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PubMed2002

Geriatric Index of Comorbidity: validation and comparison with other measures of comorbidity.

BACKGROUND: the debate about measures of chronic comorbidity in the elderly is mainly due to the lack of consensus on pathogenetic models. OBJECTIVE: the aim of the present study was to compare the concurrent validity of a number of measures of chronic comorbidity assuming different pathogenic models, versus disability in elderly patients. SETTING: the Geriatric Evaluation and Rehabilitation Unit for subacute and disabled patients. PARTICIPANTS: 493 new and consecutive elderly patients (mean age 79 years, 71% females) admitted to the Geriatric Evaluation and Rehabilitation Unit. MEASUREMENTS: we evaluated age, gender, cognitive status, depressive symptoms, functional status, somatic health, and nutritional status on admission. Functional status was assessed by the self- or proxy reported Katz's BADL scale and by the performance-based Reuben's Physical Performance Test. Somatic health was assessed as presence and severity of diseases according to standardized criteria. Comorbidity was measured as number of diseases, sum of disease severity, and with a composite score (Geriatric Index of Comorbidity) which takes into account both number of diseases and occurrence of very severe diseases. Mortality was assessed after 12 months. RESULTS: specific diseases and their severity were found to be associated with disability measures. All measures of comorbidity were significantly correlated with disability, but only the Geriatric Index of Comorbidity was independently associated after adjustment for severity of individual diseases. In addition, increasing severity of comorbidity as defined by Geriatric Index of Comorbidity was associated with greater disability while this was not true for the other comorbidity measures (F statistics for the regression model including the Geriatric Index of Comorbidity=19.9). The Geriatric Index of Comorbidity, but not the other comorbidity measures, predicted mortality (relative risk of death 2.3, 95% confidence interval 1.7-3.1). CONCLUSION: the Geriatric Index of Comorbidity, a measure of comorbidity assuming that both number of diseases and occurrence of very severe diseases are determinants of health, has the greatest concurrent validity with disability and is the best predictor of mortality.

Aged↗
PubMed2002

Three-month follow up of patients discharged from a geriatric day hospital.

OBJECTIVE: To determine if mobility and functional status of patients attending a geriatric day hospital are maintained three months after discharge. DESIGN: Prospective, before-after, quasi-experimental design. PARTICIPANTS: Community-dwelling elderly referred for comprehensive geriatric assessment and multidisciplinary management. METHODS: All patients who attended a geriatric day hospital for at least 5 visits and discharged between 1 August, 1999 and 1 March, 2000 were eligible (n = 41). Measurements were performed at admission, discharge and three months post-discharge. Data were analyzed using one way repeated measures ANOVA for parametric data and the Friedman-Chi square test for non-parametric data. OUTCOME MEASURES: Barthel Index, Timed Up and Go Test, Berg Balance Scale, Mini-Mental Status Examination, Geriatric Depression Scale. RESULTS: From admission to discharge, significant improvements were seen in Timed Up and Go Test, Berg Balance Scale, and Geriatric Depression Scale (all P<or=0.002). From discharge to 3 months post-discharge, the Timed Up and Go Test, Berg Balance Scale and Mini-Mental Status Examination declined (all P<0.001) with no significant change in Barthel Index or Geriatric Depression Scale. From admission to 3 months post-discharge, Mini-Mental Status Examination scores declined (p=0.002) and Geriatric Depression Scale scores improved (p=0.007), with all other outcomes unchanged. CONCLUSION: No sustained improvements in mobility or functional status were seen at 3 months following discharge from a geriatric day hospital. Further studies exploring methods to delay progressive deterioration in multiple domains are necessary.

Affect↗
PubMed1988

Geriatrics emphasis in physical therapy. A historical survey.

The number of elderly individuals and the health care needs of elderly persons are rapidly growing. Are physical therapists interested and involved in meeting the needs of this geriatric group? One measure of physical therapists' interest is the quantity of geriatrics-related articles that appear in our profession's journal. The purpose of this study was to conduct a historical review of the number of geriatrics-related articles published in Physical Therapy. All articles indexed under "geriatrics" between January 1921 and June 1987 were identified and categorized in five-year time intervals to assess trends over time. Geriatrics-indexed articles generally appeared infrequently in the Journal, averaging one article every two years. All Physical Therapy articles published between January 1980 and June 1987 were read to determine whether they exhibited a geriatrics orientation. An average of six geriatrically oriented articles appeared in the Journal annually (about 5% of all articles annually). An increased number of geriatrics articles appeared in the Journal between 1980 and 1987. An imbalance clearly exists when an age group that comprises 25% of our patient population receives attention in only 5% of the Journal articles. As a profession, we must examine our attitudes toward and perceptions about elderly persons if we are to address their needs responsibly.

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PubMed1982

Guidelines for graduate medical education in geriatrics.

There has been a substantial increase in training programs in geriatrics over the past several years. In this paper the authors propose guidelines for geriatric training at the graduate medical educational level, both for specialized training (geriatric fellowship) and training in geriatrics as part of other specialty training (internal medicine, family practice, psychiatry, and neurology). Experts from relevant specialty boards and societies, an advisory group in geriatrics, and the faculty of the University of California-Los Angeles Multicampus Division of Geriatrics participated in a modified Delphi study which provided the information used to formulate the guidelines. Performance objectives, core content, training experiences, and clinical exposure and program evaluations are described for geriatric fellows and house staff members in internal medicine, family practice, neurology, and psychiatry. Recommendations included here may be of use to deans, faculty members, and educators responsible for the development of the many new geriatric training programs.

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PubMed1988

Determining geriatric content in a medical school curriculum.

Geriatric content in a medical school curriculum was assayed by surveying faculty course directors and students about course content, by conducting an independent review of course content, and by analyzing the content of course examinations. The students' assessments of geriatric content were found to be not valid. Considerable variability was found in the amount of geriatric content within courses, and review of course examinations was found to be the most valid review method. Pharmacology and second-year psychiatry courses were shown to have the most coverage of geriatrics, while microbiology, biochemistry, and neuroanatomy courses were shown to have the least coverage of geriatric items. The geriatric items in the course examinations correlated strongly (r = .71) with the National Board of Medical Examiners Part I and Part II examinations; because of this correlation, the investigators felt the study findings may be generalizable outside the one medical school. It would appear that geriatric content within the medical school curriculum is low; however, the results of the review methods indicate that disagreement exists over the degree of deficiency. The authors conclude that examination review offers an expeditious method to determine the relative emphasis placed upon geriatrics material within specific courses.

Curriculum↗
PubMed2002

A Web-based geriatrics portfolio to document medical students' learning outcomes.

OBJECTIVE: The University of Michigan Medical School is integrating into its curriculum the attitudes, knowledge, and skills that pertain to the care of older individuals using a defined set of core learning outcomes encompassing all four years. Students will demonstrate proficiency in these outcomes as a graduation requirement. We have developed an individualized, interactive, Web-based geriatrics portfolio to track the acquisition and mastery of these outcomes for students. DESCRIPTION: The required learning outcomes in geriatrics are presented to first-year students in their geriatrics portfolio Web page. The outcomes have been adapted from the recommendations published by the American Geriatrics Society's Education Committee.(1) The portfolio cross-references learning outcomes to specific activities in the curriculum. The activities include content given in lectures, multidisciplinary case discussions, standardized patient instructor (SPI) experiences involving older patients, and specific types of patient encounters during the clinical years. The portfolio allows documentation of completion dates of specific activities and the evaluations the student received. Certain activities such as the SPI experiences will include hyperlinks to their descriptions and the information that should be reviewed prior to each activity. The portfolio is integrated with existing administrative databases. Data entry occurs through links (e.g., exam scores), uploading comment forms from the SPI, and direct student input. One novel example of student input is the ability to upload information concerning encounters with older patients that students are recording in personal data assistant templates such that this information maps directly to the appropriate learning outcomes in their portfolios. The portfolio is designed to encourage students to take responsibility for their geriatrics education. Several types of evaluation data are provided, some that are specific to an activity (e.g., SPI feedback) and others that provide global assessments of learning outcomes (e.g., attitude surveys). The Web page can be displayed by the list of outcomes (categorized by attitudes, knowledge, and skills), by medical school year, and by date of completion. In this way, students can see at a glance how they are performing and whether they are up-to-date with completing the required outcomes. DISCUSSION: The geriatrics portfolio serves to identify and highlight geriatrics-related content across the four years. Its interactive features make it much more dynamic than a written transcript. Requiring proficiency in learning outcomes related to geriatrics for graduation will clearly convey to students that this information is critically important in their training to become physicians. The individualized evaluation summaries will prove useful to the student because self-directed learning opportunities can be targeted to address weak areas. Evaluation of performances will also aid program directors to appropriately modify the curriculum to address any deficiencies. This innovative Web-based approach to capture learning outcomes that are dispersed throughout a four-year curriculum may also find application in similar curricula (e.g., women's health and end-of-life care).

Education, Medical, Undergraduate↗
PubMed2005

ACGME requirements for geriatrics medicine curricula in medical specialties: progress made and progress needed.

In the recent past, most physician visits by older adults were with a primary care physician, with less than 40% of ambulatory visits to other specialists. Since 1991, that trend has reversed. In 2001, 53% of ambulatory visits by patients aged 65 years or older were to nonprimary care specialists. Demographic trends and an expanding geriatrics medicine knowledge base require that every physician develop skills specific to the care of older adults. There are concerns that physicians-in-training are not learning adequate specific geriatrics medicine content to prepare them for the rapidly expanding numbers of older adults who will be seeking medical care. Training standards to prepare residents and fellows for practicing medicine are established by experts in the various medical specialties serving on individual residency review committees (RRCs) of the Accreditation Council for Graduate Medical Education. In 2002 (with a follow-up in 2003), the Association of Directors of Geriatric Academic Programs' team at the University of Cincinnati School of Medicine's Institute for Health Policy and Health Services Research reviewed all 91 nonpediatric specialties' RRC program requirements to identify the specific curriculum requirements related to geriatrics medicine training. As of 2003, 27 of the 91 RRC-accredited specialties have specific geriatrics training requirements; the other 70% of these specialties did not specifically mention geriatrics training. Even among the specialties with specific geriatrics training requirements, curriculum expectations are modest. The geriatrics-specific descriptions within the program requirements of the 27 specialties are presented in this article. The authors encourage the RRCs for all nonpediatric specialties to update their program requirements to ensure that future physicians graduating from their graduate medical education programs are adequately prepared to care for older adults.

Accreditation↗
PubMedDate not supplied

Pressure ulcer education: a pilot study of the knowledge and clinical confidence of geriatric fellows.

OBJECTIVE: To assess the educational experiences of geriatric fellows on the subject of pressure ulcers and to begin validation of a survey that assesses pressure ulcer content knowledge of physicians in training. DESIGN: Pilot study using a prospective survey. PARTICIPANTS: 42 geriatric fellows in New York State. MAIN OUTCOME MEASURES: Likert scale ranking for self-reported feeling of preparation to manage geriatric patients with pressure ulcers and to teach other clinicians about the subject; knowledge test scores using a multiple choice, single-best-answer format. RESULTS: Geriatric fellows in New York State who participated in the survey felt "adequately" prepared to lead a team and teach about pressure ulcers. Sixty-nine percent reported having teaching responsibilities. Sources of information included bedside rounds (79%), nurses (71%) lectures (67%), textbooks (67%), and geriatric attendings (60%). Educational settings were nursing homes (86%) and hospital units (64%). Forty-eight percent of geriatric fellows surveyed correctly identified the Braden Scale as a screening tool. Sixty-seven percent identified a description of a Stage I pressure ulcer and 52% identified a description of a Stage IV pressure ulcer. The mean score on the knowledge test for the cohort was 58 +/- 18% (SD) correct (range, 20% to 80%); the range for the fellowship programs was 36% to 62% correct. CONCLUSIONS: Geriatric fellows need to improve their knowledge and confidence with regard to pressure ulcer care to become competent as clinicians and educators for this condition. Specific curricular guidelines and a validated knowledge assessment instrument on pressure ulcers are needed to improve the educational effectiveness of a geriatrics fellowship.

Education, Medical, Graduate↗
PubMed1993

The critical shortage of geriatrics faculty.

To estimate the adequacy of current and future supply of geriatrics faculty, we conducted a national survey to determine the current supply of geriatrics faculty in five specialties and compared these estimates to standards for optimal faculty supply in geriatrics. Finally, we generated a model to project future faculty supply based on both current training capacity and differing assumptions regarding future training capacity. Our findings indicate that the current supply of geriatrics physician faculty is less than half the number needed in each specialty. (Existing numbers range from a high of 909 faculty in internal medicine to a low of 86 in physical medicine.) Moreover, given the current capacity for training, there will be a net loss of such faculty each year in each specialty. We conclude that the number of geriatrics faculty currently available is insufficient to provide an appropriate "core" level of geriatrics training for all undergraduate medical students and residents in relevant residency programs. In addition, the current training capacity for geriatrics faculty cannot even sustain the current level of faculty over the next 10 years. To correct the current and future deficit, substantial increases in both geriatrics fellowship positions and mid-career training positions will be necessary.

Career Mobility↗
PubMed2006

Developing geriatric social work competencies for field education.

Preparing social workers to effectively practice with the growing older population requires the identification of geriatric competencies for the profession. The John A. Hartford Geriatric Social Work Initiative provided the impetus and direction for a national strategy to improve the quality of preparation of geriatric social workers. The Geriatric Social Work Practicum Partnership Program (PPP) is the project with the Hartford Initiative that emphasizes field education. The Geriatric Social Work Education Consortium (GSWEC), one of the PPP programs, initiated the development of competencies for work with older adults. GSWEC utilized Geriatric Social Work White Papers and the pioneering work of the Council on Social Work Education's (CSWE) Strengthening Aging and Gerontology Education for Social Work's (SAGE-SW) comprehensive competency list as well as conducted focus groups locally to delineate key competencies for field education. The Coordinating Center for the PPP, located at the New York Academy of Medicine, led in collaboratively developing knowledge based skill competencies for geriatric social work across all 6 demonstration sites (11 universities). The competencies adopted across sites include skills in the following five major domains: values and ethics; assessment (individuals and families, aging services, programs and policies); practice and interventions (theory and knowledge in practice, individual and family, aging services, programs and practice) interdisciplinary collaboration; and evaluation and research. The identified competencies have proven effective in evaluating students (n = 190) pre- and post PPP field education. The implications for further development of competency driven education for geriatric social work are discussed.

Aged↗
PubMed1996

[Undergraduate teaching of geriatric medicine in western countries--literature review].

To help plan for the future of undergraduate education in geriatric medicine in Japan, we reviewed the literature concerning undergraduate teaching of geriatric medicine in western countries. Undergraduate teaching in geriatric medicine in the UK is well developed: 22 of 25 universities have a full department of geriatric medicine. Training in geriatric medicine is mandatory in almost all universities. In contrast, geriatric medicine is an elective in most universities in the US. There is a shortage of geriatric medicine faculty in the US, which is similar to the situation in Japan. Clinical and basic research in geriatric medicine and gerontology should be encouraged to attract persons into this field.

Education, Medical, Undergraduate↗
PubMed1996

Extended hospital stays with increasing age: the impact of an acute geriatric unit.

OBJECTIVES: To examine the association between increasing age and extended length of hospitalisation, and the impact of an acute geriatric unit on this association. DESIGN: Retrospective analysis of concurrently collected data of patients admitted to three general medical units, one of which was an acute geriatric unit. SETTING: Alfred Hospital, Melbourne (a tertiary referral teaching hospital), between 1 July 1993 to 30 June 1994. PATIENTS: Those classified into the same diagnosis-related groups (DRGs) as the 15 most common DRGs of the acute geriatric unit. OUTCOME MEASURE: Incidence of patients with extended lengths of stay ("high outliers"), analysed by age, medical unit and DRG. RESULTS: Of 3499 patients discharged from the hospital with the 15 study DRGs, 303 patients (8.6%) were from the acute geriatric unit, and 274 and 300 patients (7.8% and 8.5%) were from the two other general medical units, respectively. Patients in the acute geriatric unit were significantly older (median age group, 75-79; age range, 18-98) than patients in all other hospital units (median age group, 60-64; age range, 18-97) (P < 0.0001). Analysis of patients with respiratory and cardiovascular DRGs admitted to all general medical units compared with specialty units showed this age discrepancy was even more marked for patients aged over 85. There was an increased likelihood (P < 0.001) of an extended length of stay for patients aged over 55. The incidence of high outliers for comparable DRGs was lower for patients cared for by the acute geriatric unit, compared with general medical units. In the acute geriatric unit, unlike the overall trend, the proportion of high outliers did not increase with age. CONCLUSIONS: The specialised management of acute geriatric medical units can counteract the trend towards increased incidence of high outliers with increasing age, despite significantly older patients.

Acute Disease↗
PubMedDate not supplied

The influence of geriatrics education on knowledge, attitudes, and career aspirations of podiatric medical students.

A survey of podiatric medical students in Australia was undertaken prior to and following the completion of a compulsory geriatrics course to evaluate the effect of geriatrics education on knowledge of aging, attitudes toward older people, perceptions of treatment efficacy, and desire to specialize in geriatrics. Students had a reasonable knowledge of aging and favorable attitudes toward older people prior to undertaking the course, but few wanted to specialize in geriatrics. General knowledge of aging and attitudes toward older people improved after completion of the course, but career aspirations remained unchanged. Students generally considered geriatrics to be a low-profile specialty, and less than half stated that they would be interested in pursuing continuing education in geriatrics. These results provide further evidence that students' lack of desire to specialize in geriatrics may be primarily due to limited recognition within the profession, rather than unfavorable attitudes toward older people or lack of interest in geriatrics during their undergraduate education.

Aged↗
PubMedDate not supplied

Effect of training and other influences on the development of career interest in geriatric psychiatry.

OBJECTIVE: The authors examined the relationship between the timing and nature of educational exposure to geriatric psychiatry and other potential influences and subsequent development of career interest in geriatric psychiatry. METHODS: A 46-item survey was distributed to residents and fellows who attended one of the two sponsored programs for residents at the three American Association of Geriatric Psychiatry (AAGP) annual meetings held between 2000 and 2002, inclusive. RESULTS: Ninety-three percent of attendees responded (N=184). Sixty-five percent first developed interest in geriatric psychiatry during their residency years (the majority during their PGY1 or PGY2 year). The timing of individualized teaching exposure, as well as lectures in geriatric psychiatry, was associated with the development of first interest in the field. The most important influences on the development of interest in the field included specific teacher attributes, training experiences, personal experiences with seniors, and characteristics cited as unique to geriatric psychiatry, such as the medical, neuropsychiatric, and multifactorial nature of the field. Patient personal histories and outcomes, as well as non-educational experiences with seniors and cultural attitudes, also contributed to interest. CONCLUSION: It behooves geriatric psychiatry programs to create exemplary educators and commit them to teaching in the early years of general psychiatry programs as well as in medical school. These educators should be identifying potential recruits by enquiring about trainees' previous experiences with older persons as well as emphasizing the unique aspects of geriatric psychiatry that are attractive to trainees.

Adult↗
PubMedDate not supplied

Research in geriatric medicine in the Federal Republic of Germany.

The research in the field of geriatrics in the Federal Republic of Germany is based on the teachings of Max Bürger in Leipzig. Under the impulse of René Schubert, general geriatrics medicine could be investigated. A series of reasons are responsible for the relatively late development of rehabilitative geriatrics in the Federal Republic. The clinical gerontopharmacology has nevertheless achieved resounding results through the cooperation between pharmacologists and clinicans. Preclinical geriatric medicine developed only with little reference to gerontology, the concept originates from policlinical medicine, as inaugurated by Korth, 1967. The emphasis lies on prevention, with reference to the work of general physicians "outside of the clinical gates" of geriatrics. Within the special geriatrics age related angiocardiology, rheumatology, immunology and longevity are viewed as the most essential part of the research projects. Research activities in clinical geriatrics remained for a long time a domain of clinics and institutes outside the universities. There is a promising tendency yet, to establish the clinical geriatrics in the universities.

Adult↗
PubMed1995

[Geriatrics seen from the primary care perspective].

PURPOSE: To know the Primary Care Physicians opinion related to their own praxis, background, and needs for a specific medical support in geriatric medicine. METHODS: A closed mailed questionnaire, with 22 items. Descriptive analysis of the results. PEOPLE SAMPLE: 559 answers. 77% men. Age: main group (44%) between 35 and 39 years old. 80% of the sample worked in health centers as primary care physicians. RESULTS: a) Praxis: 50% of the physicians attend more than 20 elderly patients every day. 38% of them have specific aged oriented protocols. 74% of them take age into account when decide the appropriate doses of drugs. b) Geriatric background: None at the undergraduate period: 96%. Some sort of postgraduate formation: 42%. Are able to identify at less a geriatric book: 34%. A score of 4.5 (over 10) was the result of their own assessment about their level of geriatric knowledge. 95% of the answers miss a better formation in geriatrics, and 93% of them think that this formation would change their clinical approach to the elderly patient. c) Needs of specialized geriatric support: It would be helpful to them according to a 84% of the answers. It could be as a "Geriatric Inhospital Service" in the opinion of a 44% of the cases (this question had a 18% of abstentions); and with geriatricians working as extrahospitalary consultants according to the answers of the 79% (6% of abstentions). CONCLUSIONS: Primary care physicians have: 1. Many elderly patients, with an acceptable level of attention to them. 2. A poor geriatric formation and awareness of their needs. 3. Need of a specialized support in their daily work.

Adult↗
PubMedDate not supplied

[Geriatric assessment: possibilities and limits].

A recent meta-analysis has shown that comprehensive geriatric assessment can reduce mortality, increase survival at home, and improve functional status in elderly patients. Despite their high effectiveness, geriatric assessment programs have not yet been widely introduced into clinical practice. This review discusses the following four factors potentially explaining the limited spread of geriatric assessment programs. 1) There is a lack of accepted targeting criteria to select patients who need evaluation and management in costly in patient geriatric units. 2) There are effectiveness gaps in current knowledge on modifiable disability risk factors. 3) Geriatric assessment programs have been insufficiently integrated into the continuity of primary care. 4) More data are needed for evaluating the cost of geriatric assessment. Interdisciplinary research might help to optimize geriatric assessment programs and, at the same time, might ensure access of elderly patients to appropriate geriatric assessment programs despite current restraints in health care costs.

Activities of Daily Living↗
PubMed1998

[Identification of acute geriatric patients in the city of Hamburg ("direct data collection")].

In the past the calculation for an in-patient special offer (quantity of beds needed) was mainly carried out by diagnosis-based statistics of hospital cases. The decision for an in-patient care within a geriatric unit is however influenced by factors as "status of self-help abilities", "social situation" and "co-morbidity". Those factors are investigated either directly by the help of the patient himself or by questioning the nurses and/or the medical staff. A new way of measuring will be introduced for this questioning. The crucial element is the Barthel-Index (BI). Supporting measures are done by the inclusion of main data concerning the social situation as well as recording the modified screening according Lachs. From the 6th of September until 14th of December 1997 the three-part measuring technique was used at seven hospitals in Hamburg (amongst them one University hospital and one hospital with a geriatric unit) within the framework of a representative sample survey. These collected data register 18 admission days of all patients of sixty or over who at the time of questioning stayed for five days in one of those acute hospitals. In some hospitals some additional data were collected at the third or 6th day after admission. Altogether a whole "virtual day-admission" of the 60 years old or older patients was collected for the City of Hamburg at the 5th day after admission. Out of 425 patients 137 were moved or exmitted before questioning, 4 had already died. Out of the rest of 284 patients two of them refused the questioning, whilst the data of 6 patients were not feasible for evaluating. Finally 276 patients were questioned. Out of them 231 patients are "not potential candidates for a geriatric hospital or a geriatric day-care unit", 8 are "candidates for a geriatric day-care unit directly after discharge of primary care" and 37 are "candidates for an in-patient geriatric hospital". The presented three-part question-sheet shows a sensitivity of 89.2% and a specification of 92.2%. This measuring technique in the hands of a trained examiner appears to be a valid and manageable tool in the framework of geriatric consultation as well as for the investigation of own directly ascertained statistic datas for "potential candidates for an in-patient geriatric hospital".

Activities of Daily Living↗