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PubMed2004

Assessment of cognition in primary care: neuropsychological evaluation of the geriatric patient.

Some aspects of memory and other thinking abilities decline as part of the normal aging process. Normal age-related cognitive decline and disease-associated cognitive impairment can be difficult to differentiate in the typical patient-physician interaction, especially in the geriatric primary care setting where patients may present with multiple physical complaints that consume the physician's attention. It is essential that clinician's recognize even modest changes in thinking abilities in the geriatric patient since these changes may be an early warning sign of an impending dementing disorder. At the very least, reduced cognitive functioning can decrease one's quality of life as well as threaten their independence. When cognitive decline is suspected, a neuropsychological evaluation can provide an objective assessment of cognitive functioning that is useful for differential diagnosis, assessing presence and progression of cognitive disorders, and providing information relevant to treatment and planning. This article explores the challenges of cognitive assessment in older adults and provides an overview of the neuropsychological evaluation, its advantages and limitations, as well as common referral questions from primary care physicians.

Aged↗
PubMed2003

[Dysphagia, a geriatric point of view].

Dysphagia is most common in geriatric medicine. Aspirations may cause chronic inflammatory syndrome or acute pneumonia or heart failure. At-risk patients should be recognised: some risks are caused by an acute condition, some by chronic disease or handicap. Alzheimer's disease is the most common at-risk condition; it is causes a loss of the conscious part of mastication and early swallowing. Psychiatric disorders with anorexia should not be overlooked as a cause for dysphagia and malnutrition. Due to a longer life, elderly people are more likely to have multiple causes for dysphagia. Management of dysphagia in geriatric patients is sometimes curative but more often readaptative and palliative. It is not restricted to the time of the meals. It first starts with avoiding decubitus and maintaining a walking ability. Proper positioning in seats and bed involves an occupational therapist. The nutritionist selects tasty and appealing meals for each patient. Nurses detect acute confusion as opposed to, or in, dementia. The speech therapist takes charge in tutoring the staff in knowing what is the secure way to manage an assisted meal, and helps finding the best fitted texture for food and drink. Sometimes a proper rehabilitation will be feasible. Per endoscopic gastrostomies are mostly restricted to neuro-vascular patients and need discussed for their benefit/risk balance. The holistic approach needed to manage dysphagia in polypathology elderly patients calls for a "cultural" approach of the whole gerontologic team, never the less, accurate specialised diagnosis in mandatory.

Aged↗
PubMed1992

Community care services: views of patients attending a geriatric day hospital.

The NHS and Community Care reforms give increased emphasis to meeting the needs of patients as consumers of services, but little is known about patients' perceptions of services. In this study, we obtained the views of patients attending a geriatric day hospital about community care services and professional support; their knowledge of services, perceived unmet needs and perceptions of benefit. Forty-seven patients with a mental status score above 7/10 who attended the day hospital in a four week period were interviewed using structured questionnaires for consumer opinion, modified for this population. Patients had poor knowledge of services, especially of those which support carers and of private sources of support. When informed about the availability and purpose of local services, they recognised few unmet needs on average, less than one per patient, nearly always a need for social services, especially other forms of day care. Patients' perceptions of benefit from services and professional support were highest for day hospital care itself (98% of maximum possible benefit). There could be scope for the development of social work case management programmes in geriatric day hospitals; the methods used in this study provide a model for obtaining consumer opinion.

Aged↗
PubMed2004

Osteoarthritis. A review of musculoskeletal aging and treatment issues in geriatric patients.

Musculoskeletal disease is extraordinarily prevalent among geriatric patients, with an incidence that is increasing with the growth of this segment of the population. It is a major cause of disability, dependency, dysmobility, pain, and depression. Rheumatologic evaluation of the geriatric patient provides challenges to the clinician in the proper interpretation of pain, the effect of comorbidities and multiple medications, and the need to consider an interdisciplinary approach that includes the recognition of cognitive deficits, functional evaluations, and treatment of muscle atrophy. Osteoarthritis accounts for 60% to 70% of joint disease in older persons, with pathologic and radiographic findings that are a "background" against which to consider pain and limitation of motion. Therapeutic strategies that incorporate reconditioning, the reduction of load-bearing, and adequate pain control may positively impact quality of life and reduce the potential for falls.

Aged↗
PubMedDate not supplied

New paradigms for treating elderly patients with cancer: the comprehensive geriatric assessment and guidelines for supportive care.

Strategies for treating cancer are evolving to address the growing number of elderly patients with cancer. Older patients have highly variable physiologic ages, and their treatment should be individualized for optimal outcomes. Treatment paradigms should also take into account the diversity of patients' life expectancy, functional reserve, social support, and personal preference. A Comprehensive Geriatric Assessment (CGA) is a useful tool for estimating life expectancy and tolerance of treatment and for identifying reversible factors that may interfere with cancer treatment, including depression, malnutrition, anemia, neutropenia, and lack of caregiver support. Adopting a common language to describe older patients may facilitate the design and analysis of studies to determine effective drugs and care strategies for them. Information from a CGA can guide the prescription of potentially curative therapy, determine the best use of supportive care agents, and help identify frail patients for whom palliative care is the best option. There is evidence in a number of settings that the routine use of a CGA has a positive effect on health outcomes by reducing hospitalizations, preserving functional independence, and preventing geriatric syndromes. Guidelines for supportive care are also important in treating elderly patients with cancer. Pain, caused by cancer or its treatment, is prevalent, and guidelines for its assessment and treatment should be implemented to improve quality of life. Toxicities such as neutropenia and mucositis should be managed aggressively. Growth factors reduce the incidence and severity of neutropenia and its complications in older patients, particularly when they are administered in the early cycles of chemotherapy. The development of effective strategies for the management of toxicity caused by anticancer drugs may help the elderly, as much as younger patients, expect and look forward to a positive outcome with their treatment.

Aged↗
PubMedDate not supplied

Feasibility of quality indicators for the management of geriatric syndromes in nursing home residents.

PURPOSE: The assessment and management of dementia, falls and mobility disorders, malnutrition, end-of-life issues, pressure ulcers, and urinary incontinence have been identified as important quality improvement targets for vulnerable elders residing in nursing homes. This study aimed to identify valid and feasible measures of specific care processes associated with improved outcomes for these conditions. METHODS: Nine experts in nursing home (NH) care participated in a modified Delphi process to evaluate potential quality indicators (QIs) for care in NHs. Panelists met and discussed potential indicators before completing confidential ballots rating validity (process associated with improved outcomes), feasibility of measurement (with charts or interviews), feasibility of implementation (given staffing resources in average community NHs), and importance (expected benefit and prevalence in NHs). The NH panel's median votes were used to identify a final set of QIs that were subsequently reviewed by a clinical oversight committee. RESULTS: Sixty-eight geriatric syndrome QIs were identified as valid and important in NH populations. Panelists assessed 12 (18%) of these QIs as having questionable feasibility to implement in average community nursing homes trying to provide quality care. Nine (13%) would not be included in systems assessing quality of care for persons with advanced dementia or poor prognosis. CONCLUSIONS: Steps of care critical to the assessment and management of geriatric syndromes in NHs were identified. Feasibility is an important issue for a significant number of these, indicating that much remains to be done to design systems that efficiently and reliably implement these care processes.

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PubMed1992

Residency curriculum issues in geriatrics training.

Development of a satisfactory geriatrics curriculum in a family practice residency requires realistic planning in light of the residency's resources and integration of geriatrics training activities into a comprehensive system of monitoring residents' educational needs and accomplishments. This paper, drawing on principles of curriculum design and quality improvement, proposes that: 1) goals and objectives define the scope of training; 2) instructional flexibility is essential; 3) evaluation drives the system; 4) residents deserve individualized educational care; and 5) faculty deserve educational skill development.

Curriculum↗
PubMed1992

An exploratory study of the adequacy of residency education in geriatrics: a methodological description.

This study describes a method to evaluate the educational strengths and needs in a family practice residency program. Patient encounter data and a detailed questionnaire to elicit perceptions of residents and faculty were used, followed by site visit meetings using a standardized protocol to discuss the results. These separate data sets validate each other and together triangulate the support of the conclusions. The results of this study indicate that both faculty and residents in a university-affiliated residency program can benefit from increased development in geriatrics. Although this method of studying the adequacy of residency education involved geriatrics, a similar process could be applied equitably to other curricular domains.

Educational Measurement↗
PubMedDate not supplied

Narrative pedagogy: teaching geriatric content with stories and the "Make a Difference" project .

As the elderly population increases in number, the need to integrate innovative teaching strategies in geriatric education becomes more apparent. Teaching with stories promotes knowledge and values to students and is appealing and enjoyable. This article describes a geriatric nursing course in which stories in films and literature are used to teach content and values promoted by the Hartford Institute best practices curriculum. Stories are also used for the service-learning component of the course as students participate in a "Make a Difference" project with elderly people.

Aged↗
PubMed1992

A criterion-based review of preventive health care in the elderly. Part 2. A geriatric health maintenance program.

Although the geriatric population is growing rapidly and using an increasing portion of health care dollars, no consensus exists about the best approach to preventive medicine in this age group. The most comprehensive review to date is the 1989 United States Preventive Services Task Force (USPSTF) recommendations. However, the USPSTF did not specifically address the unique situation of the elderly. Consequently, we have evaluated numerous screening tests and preventive interventions for the elderly by systematically applying the geriatric-specific criteria for preventive services proposed in Part 1 of this article (J Fam Pract 1992; 34: 205-224). Tests and interventions were measured against specific screening criteria and put into one of three categories: those that have been proven effective, those that may be effective but about which more research is needed, and those that are not effective. Recommendations were compared with those of the USPSTF. Proof of the efficacy of most screening tests and interventions in the current literature was found to be lacking, pointing to the need for substantial future research in this area.

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PubMed2001

[New interventional gerontology in the geriatrization era of medicine].

The author analyzes contemporary demographic structures of the Czech population and outlines the prognosis of its future development. He draws attention to the marked ageing in the European context, analyzes its causes and deduces from this fact conclusions for clinical practice. The author draws attention to the actual needs not only of medical but also social services for senior citizens in general. With the prolongation of the mean life span and the increasing number of senior citizens (incl. those with multimorbidity) the necessity of knowledge of physicians--incl. non-geriatricians looking after senior citizens will increase. New geriatrics must be conceived as an interdiscipinary specialty frequently integrating other medical disciplines into team work. The author presents an outline on care of senior citizens in the Czech Republic and its goals. The meaning of modern geriatrics as a medical discipline is not nursing and terminal care but coping with the modified clinical picture of diseases and medical and social problems of senior citizens which frequently differ profoundly from those of the young and middle-aged generation or are not encountered in the latter groups. The final objective of new intervention gerontology are medical efforts to preserve for as long as possible self-sufficiency and independence of seniors; maximal possible efforts to restore the quality of life if it was impaired.

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PubMed2004

[Burn out of formal carers in geriatric facilities].

From a person-centered perspective, this study investigates the relationship between burn out and anxiety-depression, among geriatric caregivers, according to the helplessness-hopelessness theory. The population studied consists of 150 caregivers, drawn from different geriatric facilities throughout France. Data was collected from three self-administered questionnaires: the Maslach Burnout Inventory (MBI) measures burn out, whereas the STAI measures anxiety and the CES-D assesses symptoms of depression. These tools have been used to analyze the effects of several potential vulnerability factors. Three distinct groups have been identified by cluster analysis on the MBI's dimensions. Subjects from the first cluster (n = 88) did not suffer from burn out, whereas subjects from group 2 (n = 46) and group 3 (n = 16) have been rated "at risk" and "at high risk" of developing burn out. The three groups have significantly different levels of anxiety and depression. Age, profession and type of facility appeared as vulnerability factors for professional burn out.

Adult↗
PubMedDate not supplied

A short-term geriatric nursing programme in the US for Japanese Nurses.

Providing quality care to their growing elderly population is a top priority for Japanese nurses. As geriatric nursing has become a significant subspecialty in the US, this expertise was sought by the Japanese Hospital Administration in collaboration with Kyoto University. The result: a geriatric nursing programme developed to meet the specific needs of Japanese nurses in caring for the elderly, but yet adaptable to meet the needs of nursing students and registered nurses in other countries.

Curriculum↗
PubMedDate not supplied

Benzodiazepine premedication causes hypoxemia during spinal anesthesia in geriatric patients.

BACKGROUND AND OBJECTIVES: The use of sedatives during regional anesthesia can lead to life-threatening hypoxemia. Older patients particularly are prone to enhanced effects of these drugs. We studies whether oral premedication with benzodiazepines produced hypoxemia during spinal anesthesia in elderly patients. METHODS: In a prospective, double-blind, and randomized study, we evaluated the effect of oral benzodiazepine premedication on the incidence of hypoxemia measured by pulse oximetry (arterial oxygen saturation less than 90% for 30 seconds or longer) during surgery under spinal anesthesia in 80 geriatric patients divided into four equal groups: 1, control, no premedication; 2, 1 mg flunitrazepam; 3, 1 mg lorazepam; and 4, 7.5 mg midazolam. RESULTS: The incidence of hypoxemia in the four groups was: 1, 15%; 2, 45%; 3, 20%; and 4, 60% (p = 0.0078); overall incidence was 42% in premedicated patients versus 15% in unpremedicated controls (p = 0.0304). Seventy-four percent of patients who presented drowsiness and anesthetic level above T7 had desaturation compared to only 7% of those who were awake and had lower level (p less than 0.0005). No association between hypoxemia and other factors (age, weight, ASA physical status, and position during surgery) was found. All the episodes of desaturation were easily corrected with low supplemental oxygen concentrations. CONCLUSIONS: Premedication with oral benzodiazepines may produce hypoxemia during spinal anesthesia in elderly patients. Lorazepam appeared safer than flunitrazepam and midazolam. Monitoring of arterial blood oxygen saturation and/or supplemental oxygen is mandatory in geriatric patients with high spinal anesthetic level and/or drowsiness during surgery.

Administration, Oral↗
PubMed1988

On developing a geriatric ethic: personhood in the thought of Stanley Hauerwas.

Those who provide health care for the elderly are being confronted by a variety of ethical problems, including paternalism, withdrawal of life-support systems, and allocation of scarce resources. Discussion surrounding these issues lacks persuasive power because it lacks an appropriate theoretical grounding. This paper grounds geriatric ethics in the theory of the person described by Stanley Hauerwas. It shows that Hauerwas' emphasis on the attributes of temporality, sociality, and limitation is both consistent with the conclusions of gerontologists, and fruitful for developing specific ethical guidelines. Three ethical principles--continuity, interdependence, and normality--provide a framework from which to begin to resolve ethical problems in geriatrics.

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PubMed2005

Gerontological nursing roles within the Southeastern Regional Geriatric Program.

This paper looks at the varied roles of Registered Nurses (RNs) within the Southeastern Regional Geriatric Program (SERGP) and how these nursing roles influence client care across the continuum of services. More specifically, this paper describes the clinical services of the SERGP, the roles of RNs within these services, and the principles and dimensions of geriatric nursing assessment, treatment, and rehabilitation. The aim of this article is to promote recognition of the complex and stimulating work of RNs in gerontology. Eliopoulos (1997) states the following that reflects this excitement and complexity: Gerontological nurses help older individuals to achieve a sense of wholeness by guiding them in understanding and finding meaning and purpose in life, facilitating harmony of the mind, body, and spirit, mobilizing their internal and external resources, and promoting self-care behaviours.

Affect↗
PubMed1992

Preventive geriatrics: basic principles for primary care physicians.

The goal of preventive geriatrics is to nurture a state of health that allows maximal active life expectancy while maintaining high levels of function. The physician's role in promoting such a state of health is disease prevention and the control of chronic diseases of aging. Barriers such as insufficient time and/or staff resources and insufficient third-party reimbursement restrict the delivery of multiple risk factor intervention and healthy aging counseling in the office setting. A systematic approach to preventive geriatrics proposed by the U.S. Prevention Services Task Force is discussed.

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PubMed2005

Characteristics and outcomes of ninth and tenth decade patients hospitalized in a sub-acute geriatric hospital.

BACKGROUND: Population structures are changing across the western world, with particularly rapid growth in the number of very old people. Life expectancy has been increasing gradually over years, resulting in a larger subpopulation of people aged 90 and over. OBJECTIVES: To describe the sociodemographic, medical and functional characteristics of people aged 80-90 and 90+ who were admitted to a sub-acute geriatric hospital and to compare the hospitalization outcomes between these subgroups. METHODS: We compared the demographic and clinical data (extracted by means of chart review) of two groups of elderly who were admitted to the Reuth Medical Center during 2001-2002: those aged 90+ and those 80-89. Among survivors, the main outcome measures at discharge were mortality rate, functional ability, and place of residence. RESULTS: The study included 108 patients who were admitted to different divisions of Reuth: 55 patients aged 90+ and 53 aged 80-90. The mortality rate was significantly elevated in the older age group (49.1% vs. 28.1% in the younger age group). On multivariate analysis, the most important prognostic factors for mortality were incontinence (odds ratio 3.45) and being dependent before admission (OR 4.76). Among survivors, an association was found between being incontinent and dependent before hospitalization, and being dependent on discharge. CONCLUSIONS: The main prognostic factors for mortality and functional outcome in patients admitted to a non-acute geriatric hospital are incontinence and functional state prior to admission, and not age per se.

Activities of Daily Living↗

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