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PubMed1997

Malnutrition in geriatric patients: a neglected problem?

The nutrient intake in geriatric long-stay patients and the mortality risk associated with low energy intake were studied in 61 patients, 43 women and 18 men, with a mean age of 87 years, at a geriatric long-stay care hospital during a 6-month follow-up. Dietary intake was assessed with a 9-day dietary record. Energy expenditure was calculated assuming a physical activity level of 1.33 x basal metabolic rate (BMR), predicted from equations given by FAO/WHO. Mean energy intakes were 1557 kcal in men and 1280 kcal in women; 84% of the patients had an intake below estimated energy expenditure and 30% were below estimated BMR. Only 5% received dietary supplement. Eleven out of the 61 patients died during the follow-up and the deceased had lower energy intake than the others (1185 kcal vs 1401 kcal, P < 0.05). An energy intake below median (1378 kcal) was associated with an age adjusted increased 6-month mortality risk, odds ratio 12.5. A high proportion of geriatric long-stay patients report dietary intake far below present recommendations and are thereby at risk for having/developing malnutrition. Improved surveillance of geriatric long-stay patients' dietary habits seems justified.

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PubMed2001

Active learning of geriatric rehabilitation: deliberations of an undergraduate occupational therapy programme.

Occupational therapists working in geriatric rehabilitation must possess skills of self-directed learning and critical thinking, but conventional teaching-learning strategies are limited in acquiring the said skills. This action research aimed at developing in students an ability for active learning and problem solving. An inquiry-based learning (IBL) methodology was introduced to two geriatric-related subjects of an undergraduate occupational therapy (OT) programme. Students worked on four real-life problems in tutorials and participated in service learning. Lectures were carefully structured to consolidate theoretical knowledge generated from the problems. This study was evaluated qualitatively through interviews of both students and clinical educators, and reflective journals. Students found the problems and service learning stimulating enough to encourage active learning and develop basic study skills. Likewise, clinical educators noted students to be more competent when working with geriatric clients than former students who learned through a conventional curriculum. However, the IBL methodology was stressful in areas related to consistency of teaching-learning strategies across curriculum, workload and time constraints. Curriculum review, development of resource files and provision of systematic support are some of the recommendations to the challenges encountered. To conclude, the IBL approach provides appropriate learning environments that foster in students a self-directed learning attitude in the study of geriatric rehabilitation.

Focus Groups↗
PubMed2000

Validity of an artificial neural network in predicting discharge destination from a postacute geriatric rehabilitation unit.

OBJECTIVE: To develop an artificial neural network (ANN) designed to predict discharge destination from postacute geriatric rehabilitation units. DESIGN: Nonconcurrent prospective study. SETTING: Postacute geriatric rehabilitation units: a 20-bed unit in a nonproprietary skilled nursing facility and a 40-bed unit in a suburban private facility. PATIENTS: Consecutive sample of 661 patients admitted between January 1995 and February 1999, including a derivation group of 452 patients and a validation group of 209 patients. INTERVENTIONS: A feed-forward, back-propagation neural network to predict discharge destination. MAIN OUTCOME MEASURE: Discharge destination from postacute geriatric rehabilitation. RESULTS: An ANN was trained on clinical pattern set derived from 452 patients and validated prospectively on 209 consecutive patients admitted to postacute geriatric rehabilitation units. The neural network achieved a sensitivity of 85.7% (95% confidence interval [CI], 83.7-89.4) and specificity of 94.1% (95% CI, 84.4-99.1) in identifying discharge destination with a corresponding area under the curve of 95.7% (95% CI, 92.1-98.3). CONCLUSION: An ANN can predict discharge to the community postacute rehabilitation with a high degree of accuracy. It could have particular value to predict return to the community for older adults with multiple comorbidities after an acute hospitalization.

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PubMed2002

Rehabilitation therapists' recognition of cognitive and mood disorders in geriatric patients.

OBJECTIVE: To determine if physical and occupational therapists can recognize 2 known predictors of rehabilitation outcome, cognition and mood, in their geriatric patients. DESIGN: Survey. SETTING: Urban academic medical center rehabilitation unit. PARTICIPANTS: One hundred two consecutive geriatric admissions rated by 20 physical and 8 occupational therapists for the presence of cognitive or affective disorders. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Mini-Mental State Examination, Geriatric Depression Scale, and therapists' ratings. RESULTS: Both disciplines had low rates of accurate detection of both cognitive abnormalities and symptoms of depression. Patients scoring in the intact range of either domain were more likely to be correctly identified by the therapists than were patients whose results were possibly or probably impaired. CONCLUSION: Rehabilitation therapists had difficulty recognizing patients with cognitive and affective disorders. I recommend including a mental health professional on the treatment team, staff inservicing, and/or the use of standardized measures of mood and mental status to increase recognition of these syndromes in geriatric rehabilitation patients.

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PubMed2005

[Geriatric problems in the perioperative management of surgical interventions].

Improved healthcare and longer life expectancy have led to more and overall, healthier older patients. As a consequence, we now see more surgical complications attributable to an ever-increasing spectrum of the physiologic changes of aging. These include functional decline, psychiatric as well as medical co-morbidities, medication effects and peri-operative environmental changes. To maintain high patient care standards in geriatric operative patients, surgeons face challenges in peri-operative care (co-morbidities), anesthesia (intra-operative circulatory depression, cardiac insufficiency and limited organ reserve), and intensive care (cardiopulmonary surveillance and delirium). In contrast to the normally temporary surgical period, interdisciplinary approaches are essential during extended peri-operative, convalescent, rehabilitation and follow-up phases of care in the geriatric patient. This will require competency in the realm of geriatrics, on behalf of the treating surgeon who, as a result, will become increasingly more specialized in the future. This article addresses current epidemiology and symptomatology of particular diseases, and as well, offers treatment suggestions with explanations of geriatric pathophysiology and functional decline from a clinically relevant perspective. This review highlights the increased difficulty in treatment of multiple disease processes in the elderly as a result of natural decline in function of all organ systems.

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PubMed1995

A randomized trial of comprehensive geriatric assessment in the care of hospitalized patients.

BACKGROUND: Although many studies describe benefits from the comprehensive assessment of elderly patients by an interdisciplinary team (comprehensive geriatric assessment), the most supportive evidence for the process has come from programs that rely on specialized inpatient units and long hospital stays. We examined whether an inpatient geriatric consultation service might also be beneficial in a trial involving four medical centers of a group-practice health maintenance organization (HMO). METHODS: We conducted a randomized clinical trial with 2353 hospitalized patients 65 years of age or older in whom at least 1 of 13 screening criteria were present: stroke, immobility, impairment in any basic activity of daily living, malnutrition, incontinence, confusion or dementia, prolonged bed rest, recent falls, depression, social or family problems, an unplanned readmission to the hospital within three months of a previous hospital stay, a new fracture, and age of 80 years or older. Of the 1337 patients assigned to the experimental group, 1261 (94 percent) received a comprehensive geriatric assessment in the form of a consultation, with limited follow-up; the 1016 patients assigned to the control group received usual care. The functional and health status of the patients was measured at base line and 3 and 12 months later; survival was assessed at 12 months. Subgroups of patients who might be presumed to benefit from comprehensive assessment were also studied. RESULTS: The survival rate at 12 months was 74 percent in the experimental group and 75 percent in the control group. At base line, 3 months, and 12 months the scores of the two groups on measures of functional and health status were similar. The analysis of 16 subgroups did not identify any with either clearly improved functional status or improved survival. CONCLUSIONS: In this HMO, comprehensive geriatric assessment by a consultation team, with limited follow-up, did not improve the health or survival of hospitalized patients selected on the basis of screening criteria.

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PubMed2001

The effect of a geriatric education program on emergency nurses.

OBJECTIVE: In a previous study, emergency nurses gave a high priority to the educational topics of geriatric depression, physical assessment of the elderly, and mental status testing. Our objective was to measure the impact of a 1-day workshop for emergency nurses that addressed these educational needs. METHODS: The workshop consisted of case-based didactic sessions addressing (1) physical assessment of the elderly, (2) delirium, depression, and dementia, and (3) a practical approach to mental status testing in the elderly. The educational program was evaluated using 2 methods: (1) before, and 1 month after, the workshop, participants rated their own practice patterns; and (2) during the course of 2 years, changes in the number of referrals for geriatric assessment and home care from a large emergency department in the study area were monitored. RESULTS: Of 101 ED nurses who attended the 1-day workshop, 51 completed both preworkshop and postworkshop questionnaires (response rate, 50.5%). the most significant self-reported changes in practice 1 month after the workshop were improved screening for depression and altered mental status in older adults (P <.0001 and P <.01, respectively). Other positive changes were noted for inquiring about unplanned weight loss and assistance received at home. A steady increase in the number of referrals for geriatric assessment and home care was noted from the emergency department being monitored. DISCUSSION: Targeted geriatric educational programs can make an impact on the practice of emergency nurses when they are part of an overall, coordinated approach to improving assessment and discharge planning for elderly patients in emergency departments. Mechanisms for reinforcing learning several months after educational events may prove critical to the long-term success of such initiatives.

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PubMed1997

Integrating geriatrics and oncology.

BACKGROUND: A geriatric education retreat in oncology was held in February 1997 to develop a plan to integrate geriatrics into oncology. METHODS: A group of 42 geriatricians and medical oncologists convened to assess the means of incorporating the contents of geriatrics into oncology training. The basic science and clinical aspects of the pathogenesis, diagnosis, and treatment of cancers in older persons and the geriatric aspects of aging were presented. RESULTS AND CONCLUSIONS: This comprehensive review of the problems of aging and cancer provided encouragement to representatives of both disciplines to stimulate further research and clinical training relating to the problems of aging and cancer. The overall conclusions considered means to reach this goal.

Age Factors↗
PubMed2001

Non-traumatic lower limb older amputees: a database survey from a geriatric centre.

PURPOSE: The purpose of this survey was to examine the characteristic of a geriatric population admitted for amputation of a lower limb and to explore some of the factors that may affect the course of their hospital stay. METHOD: The study took place in the geriatric division of a tertiary general hospital and included a close geriatric-orthopaedic liaison. Two-hundred and forty-one patients were included in the final analysis. RESULTS: Many above knee amputations were performed, which correlated with advanced age. Rates of in hospital mortality and systemic complications were 16% and 19%, respectively. Thirty-three percent of the patients were discharged back home, and only 6% were supplied with an artificial limb. The general condition of most patients remained poor. CONCLUSION: We conclude that despite a team approach to the care of the geriatric amputee a poor functional result was obtained. By encouraging earlier referrals from the community it is postulated that a reduction in the costly provision of antibiotics would be beneficial and that perhaps lower levels of amputation could be performed thereby enhancing the possibilities for ambulation.

Age Distribution↗
PubMed1999

Integrating geriatrics into clinical training, research training, board certification, and continuing education in infectious diseases: meeting review and commentary.

Although adults aged 65 years and older constitute the most rapidly growing segment of the U.S. population, geriatric issues have not typically been a focus of training in infectious diseases (ID). Underrecognition of the unique aspects of geriatric care, apathy toward this population, and the feeling that "we're all geriatricians" (and thus know geriatric medicine) all contribute to this problem. This article summarizes the recent meeting focused on integrating geriatric principles within ID training at all levels. The ID/geriatric interface as an attractive area for basic and clinical research is emphasized.

Adult↗
PubMed1987

Medical audit in geriatric medicine.

A form developed to audit the case notes of general medical patients was modified for use in geriatric medicine. The case notes of 41 admissions to the geriatric wards of a teaching hospital were audited with the new form and their contents did not come up to the standard set. Deficiencies were found in those parts of the notes considered to reflect the distinctive features of the specialty, e.g. the functional history, the assessment of mobility and the recording of multidisciplinary case conferences. The introduction of a standard history and examination form to meet the needs of patients admitted to geriatric wards, better training in geriatric medicine for junior doctors and closer scrutiny of medical records by consultants are suggested as ways of improving documentation in the case notes.

England↗
PubMed1995

The prognostic significance of protein-energy malnutrition in geriatric patients.

Although it has been shown that protein-energy malnutrition is a predictor of adverse outcome in geriatric patients, it is unclear whether this is due to underlying disease or disability, or whether malnutrition is an independent outcome predictor. To clarify the predictive role of malnutrition, we analysed the 4.5-year mortality and living location follow-ups of 219 geriatric patients admitted to a geriatric assessment unit. Prevalence of anthropometric and serological malnutrition indicators were between 13.7% and 39.8% at hospital admission. In bivariate models, prealbumin, subnormal arm muscle area, and subnormal body weight were predictors of mortality and survival at home. On the other hand, albumin, transferrin, and triceps skin-fold thickness did not predict these outcomes. In multivariate models the hazard ratio (HR) of 4.5-year mortality remained significant with an HR of 1.8 (95% CI 1.3-2.6) for subnormal arm muscle area, and 1.6 (95% CI 1.0-2.6) for subnormal body weight. Prealbumin was the strongest serological outcome predictor (multivariate mortality HR 1.9, 95% CI, 1.3-2.8). In these models, subnormal cognitive function, impaired physical function, and creatinine clearance < 30 ml/min were also associated with increased mortality. Malnutrition did not predict hospital discharge location, but among patients discharged home, those with initial malnutrition had a decreased length of survival at home. Our findings indicate that certain protein-energy malnutrition indicators are independent risk factors predicting decreased length of overall survival and survival at home in geriatric patients.(ABSTRACT TRUNCATED AT 250 WORDS)

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PubMed2000

Compliance with recommendations in a geriatric outreach assessment service.

OBJECTIVES: to measure the extent to which the recommendations of a geriatric outreach assessment service were being followed, and to determine what patient-related factors were associated with compliance with assessment recommendations. METHODS: eighty-one eligible patients or caregivers who had an assessment in a geriatric outreach service participated in a telephone interview. The interview focused on the use of health services and compliance with assessment recommendations. Patient-related variables obtained from charts included demographics, caregiver support and stability, health status and assessment recommendations. RESULTS: overall compliance with recommendations from the geriatric outreach assessment service was 65%. Patients were less likely comply fully with recommendations if they had a high number of recommendations [odds ratio (OR) = 0.23; 95% confidence interval (CI) = 0.12-0.46; P = 0.0001], inadequate caregiver support (OR = 0.212; 95% CI = 0.04 to 1.02; P = 0.0523), or the ability to transfer themselves independently (OR = 0.12; 95% CI = 0.02-0.63; P = 0.0124). They were more likely to have full compliance if they had normal vision (OR = 6.67; 95% CI = 1.22-36.46; P = 0.0284). CONCLUSION: it is important to focus on key issues when developing service recommendations and on the role of the informal caregiver in facilitating compliance with them. Good communication between the patient or caregiver and the family physician and geriatric services can help to identify strategies which might improve acceptance of recommendations.

Aged↗
PubMed1978

Career plans of student physical therapists regarding geriatric medicine.

Questionnaires designed to evaluate experience in geriatric medicine and attitudes towards a career with a geriatric service were set to final-year students of eight schools of physical therapy. An analysis of replies indicates that many students are not sufficiently involved in the care of the elderly or with the practice of modern geriatric medicine. The majority of students preferred a career which involved both elderly and younger patients and work in geriatric rehabilitation wards and day hospitals.

Career Choice↗
PubMed2006

Comprehensive geriatric assessment and home-based rehabilitation for elderly people with a history of recurrent non-elective hospital admissions.

OBJECTIVE: To determine whether a co-ordinated programme of geriatric assessment and multidisciplinary home-based rehabilitation reduces disability and prevents non-elective hospital readmission in high-risk elderly patients. DESIGN: Nested case-control study comparing usual post-discharge care versus usual care plus a comprehensive geriatric assessment and home-based rehabilitation service, comprising nursing, occupational therapy and physiotherapy with geriatric medical review. Patients were >or=65 years with >or=2 non-elective hospital admissions within the previous 12 months. Disability was assessed using the 100-point Barthel index and Nottingham extended activities of daily living (EADL) score. Non-elective hospital admissions were recorded over 1-year follow-up. RESULTS: We studied 84 patients; 56 receiving the new service were matched to 28 controls. Intervention subjects received a median of 19 h [interquartile range (IQR) (7,35)] rehabilitation over 19 [IQR (6,42)] domiciliary visits. At 3 months, there was improvement in median Barthel and Nottingham EADL scores in the intervention group of 3 and 2 points, respectively, compared with reductions in controls of 3 and 6 points (both P<0.001, changes in intervention group versus controls); similar differences persisted in survivors at 12 months. There was a non-significant trend for reduction in the proportion of patients with further non-elective hospital admission in the intervention group (36/56, 64%) compared with controls (21/28, 75%; OR 0.70, 95% CI 0.34, 1.46). CONCLUSIONS: A co-ordinated programme of geriatric assessment and multidisciplinary home-based rehabilitation reduced disability in elderly patients at high risk for non-elective hospital admission. Further research is required to determine whether this approach can reduce the need for hospital admission.

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PubMed1999

An individualized approach to outcome measurement in geriatric rehabilitation.

BACKGROUND: The heterogeneity of health problems experienced by frail elderly patients makes it difficult to use a single standard measure to evaluate multiple outcomes of geriatric rehabilitation. Commonly, several measures are used, but an alternative is to use an individualized measure such as Goal Attainment Scaling (GAS). This study investigated the reliability, validity, and responsiveness of GAS as an outcome measure in geriatric rehabilitation. METHODS: We studied 173 consecutive admissions (mean age 81; 77% female; mean length of stay 33 days) to a geriatric rehabilitation unit. Assessment instruments were completed at admission and discharge. Individualized treatment goals were identified for each patient by using GAS; standardized measures included self-rated health, a global clinical assessment, the Barthel Index, the OARS IADL scale, the Folstein Mini-Mental State Examination (MMSE), and the Nottingham Health Profile (NHP). RESULTS: Mobility, future care arrangements, and functional impairment were the most commonly identified GAS goal areas. The interrater reliability of the GAS discharge score was 0.93. The GAS discharge score correlated strongly (r> or =0.50) with the standardized measures, except for self-rated health, the MMSE, and the NHP (r> or =0.31). GAS was more responsive to change than any of the standardized measures. The GAS score was used to derive receiver operating characteristic curves for other measures; this can provide insight into the interpretation of clinically important outcomes. CONCLUSIONS: GAS appears to be a feasible, reliable, valid, and responsive approach to outcome measurement in geriatric rehabilitation.

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PubMed2005

Outcomes of continuous process improvement of nutritional care program among geriatric units.

BACKGROUND: Up to 65% of elderly patients are protein-calorie undernourished at admission or acquire nutritional deficits while hospitalized. The aims of this project were: (a) to assess the quality of care concerning nutrition among Belgian geriatric units, (b) to include more routinely nutritional assessments and interventions in comprehensive geriatric assessment, and (c) to assess the impact of nutritional recommendations on nutritional status and on the length of hospitalization. Method. We studied 1139 patients consecutively admitted to 12 geriatric units of general hospitals prospectively for 6 months (from January through June 2001). All patients underwent a comprehensive geriatric assessment. For the first 3 months, the nutritional status of the patients on admission and at discharge were assessed without particular recommendations for nutritional intervention. A standardized nutritional intervention was proposed for the last 3 months. RESULTS: Median value of the Mini Nutritional Assessment test score was 18 points (range 9-29), mean admission's serum prealbumin concentration was 0.185 +/- 0.076 g/L, and C-reactive protein was 5.3 +/- 7.5 mg/100 ml. Hospitalization stay was significantly lower during the interventional period than during the observational period. A higher mean serum prealbumin concentration variation was observed during the interventional period as compared to the observational period. CONCLUSIONS: Nutritional assessment should be part of routine clinical practice in elderly hospitalized patients. A comprehensive screening tool for assessment of nutritional status is needed that is clinically relevant and cost effective to perform. If malnutrition is suggested by such screening tests, then a supplemental conventional nutritional assessment should be performed before treatment is planned.

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PubMed1991

The use of the Karnofsky Performance Scale in determining outcomes and risk in geriatric outpatients.

The Karnofsky Performance Scale (KPS) was evaluated in a geriatric outpatient population with regard to three issues: its strength of association with widely used and validated geriatric instruments; its ability to predict patient outcomes; and its ability to serve as an identifier of high-risk patients. The 134-patient sample was given a comprehensive geriatric assessment which included the KPS, the Activities of Daily Living (ADL) scale, the Instrumental Activities of Daily Living (IADL) scale, and other psychosocial and sensory tests. The KPS, ADL, and IADL were significantly correlated with each other, and the KPS showed the strongest associations with other functional measures. The KPS was also highly predictive of outcomes, performing better or equally well as the ADL and IADL. The KPS designation of high- and low-risk groups resulted in statistically significant score differences between groups in all but one assessment area, demonstrating better ability to discriminate than either the ADL or IADL. Thus, the KPS was shown to serve as an effective proxy score for a patient's health and functional status. It also was a significant predictor of hospitalizations, survival time, community residence, and institutionalization. Finally, the KPS was shown to adequately distinguish risk groups to aid in the targeting of services to ambulatory geriatric patients.

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