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Factors affecting the serum free thyroxine levels in hospitalized chronic geriatric patients.

OBJECTIVE: Determination of whether nonthyroidal factors affect the diagnostic value of free thyroxine estimation in geriatric patients. DESIGN: Survey. PARTICIPANTS: A convenience sample of 381 non-selected, chronic, hospitalized geriatric patients over 60 years of age (I = relatively good health; II = relatively poor health; III = bad health; subgroups "sine therapia," ie, patients receiving no drugs that affect FT4) and 180 20-40 year old healthy persons. MEASUREMENTS: Thyrotropin-releasing hormone test; thyrotropin (TSH); free thyroxine (FT4, measured in part by two parallel methods) estimation in a screening study; and thyroxine-binding globulin and thyroxine-binding-inhibitor activity measurements. RESULTS: The normal FT4 ranges of the euthyroid geriatric (n = 210) and healthy young groups were similar. In the "sine therapia" euthyroid patients, FT4 decreased with age but increase with the severity of illness. High FT4 levels with non-suppressed TSH were more frequent in patients in poor and bad health. (I = 6/112; II = 14/140; III = 13/74; P < 0.01). The serum thyroxine-binding-inhibitor activity of euthyroid geriatric patients correlated with the severity of their clinical state (I = 6.22 +/- 5.65 (13); II = 7.40 +/- 4.33 (23); III = 10.04 +/- 5.50 (16) micrograms merthiolate equivalent/microL; ANOVA with log-transformed values: F(2.51) = 3.50, P < 0.05). The mean FT4 was higher in 36 heparin-treated patients (22.81 +/- 4.67 pmol/L) than in the 193 "sine therapia" patients (19.03 +/- 4.23 pmol/L; -P < 0.001). In a convenience subsample of 240 patients, a weak inverse correlation was found between FT4 and the thyroxine-binding globulin (r = -0.14, P < 0.02). Only 5/11 patients with low free thyroxine had hypothyroidism, while 11/46 patients with elevated free thyroxine had hyperthyroidism. CONCLUSIONS: There is no need to modify the normal free thyroxine range for hospitalized geriatric patients. Clinical condition, drug treatment, and, to a lesser extent, age are factors that significantly affect the diagnostic value of FT4 in hospitalized chronic geriatric patients, decreasing the specificity of the test in diagnosing clinical hyper- and hypothyroidism.

Activities of Daily Living↗

Thyroid autoantibodies in hospitalized chronic geriatric patients: prevalence, effects of age, nonthyroidal clinical state, and thyroid function.

OBJECTIVE: To investigate the effect of age, clinical condition, and thyroid function on the prevalence of thyroid autoantibody positivity in hospitalized chronic geriatric patients. DESIGN: A screening study of hospitalized chronic geriatric patients. PARTICIPANTS: 249 non-selected, hospitalized, chronic geriatric patients more than 60 years of age and 81 20 to 40-year-old healthy persons. MEASUREMENTS: Thyrotropin (TSH); thyroxine (T4) and free thyroxine (FT4); and triiodothyronine (T3), thyroglobulin (Tg), antibodies against thyroid peroxidase (AbTPO) and antibodies against thyroglobulin (AbTg) estimation in a screening study. RESULTS: AbTPO positivity (AbTPO+) was found more often than AbTg positivity (AbTg+) (15.3% vs 9.2%, P = .04), one being positive (Ab+) in 19.3%. The occurrence was higher in females than males (Ab+:27.1% vs 7.1%, P < .001; AbTPO+:21.9% vs 5.1%, P < .001; AbTg+:13.2% vs 3.1%, P = .0052). Among the Ab+ patients, AbTPO was more often positive than AbTg (40/48 vs 21/48, P < .001). The sensitivity, specificity, and positive predictive value of Ab positivity to detect a thyroid disorder were 0.35, 0.85 and 0.38, respectively. Within the population of euthyroid geriatric patients, the occurrence of AbTg+ (chi 2(2) = 8.65, P = .013) and Ab+ (chi 2(2) = 8.02, P = .018) correlated positively with the age of the patients, and there was also a female predominance (AbTPO+ 18% vs 3.7% in the males; AbTg+ 13% vs 2.4%; Ab+ 25.8% vs 6.1%). When compared with 20 to 40-year-old subjects, only the euthyroid > or = 80-year-old patients showed a significantly higher occurrence of Ab+ (26.2% vs 9.9% chi 2(1) = 5.64, P = .017). In the euthyroid > or = 80-year-old females, AbTPO+ was 25%, AbTg:22.2%, and Ab+: 36.1%!. The nonthyroidal clinical state of the euthyroid patients did not correlate with the antibody prevalence. CONCLUSIONS: In hospitalized chronic geriatric patients, AbTg and especially AbTPO positivity is frequent, even in euthyroid patients without goiter. This aspecific Ab positivity in the euthyroid state correlates to the age, but not to the severity of the nonthyroidal clinical condition of the patients and explains why the Ab positivity is not predictive enough for thyroid dysfunction in this subpopulation. Thus, in hospitalized chronic geriatric patients the AbTg and AbTPO titers should be examined only in cases where thyroid screening (TSH) reveals abnormal results.

Adult↗

Plasma levels and effects of nortriptyline in geriatric depressed patients.

Pharmacokinetic, therapeutic effects, and side effects of nortriptyline were studied in geriatric depressed patients treated with a standard dose of 150 mg/day. Plasma levels and elimination half-life of nortriptyline were no different in geriatric patients than younger patients. The antidepressant therapeutic effects of nortriptyline appeared to be similar in geriatric patients as in younger depressed patients. Geriatric patients experienced few subjective side effects of nortriptyline. Overall, the drug produced no clinically significant changes in several parameters of the EKG, and no geriatric patient experienced tachycardia on nortriptyline. Nortriptyline did induce significant orthostatic hypotension in the systolic component, but not in the diastolic component. However, the orthostatic hypotension produced by nortriptyline was not greater in geriatric patients than in younger patients treated with the same dose.

Age Factors↗

Kinematic, acoustic, and perceptual analyses of connected speech produced by parkinsonian and normal geriatric adults.

Acoustic and kinematic analyses, as well as perceptual evaluation, were conducted on the speech of Parkinsonian and normal geriatric adults. As a group, the Parkinsonian speakers had very limited jaw movement compared to the normal geriatrics. For opening gestures, jaw displacements and velocities produced by the Parkinsonian subjects were about half those produced by the normal geriatrics. Lower lip movement amplitude and velocity also were reduced for the Parkinsonian speakers relative to the normal geriatrics, but the magnitude of the reduction was not as great as that seen in the jaw. Lower lip closing velocities expressed as a function of movement amplitude were greater for the Parkinsonian speakers than for the normal geriatrics. This increased velocity of lower lip movement may reflect a difference in the control of lip elevation for the Parkinsonian speakers, an effect that increased with the severity of dysarthria. Acoustically, the Parkinsonian subjects had reduced durations of vocalic segments, reduced formant transitions, and increased voice onset time compared to the normal geriatrics. These effects were greater for the more severe, compared to the milder, dysarthrics and were most apparent in the more complex, vocalic gestures.

Acoustic Stimulation↗

Anal function in geriatric patients with faecal incontinence.

The association of faecal incontinence with constipation and confusion in the elderly is well recognised but the anal function of faecally incontinent geriatric patients is poorly understood. Anal studies were therefore performed on 99 geriatric patients (49 with faecal incontinence, 19 continent patients with faecal impaction and 31 geriatric control patients with normal bowel habit) and 57 younger healthy control patients. An age related reduction in anal squeeze pressure but not resting pressure was identified. A reduction in anal resting pressure was detected in the faecally incontinent geriatric patients but squeeze pressure did not differ significantly from that found in the other geriatric patients. Anal sensation was impaired in the faecally incontinent patients. No difference was found between the groups as measured by pudendal nerve terminal motor latency. Gross neuropathy of the distal part of the pudendal nerve does not account for the observed external anal sphincter weakness in geriatric patients or for their faecal incontinence. Internal anal sphincter dysfunction is an important factor in faecal incontinence in the elderly.

Aged↗

Selected contribution: chronic intermittent hypoxia enhances respiratory long-term facilitation in geriatric female rats.

Age and the estrus cycle affect time-dependent respiratory responses to episodic hypoxia in female rats. Respiratory long-term facilitation (LTF) is enhanced in middle-aged vs. young female rats (72). We tested the hypothesis that phrenic and hypoglossal (XII) LTF are diminished in acyclic geriatric rats when fluctuating sex hormone levels no longer establish conditions that enhance LTF. Chronic intermittent hypoxia (CIH) enhances LTF (41); thus we further predicted that CIH would restore LTF in geriatric female rats. LTF was measured in young (3-4 mo) and geriatric (20-22 mo) female Sasco Sprague-Dawley rats and in a group of geriatric rats exposed to 1 wk of nocturnal CIH (11 vs. 21% O2 at 5-min intervals, 12 h/night). In anesthetized, paralyzed, vagotomized, and ventilated rats, time-dependent hypoxic phrenic and XII responses were assessed. The short-term hypoxic response was measured during the first of three 5-min episodes of isocapnic hypoxia (arterial Po2 35-45 Torr). LTF was assessed 15, 30, and 60 min postepisodic hypoxia. Phrenic and XII short-term hypoxic response was not different among groups, regardless of CIH treatment (P > 0.05). LTF in geriatric female rats was smaller than previously reported for middle-aged rats but comparable to that in young female rats. CIH augmented phrenic and XII LTF to levels similar to those of middle-aged female rats without CIH (P < 0.05). The magnitude of phrenic and XII LTF in all groups was inversely related to the ratio of progesterone to estradiol serum levels (P < 0.05). Thus CIH and sex hormones influence the magnitude of LTF in geriatric female rats.

Aging↗

Characteristics of geriatric patients seeking medication treatment for pathologic gambling disorder.

This study was constructed to compare geriatric patients seeking medication treatment for pathologic gambling disorder (PGD) with younger pathologic gamblers. This comparison study assessed three groups with PGD according to the Diagnostic and Statistical Manual of Mental Disorders, fourth edition: 16 subjects over the age of 60 years, 11 subjects between the ages of 20 and 30 years, and 46 subjects between the ages of 40 and 50 years. All subjects were evaluated in terms of demographic characteristics, clinical features of PGD, and treatment history. Geriatric gamblers had a later age of onset of gambling and developed pathologic gambling over a longer period of time. Geriatric subjects were more likely to play slot machines and demonstrate less variety in their choice of gambling activity. Geriatric gamblers were also more likely to gamble secondary to boredom. Geriatric subjects were as likely as the other age groups to report slight or no response to nonpharmacologic treatment. There appear to be some differences in the clinical features of PGD among geriatric subjects, and these differences may have treatment implications.

Adult↗

Podiatric medical students' views toward geriatrics and elderly patients. A preliminary study.

This study examines podiatric medical students' perceptions toward podiatric medicine, their impressions of their geriatric training, and their attitudes toward treating elderly patients. A questionnaire was distributed to a random sample of 240 podiatric medical students at the Ohio College of Podiatric Medicine. The survey response rate was 57.1%. In general, the podiatric medical students were satisfied with their geriatric training; however, they believed that more geriatric training is needed. Podiatric medical students who entered podiatric medicine for intrinsic reasons, who visited their grandparents frequently, and who had close relationships with them while growing up, had favorable impressions toward geriatric patients. Furthermore, those who have had good geriatric instruction are more likely to have favorable impressions of geriatric patients.

Aged↗

[The influence of socio-demographic and psychological variables on the level of satisfaction of geriatric patients from dental care].

UNLABELLED: The increasing geriatric population poses unique treatment challenges for the dental practice. Satisfaction from dental treatment is considered to be an important issue that influences the attitude and cooperation of the geriatric patient. It is associated with the quality of treatment and with different variables, such as physical, emotional, social and financial. The objectives of the present study were to perform a preliminary characterization of a group of geriatric patients and to identify possible factors that might be associated with their level of satisfaction from dental treatment. MATERIAL AND METHODS: Fifty-one geriatric patients (20 males and 31 females) participated in the study. They were given a questionnaire which included 41 items regarding: socio-demographic variables, social activity, self image, level of apprehension, locus of control and level of satisfaction from dental care. RESULTS: Twenty-two patients reported a high level of satisfaction from dental treatment and twenty-nine reported a low level of satisfaction. No significant association was found between the degree of satisfaction from dental treatment and the examined variables of social activity, self-image and level of apprehension. Good doctor-patient relationships--"the art of care", is considered to have an important impact on the level of satisfaction, especially among the geriatric patients. CONCLUSION: Therefore, it is suggested that these relationships might determine the level of satisfaction of the geriatric patient from dental treatment.

Aged↗

Megestrol acetate therapy in geriatric patients: case reviews and associated deep vein thrombosis.

OBJECTIVE: To provide a brief review of the literature discussing treatment of unplanned weight loss in geriatric patients, focusing on megestrol acetate and to report two cases of deep vein thrombosis (DVT) associated with megestrol acetate therapy in geriatric nursing facility residents. DATA SOURCES: Biomedical literature accessed through MEDLINE and PubMed (1990-2003); product manufacturer information. DISCUSSION: Unplanned weight loss, a common problem among frail geriatric nursing facility residents, is associated with increased morbidity and mortality. Once reversible causes of weight loss are identified and addressed, dietary changes, including the addition of nutritional supplements, may be of benefit. In some cases, medications are prescribed. Megestrol acetate oral suspension is approved by the Food and Drug Administration for the treatment of anorexia, cachexia, or unexplained significant weight loss in patients with AIDS. Megestrol acetate tablets are FDA-approved for palliative treatment of advanced breast or endometrial cancer. In recent years, several published prospective and retrospective reports have described the use of megestrol acetate for unplanned weight loss in geriatric patients. While clinical efficacy trials reported diarrhea, impotence, and rash as the most commonly occurring adverse events, post-marketing reports have included deep vein thrombosis and pulmonary embolism. DVP has occurred in geriatric patients. CASE SUMMARIES: Case #1: An 86-year-old female with Alzheimer's disease and decreased oral intake was prescribed megestrol acetate suspension 400 mg po bid after a 30-day weight loss of 4.8 kg. Ten days later she developed DVT. Megestrol acetate was discontinued, and she was hospitalized and treated, recovering successfully. Case #2: An 85-year old female with Alzheimer's disease who had stopped eating was prescribed megestrol acetate tablets 40 mg po bid. Four months later she developed DVT. Megestrol acetate was discontinued and she was hospitalized and treated, recovering successfully. CONCLUSION: Thromboembolic events are potential adverse events associated with megestrol acetate therapy. Caution should be observed in using megestrol acetate in geriatric patients, especially nursing facility residents who often have impaired mobility.

Journal Article↗

Quality of life as an indicator for successful geriatric inpatient rehabilitation-a validation study of the 'Vienna List'.

Quality of life (QoL) appears as an adequate outcome measure of geriatric rehabilitation since it reflects its major goals in terms of improvement in self-service, mobility, interpersonal behavior and communication. The objective of the present study was the application of a newly developed instrument, the 'Vienna List', in this context. Its sensitivity to detect changes during geriatric rehabilitation and the ability to differentiate between various diseases and disturbances of functional abilities has been investigated. The total population of patients of one geriatric rehabilitation clinic of 1 year (from November 2001 to October 2002; N=683) was evaluated at admission and discharge by means of this proxy rating. Several reasonable differences appeared between seven diagnostic groups as well as between admission and discharge concerning crucial areas, which are the focus of geriatric rehabilitation such as communication and mobility and which reflect an improved QoL. On the other hand, some factors remained mostly unaffected, e.g. negative affect and bodily contact. The 'Vienna List' which was originally developed for the assessment of QoL in severely demented patients, proved to be a useful, differentiating, less time-consuming and practical tool for the documentation of the outcome of geriatric inpatient rehabilitation.

Aged↗

Effectiveness of geriatric psychiatry consultation in an acute care hospital: a randomized clinical trial.

OBJECTIVE: To evaluate the effectiveness of geriatric psychiatry consultation in reducing the severity of confusion, anxiety, depression, abnormal behavior, and functional disability among a selected group of aged medical and surgical inpatients. DESIGN: Randomized clinical trial. Cases assessed on enrollment at 2, 4, and 8 weeks later. SETTING: Primary acute care hospital. PATIENTS: Eighty hospitalized patients aged 65 or older who were referred to a multi-disciplinary team and had not received a psychiatric consultation in the month prior to referral. Sixty-three patients completed the trial. INTERVENTIONS: Patients in the treatment group received a geriatric psychiatry consultation and, when appropriate, follow-up at least once per week for 8 weeks. Control patients received usual medical care. MAIN OUTCOME MEASURES: Short Portable Mental Status Questionnaire, Anxiety Status Inventory, Geriatric Depression Rating Scale, and Crichton Geriatric Behavioral Rating Scale. RESULTS: The effect of the consultation on psychiatric symptoms and functional status was positive but small. The differences in scores of all measures between treatment and control groups were not statistically significant, but there were consistent trends for more treatment than control cases to have improved on all measures, significantly so on the Anxiety Status Inventory (P less than 0.05). Cases with delirium or depression improved most often. More control than treatment cases were discharged after 4 and 8 weeks, but twice as many treatment cases were discharged home. CONCLUSIONS: Geriatric psychiatry consultation, while not highly effective overall, may be beneficial if targeted to those most likely to benefit and compliance by referring physicians can be improved.

Aged↗

The effect of geriatric evaluation and management on Medicare reimbursement in a large public hospital: a randomized clinical trial.

OBJECTIVE: To study the effect of a geriatric evaluation and management program on health care charges and Medicare reimbursement. DESIGN: Prospective randomized controlled trial during a 1-year study period. SETTING: Large medical school-affiliated public hospital in an urban community. SUBJECTS: Patients at least 70 years old admitted to the medicine service were screened and randomized into two groups of 100 patients each. INTERVENTION: Patients randomized to the experimental group underwent initial comprehensive geriatric evaluation and once discharged from the hospital were enrolled in a geriatric care management and treatment program. The control group received usual care only. The major intervention of this study was in outpatient long-term care. MAIN OUTCOME MEASURE: Total charges for services billed to Medicare Part A and Part B and total Medicare reimbursement. The Medicare charge and reimbursement data were obtained by use of the Medicare Automated Data Retrieval System, a linked Medicare Part A and Part B utilization file. RESULTS: Total charges and reimbursement were greater for the control group but not significantly so. Subset analysis revealed significantly greater inpatient charges (P < 0.03) and Medicare reimbursement (P < 0.005) for the control patients and a greater likelihood of utilization of home health care services in the experimental group (P < 0.01). CONCLUSION: A geriatric evaluation and management program appeared to shift utilization and Medicare expenditures from inpatient services to home health care services. There was no evidence that the experimental program resulted in increased expenditures for Medicare. In selected populations, geriatric evaluation and management programs may contribute to cost containment.

Activities of Daily Living↗

Underutilization of angiotensin-converting enzyme inhibitors in older patients with Q-wave anterior myocardial infarction in an academic hospital-based geriatrics practice.

OBJECTIVE: To investigate the prevalence of angiotensin-converting enzyme (ACE) inhibitors use in older persons without contraindications to ACE inhibitors and with prior Q-wave anterior myocardial infarction (MI), anterior MI with congestive heart failure (CHF), and with anterior MI and a left ventricular ejection fraction (LVEF) < or = 40% in an academic hospital-based geriatrics practice. DESIGN: A retrospective analysis of charts from all older patients seen from January 1996 through July 1997 at an academic hospital-based geriatrics practice was performed to investigate the prevalence of ACE inhibitor use in older patients with prior Q-wave anterior MI, anterior MI with CHF, and anterior MI with LVEF < or = 40% without contraindications to ACE inhibitors. SETTING: An academic hospital-based primary care geriatrics practice staffed by fellows in a geriatrics training program and full-time faculty geriatricians. PATIENTS: Ninety-six women and 65 men, mean age 82 +/- 8 years (range 65 to 96), were included in the study. MEASUREMENTS AND RESULTS: Of 161 patients with Q-wave anterior MI and no contraindications to ACE inhibitors, LVEF was measured in 58 patients (36%), 56 (35%) of whom were receiving ACE inhibitors. Of 45 patients with Q-wave anterior MI and CHF, 30 patients (67%) were receiving ACE inhibitors. Of 15 patients with Q-wave anterior MI and asymptomatic LVEF < or = 40%, four patients (27%) were receiving ACE inhibitors. CONCLUSIONS: There is a marked underutilization of use of ACE inhibitors in treating older patients with Q-wave anterior MI in an academic hospital-based geriatrics practice.

Aged↗

Effect of a mandatory geriatric medicine clerkship on third-year students.

A nationwide push has increased geriatric medicine instruction within medical school curricula. Some institutions have proceeded with an integrated 4-year curriculum while others have constructed discrete courses in the third or fourth year of medical school. This paper describes the impact of a new mandatory 4-week geriatric medicine clerkship on third-year students developed by the Donald W. Reynolds Department of Geriatric Medicine at the University of Oklahoma Health Sciences Center. In the first year of implementation, 135 students took the course on both the Oklahoma City and Tulsa campuses. Clinical sites included inpatient, VA extended care unit, outpatient clinics, dementia clinics, home care, long-term care settings, and hospice. Didactic instruction used formal lectures and problem-based learning. The impact of the clerkship on students was assessed in three areas: knowledge, skills, and attitude using a pre- and postknowledge test, student satisfaction survey, and written comments. This article discusses how the clerkship resulted in increased knowledge of geriatric medicine. Student self-report indicates that the clerkship enhanced clinical evaluation and patient assessment skills. Students indicated that the experience was positive and recognized the importance of geriatric medicine in their development as doctors.

Aged↗

[Who should be admitted to a geriatric unit?].

Potential geriatric patients are frail old persons characterized by the presence of one or several geriatric conditions: polypharmacy, socio-economic problems, vision/hearing impairment, confusion, impaired mobility, incontinence, weight loss, depression, falls, dementia, and prolonged bedrest. Admission of these frail old patients to a geriatric unit may reduce mortality, improve function, and decrease the risk of nursing home placement. These frail old patients may not all be able to profit from geriatric rehabilitation. The published randomized trials showing substantial effect of geriatric rehabilitation exclude patients with severe dementia, terminal disease or those with a single medical disease for which there is no further treatment. Careful selection of patients is necessary in order to achieve superior, clear-cut effect when compared to conventional treatment in general medical wards.

Aged↗

Geriatric patient simulations for dental hygiene.

The rapidly increasing number of this country's elderly requires that dental hygiene students practice the clinical problem-solving skills of information gathering, assessment, and treatment applied to geriatric patients. Computer-based simulations are purported to provide this experience, but little research has been completed with simulations in the education of dental hygienists. This paper summarizes the process used to design, develop, and evaluate a series of eighteen computer-based geriatric simulated patients. It contains a brief description of the simulations and a description of the design, validation, authoring, and formative evaluation phases. The paper also describes the summative evaluation, provides implementation suggestions, and summarizes future directions. The summative evaluation, conducted at four institutions, suggests that computer-based simulations are an effective instructional method as measured by pre/post-tests. The results suggest that simulations can provide a standardized set of geriatric patient experiences. These simulations may prove especially valuable at institutions that are unable to provide clinical geriatric experiences or lack the expertise to conduct a didactic course in geriatrics.

Aged↗

Developing a cancer-specific geriatric assessment: a feasibility study.

BACKGROUND: As the U.S. population ages, there is an emerging need to characterize the "functional age" of older patients with cancer to tailor treatment decisions and stratify outcomes based on factors other than chronologic age. The goals of the current study were to develop a brief, but comprehensive, primarily self-administered cancer-specific geriatric assessment measure and to determine its feasibility as measured by 1) the percentage of patients able to complete the measure on their own, 2) the length of time to complete, and 3) patient satisfaction with the measure. METHODS: The geriatric and oncology literature was reviewed to choose validated measures of geriatric assessment across the following domains: functional status, comorbidity, cognition, psychological status, social functioning and support, and nutritional status. Criteria applied to geriatric assessment measurements included reliability, validity, brevity, and ability to self-administer. The measure was administered to patients with breast carcinoma, lung carcinoma, colorectal carcinoma, or lymphoma who were fluent in English and receiving chemotherapy at Memorial Sloan-Kettering Cancer Center (New York, NY) or the University of Chicago (Chicago, IL). RESULTS: The instrument was completed by 43 patients (mean age, 74 yrs; range, 65-87 yrs). The majority had AJCC Stage IV disease (68%). The mean time to completion of the assessment was 27 minutes (range, 8-45 mins). Most patients were able to complete the self-administered portion of the assessment without assistance (78%) and were satisfied with the questionnaire length (90%). There was no association noted between age (P = 0.56) or educational level (P = 0.99) and the ability to complete the assessment without assistance. CONCLUSIONS: In this cohort, this brief but comprehensive geriatric assessment could be completed by the majority of patients without assistance. Prospective trials of its generalizability, reliability, and validity are justified.

Activities of Daily Living↗