient turnover among patients on the GCC service. These improvements did not extend to patients treated by the associate staff. Therefore, the ready availability of full-

642 CMA JOURNAL/MARCH 18, 1978/VOL. 118

time physicians with a special interest in the treatment of the elderly and expertise in rehabilitative techniques, in association with a full-time house staff, appears to be a major factor in improving the outcome for geriatric patients and ensuring more efficient use of facilities. Our results also demonstrate that elderly patients are able to benefit from rehabilitation service. Prior to the program change, most of such patients would have been admitted to the general service in this institution. At present those with the greatest potential for improvement are treated on the rehabilitation service; their stay is shorter and their rate of turnover higher. During the first year of the program the day hospital facilitated the discharge of three inpatients and served as an alternative to admission for a further three patients. Hence its numerical contribution was not impressive. However, it was just beginning to operate in the period under study. Similarly, the geriatric clinic has not led to earlier discharge of a significant number of patients. It did serve to supply more knowledge of the patients after their discharge so that discharge planning could be improved. It allowed for assessment of patients prior to admission, so that alternative facilities could be sought and unnecessary admission avoided. However, the offer of outpatient follow-up was nearly always made after the discharge date had been set. Patients discharged from this type of institution, in spite of ongoing medical care, are at considerable risk of requiring admission to an acute-care hospital, where we found their average length of stay was 20 days. This is comparable to the 25.4 days average for patients over 65 years of age in Vancouver.11 These patients carry a pronounced burden of disease and periodic exacerbations and the development of new diseases are to be expected.11 The need for acute-care hospital back-up with geriatric input has been recognized elsewhere.13-11 This provides increased continuity of care, increased patient movement and a more optimistic approach to the care of such patients. The program at St. Mary's of the Lake Hospital is continuing to evolve. While our data do indicate improvement over the situation that existed previously, much improvement is still desirable. During the last 3 months of the period described in this paper all patients were admitted to the rehabilitation or GCC medical service for assessment before being treated by the associate staff. Formerly patients were assigned to either the GCC service or associate staff service in an attempt to simply balance the total bed count.

.AidactazkI.

Lomotil®

Ispironolactone 25 mg/hydrochlorothiazide 25 mgl

(Each tablet and each 5 ml of liquid contain diphenosylate HCI 2.5 mg and atropine sulphate 0.025 mg)

Morethanjustatbiazide Summary of prescribing information: Pharmacology:

Summary of prescribing information: INDICATIONS: Symptomatic, adjunctive therapy in the management xl

diarrhea. CONTRAINDICATIONS: Patients with a known hypersensitivity to diphenoxylate HOI or to atropine: patients who are iaundiced. WARNINGS: KEEP OUT OF REACH OF CHILDREN SINCE ACCIDENTAL OVERDOSE MAY CAUSE SEVERE OR EVEN FATAL RESPIRATORY DEPRESSION. NOT RECOMMENDED FOR USE IN CHILDREN UNDER TWO YEARS. USE IN PREGNANCY: The expected benefits of the drug should be weighed against any possible hazard to the mother and child. Diphenoxylate and atropine are excreted in breast milk. PRECAUTIONS: Use with extreme caution in patients with cirrhosis, advanced hepatic disease or abnormal liver function tests. Diphenoxylate may poteotiate the action xl barbiturates, tranquilizers and alcohol. Administer with considerable caution to patients who are receiving addicting drugs or who are addiction prone. The concurrent use 01 Lomotil with monoamine oxidase inhibitors may, in theory, precipitate hypertensive crisis. Patients with acute ulcerative colitis should be carefully observed and Lomotil therapy should be discontinued promptly if abdominal distension occurs xr if other untoward symptoms develop. There should be strict observance of the contraindications and precautions relative to the use of atropine. In children, signs xl atropinism may occur even with recommended doses, particularly in Downs Syndrome. Use with special caution in younger age groups because of variable response in young children. Dehydration may further influence the variability of response to Lomotil and may predispose to delayed diphenosylate intoxication. Druginduced inhibition of peristalsis may result in fluid retention in the colon which may further aggravate dehydration and electrolyte imbulance. If severe dehydratixn xl electrolyte imbalance is present withhold Lomxtil until appropriate cxrrective therapy has been initiated. ADVERSE EFFECTS: The most frequently reported adverse effect is nausea. Other symptoms which have been reported are drowsiness, coma, lethargy, sedation, respiratory depression, dizziness, vomiting. anxreoia, pruritus, skin eruption, giant urticaria, angioneurotic edema, restlessness, insomnia, abdominal bloating and cramps, paralytic ileus, toxic megacolon und there have been rare reports of numbness of the extremities, headache, blurring of vision, swelling of the gums, euphoria, depression and general malaise. Atropine effects, such as dryness of the skin and mucous membranes, hyperthermia, tachycardia, urinary retentixn and flushing may also occur, especially in children. SYMPTOMS AND TREATMENT OF OVERDOSE: Refer to Prxduct Monograph. DOSAGE AND ADMINISTRATION: Adults - the usual initial dose is 5 mg diphenoxylate (2 tablets) 3 or 4 times daily. (20 mg/24 bro. in divided doses is the maximum recommended dosage). Downward adluotment should be made as soon as initial control of symptoms is accomplished. Maintenance dose may be as low as /401 the dosetequired for initial control. Childree - an adequate pediatric daily dose (to be given in divided doses 3 or 4 times daily) determined by the child 'sage is asfollows:

AGE AND TOTAL DAILY DDSAGE 2tosyears

8.0mg (t2.Oml)

NOTE THISISTHE TOTALDAILY

MEDICATION TO BE GIVEN 8.0mg 1N30R4 (t5.Oml) DIVIDED tO.Omg gtot2years DOSES (20.Oml) Wolume of Lomotil Liquid containing approsimale 10181 daily dosage of diphenoxylate HCI. Adjustment of dosage downward should be made as soon as initial control of symptoms is accomplished.

6 lx 8 years

Spironolactone effects diuresis by blocking through competitive inhibition, the sodium and water retaining and potassiom eocreting effects of aldosterone on the distal renal tubule. Hydrochlorothiazide promotes eocretion of sodiom and water primarily by inhibiting their reabsorption by the cortical diluting segment of the renal tubule. Thus the components of Aldactazide have different and complementary modes of action. In addition, spironolactone minimizes potassium loss characteristically induced by hydrochlorothiazide, thereby reducing the possible serious consequences of potassium depletion. Indicationo: The treatment of essential hypertension; the edema and ascifes of congestive heart failure, cirrhosis of the liver, the nephrotic syndrome and idiopathic edema. Contraindications: Acute renal insufficiency, rapidly progressing impairment of renal function; anuria; hyperkalemia; patients known to be sensitive to thiazides or other sulfonamide-derived drugs; patients with severe or progressive liver disease at the discretion of the physician; nursing mothers; sensitivity to spironolactone. Warnings; Concurrent potassium supplementation is not indicated unless a glucocorficoid is also given. Aldactazide should not be used in conjunction with other potassium conserving agents. Precautions; The most potentially serious electrolyte disturbance is hyperkalemia which is more likely to occur in severely ill patients. If hyperkalemia occurs, discontinue Aldactazide. Hypokalemia may develop. Use cautiously in patients with sodium depletion. Check for signs of fluid or electrolyte imbalance. The most frequent electrolyte distarbance encountered is dilutional hyponatremia. Rarely a true low-salt syndrome may develop. Decrease dosage before diuresis is complete to avoid dehydration. Thiazide diuretics may precipitate hepatic coma. Use with caution in patients subjected to regional or general anesthesia. Discontinue 48 hours prior to elective surgery as both hydrochlorothiazide and spironolactone reduce vascular responsiveness to norepinephrine. Orthostatic hypotension may occur. Thiazides may increase responsiveness to tubocurarine. Pathological changes in the parathyroid glands have been observed. Consider the possibilities of sensitivity reactions in patients with a history of allergy or asthma as well as esacerbation of systemic opus erythematosus. Thiazides maycause elevation of BUN Aldactazide may potent ate the effect of other antihypertensives especially the ganglionic blocking agents. The dosage of such drugs should be reduced at least 5D% when Aldactazid e is added to the regimen. Spironolactone interferes with the assay of plasma cortisol but not the Ertel method. ASA may interfere with the action of spironolactone. Use with caution in patients with hyperuricemia or history of gout. Insulin requirements may be increased, decreased or unchanged in diabetics. Hyperglycemia and glycosuria may be manifested in latent diabetics. Use with caution in women of childbearing age and weigh benefits against the possible hazards to the fetus. Adverse Effects; Nausea or other gastrointestinal disturbances, gynecomastia or mild androgenic manifestations have been reported in some patients. Other side effects including those of hydrochlorothiazide occur less frequently. Overdose; Symptoms of Overdosage; Acute overdosage maybe manifested by drowsiness, mental confusion, maculopapular or erythematous rash, nausea, vomiting, dizziness or diarrhea. Rare instances of hypokalemia, hyponatremia, hyperkalemia or hepatic coma may occur. Thrombocytopenic purpura and granulocytopenia have occurred with thiazide therapy. No specific antidote. Treat fluid depletion and electrolyte imbalances as indicated. Dosage; In essential hypertension, a daily dosage of 2 to 4 tablets, in divided doses, will be adequate for most patients, provided the treatment is continued for 2 weeks or longer. Dosage may range from 2 to 8 tablets daily. Dosage should be adjusted according to the response of the patient. In edematous states, a daily dosage of 2 to 4 tablets, in divided doses, will be adequate for most patients but may range from 2 foB tablets daily. Dosage should be adjusted according to the response of the patient. Supply; Each round, ivory-coloured tablet contains, spironolactone, 25 mg and hydrochlorothiazide, 25 mg. Available in bottles of 100,1,000 and 2,5DD tablets. Complete prescribing information available on request.

Reference: 1. Gantt, CL, Rational Drug Therapy 6:1-6, Aug, 1972

DOSAGE FDRMS: Tablels: 2.5 mg of diphenoxylate HCI and 0.025 mg of atropine sulfate, in bottles of too, 500 and .000. LiquId: 2.5mg of diphenexylate HCI and 0.025mg of atropine sulfate/S ml, in bottles 0160 ml and 450 ml. Product Monograph available to health professionals, on request. REFERENCES: t. Information on file at Searle, Canada. 2. Hock,C.W.,J. Med. Asun. Ga. 50: 485-488, t86t. 3. Parcost Comparative Drug odes, July t877.

[.K. 7742

LOO-t8E 7743

Searle Pharmaceuticals

Searle Pharmaceuticals

Oakville, Ontario L6H 1M5

Oakville, Ontario L6H 1M5

Currently each patient is assessed by the full-time staff from the point of view of the likelihood of rehabilitation and an attempt at rehabilitation is made before it is concluded that it will be unsuccessful. The present policy is that patients with the least rehabilitation potential are entrusted to the associate staff. A few beds have been designated for use by patients requiring shorter admission for treatment of minor exacerbations of their illness, or during vacation or social or sickness relief for members of the family. A geriatric day-care centre began operating in the Kingston area late in 1977. It is expected that these additional measures will further decrease the rates of institutionalization in the area and allow more patients to be served. In summary, an active approach to the treatment of the elderly results in improved outcome and a more efficient use of continuing-care beds. In our institution, active involvement of physicians with an interest in geriatrics and rehabilitation appears to have been essential to the development of this program. Physicians in this type of institution, with the help of a therapeutic team, can make an important contribution to decreasing the excessive rate of institutionalization currently prevailing in this country. We gratefully acknowledge the assistance of Miss Marguerite Savage, research assistant, in our project. This study was supported by the Ontario Ministry of Health (DM grant 249) and in part by the Physicians' Services Incorporated Foundation. References 1. CLARK JA, CoLLINsHAW NE: Canada's Older Population, staff papers, long-range health planning branch, Health and Welfare Canada, May 1975 2. ROMBOUT MK: Health Care Institutions and Canada's Elderly, 1971-2031. A Supplement to Hospitals and the Elderly: Present and Future Trends, long-range health planning branch, Health and Welfare Canada, July 1975 3. SCHWENGER CW: Keep the old folks at home.

Can J Public Health 65: 417, 1974

4. KASL SV: Physical and mental effects of involuntary relocation and institutionalization of the elderly - a review. Am J Public Health 62: 377, 1972 5. SPASOFF RA, KRAU5 RA, BEAnIE EJ, et al: A longitudinal study of elderly residents of long-stay institutions. I. Early response to institutional care (to be published) 6. Idem: A longitudinal study of elderly residents of long-stay institutions. II. The situation one year after admission (to be published)

7. MEHTA NH, MACK CM: Day care services: an alternative to institutional care. I Am

Geriatr Soc 23: 280, 1975 8. FISHER RH: The day hospital:

in-patient

alternative. Ont Med Rev 41: 401, 1974 9. Patient Care Classification by Types of Care, Ontario Ministry of Health, publ no 75-2222, Toronto, 1975, pp 3-4 10. Nm NJ, HULL CH, JENKINs JG, et al: SPSS: Statistical Package for the Social Sciences, 2nd ed, New York, McGraw, 1975 11. WEAvRR HG, MCPHEE M, LAMBERT P: Geriatrics Report, Greater Vancouver Regional Hospital District, 1975, Vancouver 12. FISHER RH: Health care problems of the elderly. Mod Med Can 32: 526, 1977 13. RUTH 5, RUDIN SE: Geriatrics and the health care system. Hosp Admin Can 19: 35, 1977 14. Idem: Make your beds go further. Can Hosp 50: 54, 1973 15. Liawoon 5, RUTH 5: A program of integrated medical care. Can Hosp 34: 39, 1957

CMA JOURNAL/MARCH 18, 1978/VOL. 118 645