Quality Assurance in Health Cart. Vol. 2, No. 3/4. pp. 387-392. 1990 Printed in Great Britain.
1040-6166/90 S3.00 + 0.00 © 1991 Pergamon Press pic
THE IMPORTANCE OF DIAGNOSTIC PROCEDURES TO ENSURE QUALITY OF HEALTH CARE IN GERIATRIC MEDICINE Examples from recent studies Bertil Steen* Vasa Hospital S-411 33 Gothenburg Sweden (First submitted 16 June 1990; accepted 19 June 1990)
Keywords: Diagnosis, quality of health care, geriatrics, old age.
INTRODUCTION There are no clear-cut boundaries between prevention, diagnosis, therapy, rehabilitation, nursing care and social services in the care of the elderly. This may • Professor of geriatric medicine, Department of Geriatric and Long-term Care Medicine, Gothenburg University, Sweden. 387
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Within the health care of the elderly with prevention, diagnosis, therapy, rehabilitation, nursing care and social service, diagnostic procedures are of great importance to avoid under- and over-diagnosis. Many diagnostic difficulties exist in elderly patients such as changed reference values, changed normal values and changed signs and symptoms. Well-known examples of conditions which are likely to be underdiagnosed include depression and urinary incontinence. Examples are given from the cardiopulmonary field where e.g. dyspnoea showed to be very common, but in only 36% of males and 52% in females related to cardiac failure or pulmonary disease. The most common symptom of acute myocardial infarction in elderly patients was shown to be dyspnoea, whereas chest pain occurred in only one fifth of the cases. In another study of patients with ulcer disease loss of appetite and weight, nausea and anemia were more common than abdominal pain and heartburn. In peritonitis patients, abdominal pain was observed in only just more than half of the cases and guarding and/or abdominal rigidity in about one third. In patients with suspect age dementia a detailed investigation showed the prevalence of organic dementia to be 89% whereas 3% had treatable dementia and 8% non-dementia conditions. In geriatric long-term patients the mean hearing loss in the speech area was about 50 dB, in spite of the fact that only about 10% of the patients had hearing aids. The need for nursing diagnosis is also obvious. It is concluded that a detailed multidisciplinary diagnostic investigation procedure is very important in geriatric medicine.
388
B. Steen
THE CARDIOPULMONARY FIELD Within the framework of the gerontological and geriatric population studies in Gothenburg, Sweden [4] the prevalence of digitalis therapy and symptoms and signs
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result in some confusion and debate about what is the most important aspect—the medical, the nursing care or the social one. The truth is certainly that all aspects are equally important and that they should be considered together in health care planning and in handling of patients. However, there is a risk for a preponderance towards social matters in the care of the elderly at least in certain areas. Within the medical field there is in fact also a tendency in many countries that geriatric medicine and psychogeriatric medicine too often concentrate on the pure caring of patients. Rehabilitation attempts are certainly included, but the primary importance of the highly qualified and detailed diagnosis may sometimes be neglected. Many special diagnostic difficulties exist in elderly patients, and changed reference and normal values and thereby changed disease criteria, changed signs and symptoms, and unawareness of the diagnostic difficulties may lead to overdiagnosis/ overtreatment on one hand and underdiagnosis/undertreatment on the other hand. Such difficulties increase with advancing age also within the group of elderly. It is therefore important to realize that although "young elderly" (age 65-75) seem in some respects to have a better general health nowadays compared to a couple of decades ago—at least in countries like Sweden, the proportion and number of the very old is rapidly increasing which leads to an accumulation of severe disease at ages where disease is very common. The multi-factorial symptomatology in these age groups depending on many concomitant diseases may also make diagnosis even more difficult. Well-known examples of conditions which are likely to be under-diagnosed because of varying reasons include depression and urinary incontinence. Apart from the medical qualitative aspect this has also an obvious quantitative impact since such conditions have a high prevalence in the higher age groups. Blazer and Williams studied dysphoric symptoms and symptoms of depressive disease by using DSM-III in an elderly population, and found about 15% with marked depressive symptoms, and the prevalence increased somewhat with advancing age [1]. Regarding urinary incontinence it is a well-known fact that this condition is often confused with normal ageing even in persons who are obviously cases for further diagnosing and treatment. Such misjudgements are often done by the patient himself and his relatives but in some cases also by health professionals. The prevalence of urinary incontinence is hard to assess. However, prevalence figures between 10 and 20% are not uncommon in the literature. Thus, the prevalence in women aged 65 or more in London studied by questionnaire was 12% [2], and in another study of 200 women over age 65 a prevalence of 17% could be revealed [3]. In this paper, some examples of the importance of diagnosis in geriatric medicine are given from the cardiopulmonary, abdominal, psychiatric, audiological and nursing care field, respectively. The studies are published during the last decade— mostly during the last few years—from the Departments of Geriatric Medicine at Gothenburg University [4-6] and Lund University [7-12], and the Department of Advanced Nursing, Umea University [15,16].
Diagnostic Procedures
389
THE ABDOMINAL FIELD Ulcer Disease
In one study from a large geriatric university hospital with a high autopsy rate (81%) the results from 6200 autopsies were scrutinized [8]. One patient out of twenty had had an active peptic ulcer and the diagnostic accuracy was studied retrospectively. Only 16% of patients with duodenal ulcer and 29% with gastric ulcer had been correctly diagnosed ante mortem. The different symptomatology seemed to be the major reason, since loss of appetite and weight, nausea and anemia were more common among the ulcer patients than abdominal pain and heartburn. The diagnosis of peptic ulcer seems to be very difficult in geriatric medicine since the predictive values of single symptoms and of combined findings in that study were as low as 221%. The same group studied more than 2500 patients admitted to a geriatric clinic by
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of cardiac disease were investigated in more detail [5]. Out of 1007 70-year-old probands taking part in the home-call part of the study almost 14% stated that they used digitalis. Out of these 70-year-olds 37% had obvious symptoms of heart disease requiring such treatment, 35% lacked symptoms of arrythmia and/or congestive heart failure but had heart volumes larger than those used as reference values in younger age groups, and 29% had no symptoms indicating digitalis treatment. It seemed that at most 25% and at least 13% of that population needed digitalis therapy at this age, and that about 14% of the population had such treatment. Furthermore, only about two thirds of those apparently needing digitalis therapy at that time were on such treatment, and the conclusion reached from that investigation was that both over- and under-diagnosis of heart disease requiring digitalis therapy were common in this age group. Another substudy within the gerontological and geriatric population studies of 70year-olds in Gothenburg aimed at investigating to what extent a subjective feeling of dyspnoea could be related to definable diseases at age 70, rather than being a manifestation of normal ageing processes [6]. Not less than 46% of the probands were found to have an increased exertional dyspnoea or an "objective" shortness of breath at the health control. Out of such 70-year-olds 64% of the males and 48% of the females had cardiac failure or pulmonary disease. However, large proportions of probands without dyspnoea had also such conditions, namely 48% of males and 24% of females. Dyspnoea not statistically related to disease was found in one third of the males and almost half of the females. Within the framework of their studies on symptomatology in old age with clinical and pathological methods Wroblewski and collaborators studied symptoms of myocardial infarction in old age [7]. In both clinical case, retrospective, and prospective approaches prevalence and kind of symptoms of myocardial infarction were studied in elderly long-stay patients. The most common symptom of acute myocardial infarction in the retrospective and prospective studies was dyspnoea, whereas chest pain occurred in only about one fifth of the cases. The conclusions from these studies were clear-cut: clinical features of myocardial infarction in the elderly often differ from the classic presentation.
390
B. Steen
screening with fecal occult blood tests and B-hemoglobin analyses [9]. In patients positive in these respects a high prevalence of ulcer disease (22%) was found. Also in this study the symptomatology was different from the classical presentation. Thus, abdominal pain occurred in less than one patient out of five, whereas loss of appetite and weight, and nausea were common. Peritonitis
The diagnostic accuracy regarding peritonitis has also been found to be low (less than 50%) in geriatric in-patients [10]. In that study 212 cases of peritonitis were found at autopsy out of 7668 patients. The poverty of the symptomatology can be exemplified by tie fact that abdominal pain was observed in only just more than half of the patients, and that garding and/or abdominal rigidity was found in about one third. THE PSYCHIATRIC FIELD
THE AUDIOLOGICAL FIELD
It is well known that insufficient hearing might contribute to social isolation,.and even be the cause of "pseudodementia" conditions. Sensory neural hearing loss is a common phenomenon which, thus, may lead to severe communication problems. The importance of hearing loss in the elderly is emphasized by concomittant other mental or physical illness. In geriatric long-term care medicine disturbances of hearing ability are common. In one study of about 200 patients in geriatric long-term care wards information regarding hearing problems was collected by questionnaire, and hearing was tested with pure-tone audiometry [12]. Only one patient out of four
Downloaded from by guest on March 21, 2016
In countries with a high proportion and high number of elderly, age dementia syndromes are one of the most prominent public health problems. Obviously a high diagnostic accuracy is of utmost importance in every case of supposed organic dementia to avoid overdiagnosis and underdiagnosis. --- -• In one study 75 patients admitted to a geriatric clinic with symptoms or signs of organic brain failure and suspicion of age dementia were investigated in detail with a wide test battery including clinical examination, chemical analyses, electroencephalogram, regional cerebral bloodflowmeasurement and psychometric tests [11]. The prevalence of organic dementia turned out to be 89%, whereas 3% of the patients had treatable dementia and 8% non-dementia conditions. The dominating reason for the symptoms of the patients was confusional reactions. Although depression, drug intoxication, and reduced hearing ability were noted, these conditions were in no case the only cause of the symptoms. It should, however, be noted that not less than 19% of the patients were deaf, and another 65% had reduced hearing ability. It could be said that the prevalence of treatable conditions was rather low. On the other hand also a prevalence of around 10% of treatable and non-dementia conditions is important enough from medical, ethical, and economic points of view, and strongly emphasizes the need to find these patients with screening procedures.
Diagnostic Procedures
391
was able to participate in the hearing test due to severe somatic or mental handicap. The mean hearing loss in the speech area was about 50 dB, indicating that a majority of the patients needed hearing aids. However, only one patient in ten had such aids. It was concluded that impaired hearing in such patients was an underestimated and neglected problem. Obviously the need for education and more thorough diagnostic procedures is marked. The situation that caused most problems was group conversation, but as much as one patient out of three was unable to manage face to face conversation without difficulty, and only about one patient out of four managed without problems in the hearing situations tested. The patients had an increasing hearing loss with age. THE NURSING CARE FIELD
CLOSING WORDS
The above mentioned and other studies underline the importance of a detailed multidisciplinary diagnostic investigation procedure in geriatric medicine to avoid both overdiagnosis and underdiagnosis. REFERENCES 1. Blazer D and Williams C D, Epidemiology of dysphoria and depression in an elderly population. Am J Psychiatry 137: 439-444, 1980. 2. Thomas T, Plymat K R, Blannin J and Meade T W, Prevalence of urinary incontinence. Br MedJ 281: 1243-1245,1980. 3. Yamell J M and St Leger A S, The prevalence, severity and factors associated with urinary incontinence in a random sample of the elderly. Age Ageing 8: 81-85,1979. 4. Rinder L, Roupe S, Steen B and Svanborg A, 70-year-old people in Gothenburg. A population study in an industrialized Swedish city. I. General presentation of the study. ActamcdScand 198: 397-407, 1975. 5. Landahl S, Lindblad B, Roupe S, Steen B and Svanborg A, Digitalis therapy in a 70-year-old population. Acta med Scand 202: 437-443, 1977. 6. Landahl S, Steen B and Svanborg A, Dyspnea in 70-year-old people. Acta med Scand 207: 225-230, 1980. 7. Wroblewski M, Milculowski P and Steen B, Symptoms of myocardial infarction in old age: Clinical case, retrospective and prospective studies. Age Ageing 15: 95-104, 1986.
Downloaded from by guest on March 21, 2016
The need for nursing diagnoses is sometimes neglected when handling geriatric patients. This is obviously important, especially in nursing homes but also in other caring situations in for example geriatric clinics. Much work has been produced during the last few years to develop systems for nursing diagnostic procedures [13]. For example a list of nursing diagnoses has been produced by the North American Nursing Diagnosis Association [14]. A more detailed diagnostic activity regarding the nursing care situation is of great importance in many situations m geriatric medicine, such as rehabilitation in patients with Parkinson's disease [15]. For review regarding nursing diagnosis related to eating problems, see Ref. [16].
392
B. Steen
8. Wroblewski M, Peptic ulcer in geriatric long-term care medicine. Aging 1: 77-83, 1989. 9. Wroblewski M and Ostberg H, Ulcer disease among geriatric in-patients with positive fecal occult blood test and/or iron deficiency anamaeia—a prospective study. ScandJ Gastroenterology 25: 489495,1990. 10. Wroblewski M and Mikulowski P, Peritonitis in geriatric in-patients: Causation, diagnostic accuracy and symptomatology. Age Ageing, in press, 1990. 11. Hedner K, Gustafson L, Steen G and Steen B, Screening of patients admitted to a geriatric hospital with supposed organic dementia. Compr Gerontol Al: 55-60,1987. 12. Hedner K, Broms P, Harris S and Steen B, Hearing in geriatric long-stay patients. Compr Gerontol Al: 69-71, 1987. 13. Iyer P W, Taptich B J and Bemocchi-Losey D, Nursing process and nursing diagnosis. W B Saunders Company, 1986. 14. McLare A M (Ed.), Classification of nursing diagnoses. North American Nursing Diagnosis Association. The C V Mosby Company, St Louis, 1987. 15. Norberg A, Athlin E and Winbl»d B, A model for the assessment of eating problems in patients with Parkinson's disease. / Advanced Nursing 12: 473-481,1987. 16. Axelsson K, Earing problems and nutritional status after stroke. Umei University medical dissertations. New series No. 218,1988.
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1040-6166/90 S3.00 + 0.00 © 1991 Pergamon Press pic
THE IMPORTANCE OF DIAGNOSTIC PROCEDURES TO ENSURE QUALITY OF HEALTH CARE IN GERIATRIC MEDICINE Examples from recent studies Bertil Steen* Vasa Hospital S-411 33 Gothenburg Sweden (First submitted 16 June 1990; accepted 19 June 1990)
Keywords: Diagnosis, quality of health care, geriatrics, old age.
INTRODUCTION There are no clear-cut boundaries between prevention, diagnosis, therapy, rehabilitation, nursing care and social services in the care of the elderly. This may • Professor of geriatric medicine, Department of Geriatric and Long-term Care Medicine, Gothenburg University, Sweden. 387
Downloaded from by guest on March 21, 2016
Within the health care of the elderly with prevention, diagnosis, therapy, rehabilitation, nursing care and social service, diagnostic procedures are of great importance to avoid under- and over-diagnosis. Many diagnostic difficulties exist in elderly patients such as changed reference values, changed normal values and changed signs and symptoms. Well-known examples of conditions which are likely to be underdiagnosed include depression and urinary incontinence. Examples are given from the cardiopulmonary field where e.g. dyspnoea showed to be very common, but in only 36% of males and 52% in females related to cardiac failure or pulmonary disease. The most common symptom of acute myocardial infarction in elderly patients was shown to be dyspnoea, whereas chest pain occurred in only one fifth of the cases. In another study of patients with ulcer disease loss of appetite and weight, nausea and anemia were more common than abdominal pain and heartburn. In peritonitis patients, abdominal pain was observed in only just more than half of the cases and guarding and/or abdominal rigidity in about one third. In patients with suspect age dementia a detailed investigation showed the prevalence of organic dementia to be 89% whereas 3% had treatable dementia and 8% non-dementia conditions. In geriatric long-term patients the mean hearing loss in the speech area was about 50 dB, in spite of the fact that only about 10% of the patients had hearing aids. The need for nursing diagnosis is also obvious. It is concluded that a detailed multidisciplinary diagnostic investigation procedure is very important in geriatric medicine.
388
B. Steen
THE CARDIOPULMONARY FIELD Within the framework of the gerontological and geriatric population studies in Gothenburg, Sweden [4] the prevalence of digitalis therapy and symptoms and signs
Downloaded from by guest on March 21, 2016
result in some confusion and debate about what is the most important aspect—the medical, the nursing care or the social one. The truth is certainly that all aspects are equally important and that they should be considered together in health care planning and in handling of patients. However, there is a risk for a preponderance towards social matters in the care of the elderly at least in certain areas. Within the medical field there is in fact also a tendency in many countries that geriatric medicine and psychogeriatric medicine too often concentrate on the pure caring of patients. Rehabilitation attempts are certainly included, but the primary importance of the highly qualified and detailed diagnosis may sometimes be neglected. Many special diagnostic difficulties exist in elderly patients, and changed reference and normal values and thereby changed disease criteria, changed signs and symptoms, and unawareness of the diagnostic difficulties may lead to overdiagnosis/ overtreatment on one hand and underdiagnosis/undertreatment on the other hand. Such difficulties increase with advancing age also within the group of elderly. It is therefore important to realize that although "young elderly" (age 65-75) seem in some respects to have a better general health nowadays compared to a couple of decades ago—at least in countries like Sweden, the proportion and number of the very old is rapidly increasing which leads to an accumulation of severe disease at ages where disease is very common. The multi-factorial symptomatology in these age groups depending on many concomitant diseases may also make diagnosis even more difficult. Well-known examples of conditions which are likely to be under-diagnosed because of varying reasons include depression and urinary incontinence. Apart from the medical qualitative aspect this has also an obvious quantitative impact since such conditions have a high prevalence in the higher age groups. Blazer and Williams studied dysphoric symptoms and symptoms of depressive disease by using DSM-III in an elderly population, and found about 15% with marked depressive symptoms, and the prevalence increased somewhat with advancing age [1]. Regarding urinary incontinence it is a well-known fact that this condition is often confused with normal ageing even in persons who are obviously cases for further diagnosing and treatment. Such misjudgements are often done by the patient himself and his relatives but in some cases also by health professionals. The prevalence of urinary incontinence is hard to assess. However, prevalence figures between 10 and 20% are not uncommon in the literature. Thus, the prevalence in women aged 65 or more in London studied by questionnaire was 12% [2], and in another study of 200 women over age 65 a prevalence of 17% could be revealed [3]. In this paper, some examples of the importance of diagnosis in geriatric medicine are given from the cardiopulmonary, abdominal, psychiatric, audiological and nursing care field, respectively. The studies are published during the last decade— mostly during the last few years—from the Departments of Geriatric Medicine at Gothenburg University [4-6] and Lund University [7-12], and the Department of Advanced Nursing, Umea University [15,16].
Diagnostic Procedures
389
THE ABDOMINAL FIELD Ulcer Disease
In one study from a large geriatric university hospital with a high autopsy rate (81%) the results from 6200 autopsies were scrutinized [8]. One patient out of twenty had had an active peptic ulcer and the diagnostic accuracy was studied retrospectively. Only 16% of patients with duodenal ulcer and 29% with gastric ulcer had been correctly diagnosed ante mortem. The different symptomatology seemed to be the major reason, since loss of appetite and weight, nausea and anemia were more common among the ulcer patients than abdominal pain and heartburn. The diagnosis of peptic ulcer seems to be very difficult in geriatric medicine since the predictive values of single symptoms and of combined findings in that study were as low as 221%. The same group studied more than 2500 patients admitted to a geriatric clinic by
Downloaded from by guest on March 21, 2016
of cardiac disease were investigated in more detail [5]. Out of 1007 70-year-old probands taking part in the home-call part of the study almost 14% stated that they used digitalis. Out of these 70-year-olds 37% had obvious symptoms of heart disease requiring such treatment, 35% lacked symptoms of arrythmia and/or congestive heart failure but had heart volumes larger than those used as reference values in younger age groups, and 29% had no symptoms indicating digitalis treatment. It seemed that at most 25% and at least 13% of that population needed digitalis therapy at this age, and that about 14% of the population had such treatment. Furthermore, only about two thirds of those apparently needing digitalis therapy at that time were on such treatment, and the conclusion reached from that investigation was that both over- and under-diagnosis of heart disease requiring digitalis therapy were common in this age group. Another substudy within the gerontological and geriatric population studies of 70year-olds in Gothenburg aimed at investigating to what extent a subjective feeling of dyspnoea could be related to definable diseases at age 70, rather than being a manifestation of normal ageing processes [6]. Not less than 46% of the probands were found to have an increased exertional dyspnoea or an "objective" shortness of breath at the health control. Out of such 70-year-olds 64% of the males and 48% of the females had cardiac failure or pulmonary disease. However, large proportions of probands without dyspnoea had also such conditions, namely 48% of males and 24% of females. Dyspnoea not statistically related to disease was found in one third of the males and almost half of the females. Within the framework of their studies on symptomatology in old age with clinical and pathological methods Wroblewski and collaborators studied symptoms of myocardial infarction in old age [7]. In both clinical case, retrospective, and prospective approaches prevalence and kind of symptoms of myocardial infarction were studied in elderly long-stay patients. The most common symptom of acute myocardial infarction in the retrospective and prospective studies was dyspnoea, whereas chest pain occurred in only about one fifth of the cases. The conclusions from these studies were clear-cut: clinical features of myocardial infarction in the elderly often differ from the classic presentation.
390
B. Steen
screening with fecal occult blood tests and B-hemoglobin analyses [9]. In patients positive in these respects a high prevalence of ulcer disease (22%) was found. Also in this study the symptomatology was different from the classical presentation. Thus, abdominal pain occurred in less than one patient out of five, whereas loss of appetite and weight, and nausea were common. Peritonitis
The diagnostic accuracy regarding peritonitis has also been found to be low (less than 50%) in geriatric in-patients [10]. In that study 212 cases of peritonitis were found at autopsy out of 7668 patients. The poverty of the symptomatology can be exemplified by tie fact that abdominal pain was observed in only just more than half of the patients, and that garding and/or abdominal rigidity was found in about one third. THE PSYCHIATRIC FIELD
THE AUDIOLOGICAL FIELD
It is well known that insufficient hearing might contribute to social isolation,.and even be the cause of "pseudodementia" conditions. Sensory neural hearing loss is a common phenomenon which, thus, may lead to severe communication problems. The importance of hearing loss in the elderly is emphasized by concomittant other mental or physical illness. In geriatric long-term care medicine disturbances of hearing ability are common. In one study of about 200 patients in geriatric long-term care wards information regarding hearing problems was collected by questionnaire, and hearing was tested with pure-tone audiometry [12]. Only one patient out of four
Downloaded from by guest on March 21, 2016
In countries with a high proportion and high number of elderly, age dementia syndromes are one of the most prominent public health problems. Obviously a high diagnostic accuracy is of utmost importance in every case of supposed organic dementia to avoid overdiagnosis and underdiagnosis. --- -• In one study 75 patients admitted to a geriatric clinic with symptoms or signs of organic brain failure and suspicion of age dementia were investigated in detail with a wide test battery including clinical examination, chemical analyses, electroencephalogram, regional cerebral bloodflowmeasurement and psychometric tests [11]. The prevalence of organic dementia turned out to be 89%, whereas 3% of the patients had treatable dementia and 8% non-dementia conditions. The dominating reason for the symptoms of the patients was confusional reactions. Although depression, drug intoxication, and reduced hearing ability were noted, these conditions were in no case the only cause of the symptoms. It should, however, be noted that not less than 19% of the patients were deaf, and another 65% had reduced hearing ability. It could be said that the prevalence of treatable conditions was rather low. On the other hand also a prevalence of around 10% of treatable and non-dementia conditions is important enough from medical, ethical, and economic points of view, and strongly emphasizes the need to find these patients with screening procedures.
Diagnostic Procedures
391
was able to participate in the hearing test due to severe somatic or mental handicap. The mean hearing loss in the speech area was about 50 dB, indicating that a majority of the patients needed hearing aids. However, only one patient in ten had such aids. It was concluded that impaired hearing in such patients was an underestimated and neglected problem. Obviously the need for education and more thorough diagnostic procedures is marked. The situation that caused most problems was group conversation, but as much as one patient out of three was unable to manage face to face conversation without difficulty, and only about one patient out of four managed without problems in the hearing situations tested. The patients had an increasing hearing loss with age. THE NURSING CARE FIELD
CLOSING WORDS
The above mentioned and other studies underline the importance of a detailed multidisciplinary diagnostic investigation procedure in geriatric medicine to avoid both overdiagnosis and underdiagnosis. REFERENCES 1. Blazer D and Williams C D, Epidemiology of dysphoria and depression in an elderly population. Am J Psychiatry 137: 439-444, 1980. 2. Thomas T, Plymat K R, Blannin J and Meade T W, Prevalence of urinary incontinence. Br MedJ 281: 1243-1245,1980. 3. Yamell J M and St Leger A S, The prevalence, severity and factors associated with urinary incontinence in a random sample of the elderly. Age Ageing 8: 81-85,1979. 4. Rinder L, Roupe S, Steen B and Svanborg A, 70-year-old people in Gothenburg. A population study in an industrialized Swedish city. I. General presentation of the study. ActamcdScand 198: 397-407, 1975. 5. Landahl S, Lindblad B, Roupe S, Steen B and Svanborg A, Digitalis therapy in a 70-year-old population. Acta med Scand 202: 437-443, 1977. 6. Landahl S, Steen B and Svanborg A, Dyspnea in 70-year-old people. Acta med Scand 207: 225-230, 1980. 7. Wroblewski M, Milculowski P and Steen B, Symptoms of myocardial infarction in old age: Clinical case, retrospective and prospective studies. Age Ageing 15: 95-104, 1986.
Downloaded from by guest on March 21, 2016
The need for nursing diagnoses is sometimes neglected when handling geriatric patients. This is obviously important, especially in nursing homes but also in other caring situations in for example geriatric clinics. Much work has been produced during the last few years to develop systems for nursing diagnostic procedures [13]. For example a list of nursing diagnoses has been produced by the North American Nursing Diagnosis Association [14]. A more detailed diagnostic activity regarding the nursing care situation is of great importance in many situations m geriatric medicine, such as rehabilitation in patients with Parkinson's disease [15]. For review regarding nursing diagnosis related to eating problems, see Ref. [16].
392
B. Steen
8. Wroblewski M, Peptic ulcer in geriatric long-term care medicine. Aging 1: 77-83, 1989. 9. Wroblewski M and Ostberg H, Ulcer disease among geriatric in-patients with positive fecal occult blood test and/or iron deficiency anamaeia—a prospective study. ScandJ Gastroenterology 25: 489495,1990. 10. Wroblewski M and Mikulowski P, Peritonitis in geriatric in-patients: Causation, diagnostic accuracy and symptomatology. Age Ageing, in press, 1990. 11. Hedner K, Gustafson L, Steen G and Steen B, Screening of patients admitted to a geriatric hospital with supposed organic dementia. Compr Gerontol Al: 55-60,1987. 12. Hedner K, Broms P, Harris S and Steen B, Hearing in geriatric long-stay patients. Compr Gerontol Al: 69-71, 1987. 13. Iyer P W, Taptich B J and Bemocchi-Losey D, Nursing process and nursing diagnosis. W B Saunders Company, 1986. 14. McLare A M (Ed.), Classification of nursing diagnoses. North American Nursing Diagnosis Association. The C V Mosby Company, St Louis, 1987. 15. Norberg A, Athlin E and Winbl»d B, A model for the assessment of eating problems in patients with Parkinson's disease. / Advanced Nursing 12: 473-481,1987. 16. Axelsson K, Earing problems and nutritional status after stroke. Umei University medical dissertations. New series No. 218,1988.
Downloaded from by guest on March 21, 2016
