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PubMed1985

Performance of candidates on the geriatric medicine items of the American Board of Internal Medicine Certifying Examination.

The performance of candidates on the geriatric medicine items on the American Board of Internal Medicine's 1980, 1981, and 1982 Certifying Examinations was analyzed. For the 1981 and 1982 examinations, candidates who trained in residency programs having a special emphasis on geriatric medicine performed significantly better on the geriatric item than did candidates who attended other residency programs, regardless of overall medical knowledge. This finding suggests the efficacy of training in geriatric medicine as measured by a written examination.

Certification↗
PubMed1986

Integrated university training program in geriatric medicine accredited and evaluated by the Royal College of Physicians and Surgeons of Canada.

The Federated Council for Internal Medicine recommended in 1981 "increased emphasis on geriatric medicine in the medical school curriculum, the medical residency, and continuing medical education." In the same year the first examination for a Certificate of Special Competence in Geriatric Medicine was held in Canada. This was the culmination of a process begun in 1974 to establish the subject as a subspecialty within Internal Medicine. The Royal College of Physicians and Surgeons of Canada set up a Specialty Committee which developed criteria for the accreditation of training programs. Candidates have to be eligible to sit for the certification examination in Internal Medicine before they can sit for the Certificate of Special Competence in Geriatric Medicine which is awarded only after passing both examinations. Thirty-nine individuals sat for the examination in its first five years of whom 26 were successful. These now form a nucleus of well-qualified internist-geriatricians who are developing academic programs in geriatric medicine in Canadian Medical Schools.

Canada↗
PubMed1986

Selected bibliography of recent articles in ethics and geriatrics.

The disciplines of bioethics and geriatrics have had parallel development in recent years. From small and relatively esoteric fields 15 or 20 years ago, both have grown enormously. Although the numbers of geriatricians and ethicists in practice or in academic centers have increased substantially, these disciplines represent areas in which better understanding is sorely needed. This bibliography is intended to assist the clinician in locating salient literature concerning bioethical issues in geriatric medicine and research. It is highly selective; it does not attempt to cover all the literature on bioethics. There are several excellent general bioethics bibliographies for clinicians in the recent literature, as well (not limited to clinical journals or clinical topics), some of which are included in section 13 for the reader's further information. The ethical issues that arise in geriatric medicine are similar to those that arise in the care of younger patients, but certain kinds of problems happen with far greater frequency. Dilemmas concerning decisions about care at the end of life are particularly relevant in geriatrics, as persons of extreme old age are often presented with choices about life-sustaining therapy when critical illness occurs. This includes decisions about cardiopulmonary resuscitation and nutritional support. When these clinical decisions arise in the care of patients who cannot decide for themselves, the question arises as to what role the assessment of "quality of life" ought to play in decisions to pursue or to forego life-sustaining therapy. Informed consent to treatment and to participation in research has been an important area of ethical investigation. Dilemmas about consent to treatment are complicated in some elderly populations because of the higher incidence of cognitive impairment and the higher incidence of the clinician's suspicion (or assumption) of cognitive impairment. In consent to research, there are additional issues of voluntariness and equitable selection, especially when subjects are residents of nursing homes. Because of the increasing numbers of elderly persons in our society, and because of the role of social resources (federal, state, and local) in acute and long-term medical major concern in gerontologic bioethics. The topic headings for this bibliography reflect these common issues which arise in the care of the elderly.+2

Bibliographies as Topic↗
PubMed1987

Geriatrics. An updated bibliography.

This is the author's fourth revision of a geriatrics bibliography. Approximately one-third of the previous references have been replaced by more current or more detailed articles. Because the literature pertinent to geriatrics has continued to grow ever more rapidly, it has been necessary to omit many informative articles from the bibliography. Preference is given to recent publications; almost all of the references date from the past four years. Some articles were selected to highlight current controversies or changes in viewpoint. An occasional unreferred article is cited to amplify geriatric aspects of common diseases. Most of the references deal specifically with an elderly patient population, though few use a multidisciplinary approach. Studies of the elderly are confounded by concomitants of aging frequent but not universal in our society: inactivity, obesity, malnutrition, and psychosocial trauma. The articles cited concern primarily medical ailments of the elderly but legal, ethical, and sociologic topics are also covered. The references are divided into categories. The first set deals with some possible causes of aging, the second with physiologic decline accompanying aging, the third with the atypical and nonspecific characteristics of illness among geriatric patients, the fourth with the elderly and society, and the fifth with care options. The remainder of the references are cited by pertinent medical specialty. Within each category, references are divided by disease process. Articles are further subgrouped by aspects of those diseases such as evaluation or therapy.

Bibliographies as Topic↗
PubMed1987

How does the team approach to outpatient geriatric evaluation compare with traditional care: a report of a randomized controlled trial.

Although team-oriented geriatric assessment clinics are growing throughout the country, little documentation exists regarding their clinical efficacy, cost-effectiveness, or impact on patient functioning and well-being. This report describes a randomized controlled clinical trial to evaluate the effectiveness of a team-oriented geriatric assessment approach compared to traditional care. One hundred-seventeen subjects 65 years of age and over, meeting eligibility criteria to target frail older persons with changing medical and social needs, were randomly assigned to receive a comprehensive geriatric assessment by a multidisciplinary team (treatment) or by one of a panel of community internists who were reimbursed according to their usual and customary fee (controls). Extensive analysis of baseline information failed to identify any significant differences between groups. Over the 1-year follow-up period, treatment participants experienced 26 hospital admissions and used 670 hospital days compared with 23 admissions and 1113 days for controls (a 39.8% difference). Annual hospital costs averaged $4297 for treatment subjects and $7018 for controls. Overall institutional costs including hospital and nursing home care revealed an average saving of $2189 per person for treatment subjects compared with controls, a 25% reduction. A small proportion of subjects accounted for this difference. No significant differences were noted in patient or caregiver satisfaction with the evaluation process, functional ability, or health status. These findings suggest that team-oriented outpatient geriatric assessment provides a promising way to deliver high-quality, satisfying care to older persons without increasing (and possibly decreasing) health care costs.

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PubMed1989

Clinical funding for geriatric fellowship programs.

The Medicare program provides the largest single source of funding for the clinical portion of housestaff training programs. Despite the fact that the clinical training in geriatric fellowship programs focuses heavily on the care of Medicare recipients, the proportion of funds supporting geriatric fellowships that is derived from Medicare is actually smaller than that of most other fellowship programs. Legislation passed by Congress in 1986, and just recently implemented, creates an opportunity to increase Medicare funding for geriatrics. Those concerned with geriatric fellowship training must have a clear understanding of how Medicare funding for graduate medical education will occur under the new legislation if the opportunity is to be used effectively. Finally, other barriers created by general pressures on housestaff budgets that may interfere with capitalizing on the opportunity are discussed.

Fellowships and Scholarships↗
PubMed1989

Geriatric medicine in the United States. The current activities of former trainees.

To improve the health care received by frail older persons, an effort has been made in the United States to increase the number of physicians trained in geriatric medicine and geropsychiatry. The goal of training has been to create leaders in education, research, and patient care. To assess the progress of this effort, we surveyed physicians (284 in geriatric medicine and 91 in geropsychiatry) who graduated from U.S. geriatrics fellowship programs. Responses were obtained from 224 medicine (79% response) and 59 psychiatry fellows (65% response). Sixty-five percent of former geriatric medicine fellows report spending 10% or less time on teaching; 44% report doing no research, and 44% report spending more than half their time in patient care. Compared to other primary care specialties, the geriatricians reported caring for larger proportions of older patients and spending more time per patient visit. However, their role in teaching, research, and long-term care is minimal.

Data Collection↗
PubMed1990

Cognitive function testing in comprehensive geriatric assessment. A comparison of cognitive test performance in residential and clinic settings.

Tests of cognitive function are frequently used in geriatric assessment, but the effect of test setting has rarely been explored. To determine the effect of testing site on the performance of elderly patients undergoing a comprehensive geriatric assessment, we administered the Mini-Mental State Exam to 116 geriatric patients in the clinic and at their residence. Their cognitive abilities varied from normal to severely impaired. The patients' scores were 1.5 +/- 3.6 (mean +/- SD) higher at their residence. The clinical importance of a difference in score of 1.5 is not clear. For this reason a second analysis was performed in which a difference in scores of five points or greater between settings was considered clinically meaningful. Twenty-five percent (29 of 116) differed by five points or more. Of these 29 patients, 22 (76%) tested better in the residential setting. These differences were statistically significant (P = .001). We conclude that the testing site may affect test performance and that in-home assessment may reveal the optimal cognitive function of geriatric patients.

Aged↗
PubMed1991

Impacts of geriatric evaluation and management programs on defined outcomes: overview of the evidence.

Comprehensive geriatric assessment is a technique for multidimensional diagnosis of frail elderly people with the purpose of planning and/or delivering medical, psychosocial, and rehabilitative care. When comprehensive geriatric assessment is coupled with some therapy, then the term geriatric evaluation and management (GEM) will be used. Following a brief history of comprehensive geriatric assessment, we describe the varied patterns of GEM program organization and review the literature of studies examining GEM effectiveness. Program diversity complicates drawing firm conclusions about GEM effects; however, the vast majority of studies report positive, if not uniformly significant, results. Our analysis suggests that much of the variability in findings is due to sample size limitations. In order to reach conclusions of program effects across studies and to avoid problems of small sample sizes, we undertook a formal meta-analysis. In this initial meta-analysis, we sought to evaluate the effect of GEM programs on a single outcome: mortality. We pooled all published GEM controlled trials into four major groups: inpatient consultation services, inpatient GEM units, home assessment services, and outpatient GEM programs. Meta-analysis of 6-month mortality demonstrates a 39% reduction of mortality for inpatient consultation services (odds ratio 0.61, 95% confidence interval 0.46-0.81, P = 0.0008) and a 37% reduction of mortality for inpatient GEM units (odds ratio 0.63, 95% CI 0.42-0.93, P = 0.02). Home assessment services reduced mortality by 29% (odds ratio 0.71, 95% CI 0.55-0.90, P = 0.005). On the other hand, no significant survival effect was found for outpatient GEM programs (odds ratio 0.96, 95% confidence interval 0.61-1.49).(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗
PubMed1991

Working group recommendations: research on content and efficacy of geriatric evaluation and management interventions.

Methods of conducting comprehensive geriatric evaluation and management (GEM) are proliferating in a variety of clinical settings. However, rigorous evaluations of efficacy for this new approach to care of older patients have demonstrated a favorable impact on patient outcome in only a few studies. All of these have been controlled single site studies, and replication is needed. If replication studies show similar results, further studies should be undertaken to define the minimum necessary intervention to achieve the desired outcome. Controlled trials are needed to determine if consultative geriatric evaluation and/or primary patient management is effective. Further innovative work is needed in model development for geriatric assessment and management in outpatient settings. Finally, studies of geriatric evaluation and management in other environments, such as home care or the nursing home, are recommended.

Forecasting↗
PubMed1995

Do geriatric programs decrease long-term use of acute care beds?

OBJECTIVE: To determine whether the introduction of coordinated geriatric and discharge planning services at teaching and community hospitals in Toronto has changed the number of beds occupied by patients awaiting transfer to long-term care institutions. DESIGN: Retrospective review of social work records for the period 1985-1992. SETTING: Two tertiary and four primary acute care hospitals in Metropolitan Toronto. PARTICIPANTS: Hospitals were matched for location, acuity, and teaching affiliation. MAIN OUTCOME MEASURES: The numbers of beds occupied by patients awaiting transfer to nursing homes or chronic care hospitals were noted. RESULTS: In those teaching and community hospitals that had introduced coordinated geriatric and discharge planning services, there was a reduction in the percentage of beds occupied by patients awaiting long-term care placement (average-51%), whereas in hospitals without geriatric services, the percentage of beds occupied by patients awaiting long-term care placement increased (average + 25%) (P = .05 by Fisher's exact method, 95% confidence limit odds ratio 0, .9999). CONCLUSION: The introduction of coordinated geriatric and discharge planning services was associated with a decrease in the percentage of beds occupied by patients awaiting long-term care in both teaching and community hospitals.

Aged↗
PubMed1996

A community development and outreach program in geriatric mental health: four years' experience.

OBJECTIVES: To describe a geriatric mental health outreach program based on a community development model and to review 4 years of experience with this program. DESIGN: Program model and description of implementation experience. SETTINGS: A geriatric mental health outreach program of a regional psychiatric hospital, serving a primarily non-urban area, with offices in the community it serves. PARTICIPANTS: The program targets community-dwelling or institutionalized older persons with late-onset mental health problems and/or behavioral disturbances, persons with long-standing psychiatric disorders with age-related changes, and their caregivers. INTERVENTION: The program is a geriatric mental health outreach and consultation service that emphasizes community development and caregiver education. Program components include an interprofessional consultation team, a specialized information and resource service, educational service initiatives, and an ongoing role in planning and coordination activity in the local health care system. MEASUREMENTS: Program monitoring, including a patient database and a description of program activities. RESULTS: Cognitive impairment, behavioral disturbance, physical/medical problems and depression are the most common reasons for referral to the outreach program. Referred patients (mean age 78; 65% female) have usually (almost 90% of cases) been managed at a similar or lower level of care. Program activities have included focused educational initiatives in community and institutional settings and have emphasized the involvement and development of community caregivers and other local resources. CONCLUSION: The program is a multifaceted effort to make efficient use of scarce specialized resources in a manner that is sensitive and responsive to local circumstances and needs. Experience to date has shown evidence of the feasibility and potential benefits of a comprehensive approach to community development and outreach in geriatric mental health.

Aged↗
PubMed1996

Geriatric targeting criteria as predictors of survival and health care utilization.

OBJECTIVE: To assess the utility of geriatric targeting criteria in predicting survival and health care utilization in a cohort of hospitalized older veterans. DESIGN: A prospective cohort study assessing geriatric targeting criteria, e.g., polypharmacy, falls, or confusion, with respect to adverse outcomes at 12 months. SETTING: A Tertiary Care VA Medical Center. PATIENTS: 507 acutely hospitalized male veterans aged 65 years or more. MAIN OUTCOME MEASURES: Survival status, nursing home placement, and total hospital days during 12 months following hospital admission. RESULTS: Patients who had a higher number of targeting criteria at admission showed a significantly increasing trend toward death (P < or = .001), nursing home placement (P < or = .01), and longer hospital stays (P < or = .01) at 12 months. In univariate analyses, weight loss (relative hazard 3.8, 95% CI 2.4, 5.9), appetite loss (relative hazard 3.3, 95% CI 1.9, 5.8), depression (relative hazard 2.5, 95% CI 1.4, 4.5), falls (relative hazard 2.2, 95% CI 1.2, 4.1), confusion (relative hazard 2.2, 95% CI 1.2, 4.0), and socioeconomic problems (relative hazard 1.6, 95% CI 1.0, 2.5) predicted death. Polypharmacy (OR 3.4, 95% CI 1.3, 8.8), confusion (OR 4.4, 95% CI 1.5, 13.0), and prolonged bedrest (OR 7.6, 95% CI 1.5, 39.3) predicted nursing home placement. Confusion (Beta 12.0, 95% CI 2.9, 21.3), falls (Beta 14.2, 95% CI 4.2, 24.3), and prolonged bedrest (Beta 22.4, 95% CI 3.9, 41.0) predicted total hospital days. In multivariate analyses, weight loss, depression, and socioeconomic problems predicted death; confusion and polypharmacy predicted nursing home placements; and falls predicted total hospital days. CONCLUSION: This prospective cohort study of hospitalized older veterans demonstrated geriatric targeting criteria as predictors of adverse hospital outcomes. Our findings suggest screening acutely hospitalized patients using chart abstracted geriatric targeting criteria is useful in identifying patients at risk for adverse outcomes of hospitalization.

Activities of Daily Living↗
PubMed1997

Is managed care good or bad for geriatric medicine?

This article uses clinical vignettes to examine the simultaneous dangers and opportunities that managed care brings to geriatric medicine. While the complex multifactorial syndromes prevalent in older adults might at first glance seem poorly handled under capitation, we argue that the incentives provided under existing delivery systems can be equally perverse. These improper incentives have arisen from (1) the fee-for-service payment mechanism itself, which has spawned a subspecialty culture ill-equipped to deal with the primary care needs of older adults and (2) the fragmentation of funding sources for geriatric care into two major payers (Medicare and Medicaid), encouraging providers to focus on cost shifting rather than the logical integration of services. The result has been a delivery system that provides little impetus to maximize functional status, the central goal of modern geriatric medicine. Because physicians may assume financial risk under global capitation, and because the cost of caring for a frail older adult is inversely related to functional status, managed care offers the potential to align the goals of cost containment with the goals of modern geriatric medicine. Physicians should have a substantive voice in the design and implementation of these systems.

Activities of Daily Living↗
PubMed1999

Drug treatment of hypertension in older persons in an academic hospital-based geriatrics practice.

OBJECTIVE: To investigate the prevalence of hypertension in older persons, the prevalence of the different antihypertensive drugs used to treat hypertension, the prevalence of the different antihypertensive drugs used to treat hypertension in persons with prior myocardial infarction (MI) or congestive heart failure (CHF), and the prevalence of lowering the blood pressure to <140/90 mm Hg with therapy. DESIGN: A retrospective analysis of charts from all older patients seen from December 1, 1997, through August 31, 1998, at an academic, hospital-based geriatrics practice was performed to investigate the prevalence of hypertension in older persons, the prevalence of different antihypertensive drugs used to treat hypertension, the prevalence of different antihypertensive drugs used to treat hypertension in persons with prior MI or CHF, and the prevalence of lowering the blood pressure to <140/90 mm Hg with therapy. SETTING: An academic hospital-based geriatrics practice staffed by fellows in a geriatrics training program and fulltime faculty geriatricians. PATIENTS: A total of 459 men and 1360 women, mean age 80 +/- 8 years (range 59 to 101 years), were included in the study. MEASUREMENTS AND MAIN RESULTS: Hypertension was present in 1051 of the 1819 persons in the study (58%). Target organ damage, clinical cardiovascular disease, or diabetes mellitus was present in 738 (70%) of these 1051 persons. Of the 1051 persons with hypertension, 520 (49%) were treated with diuretics, 297 (28%) with beta-blockers, 445 (42%) with angiotensin-converting enzyme (ACE) inhibitors, 171 (16%) with calcium channel blockers, and 13 (1%) with other antihypertensive drugs; 41 (4%) received no antihypertensive therapy. The last blood pressure recorded on the chart was <140/90 mm Hg for 735 of the 1051 persons (70%) with hypertension. Of 306 persons with hypertension and prior MI, 182 (59%) were treated with beta-blockers, 146 (48%) with ACE inhibitors, 96 (31%) with diuretics, and 29 (9%) with calcium channel blockers. Of 103 persons with hypertension and CHF, 103 (100%) were treated with diuretics, 94 (91%) with ACE inhibitors, 22 (21%) with beta-blockers, and 3 (3%) with calcium channel blockers. CONCLUSIONS: The prevalence of hypertension in the 1819 older persons seen in an academic, hospital-based geriatrics practice was 58%. Educational efforts led to increased use of diuretics and beta-blockers and decreased use of calcium channel blockers in treating hypertension. The last blood pressure recorded on the chart was <140/90 mm Hg in 70% of older persons with hypertension in the study.

Aged↗
PubMed2000

The Geriatric Pain Measure: validity, reliability and factor analysis.

BACKGROUND: Pain is a multidimensional experience that should be evaluated beyond an estimate of intensity. A multidimensional pain measure has not been developed for older persons undergoing comprehensive geriatric assessment. OBJECTIVE: To develop and evaluate validity and reliability of a multidimensional pain assessment instrument for older persons. RESEARCH DESIGN: A series of steps in instrument development and evaluation. SUBJECTS: A total of 176 subjects (mean age 84 +/- 6.0 years) in ambulatory geriatric clinics; 64% were women, and 73% had a history of chronic pain. MEASUREMENTS: Measurements included the Geriatric Pain Measure (GPM), the McGill Pain Questionnaire, Yesavage GDS, Katz ADLs, Lawton IADLs, Tinetti Gait and Balance, Folstein MMSE, and other demographic and clinical characteristics from interview and chart review. RESULTS: The GPM demonstrated a standardized alpha = 0.9445, homogeneity ratio =0.457, and average inter-item correlation =0.415. A subgroup of 50 subjects demonstrated concurrent validity of the GPM in comparison with the McGill Pain Questionnaire (Pearson's r correlation 0.6269 (P < .0000). Test-retest reliability was demonstrated in another subgroup of 50 subjects who repeated the GPM within 48 to 72 hours (Pearson's r = 0.9018; P < .0000). Factor analysis revealed five clusters of components: Pain Intensity, Disengagement, Pain with Ambulation, Pain with Strenuous Activities, and Pain with Other Activities. CONCLUSIONS: The GPM is a 24-item questionnaire that is easy to administer and has significant validity and reliability in older persons with multiple medical problems. The GPM may be a useful addition to the multidimensional geriatric assessment process.

Activities of Daily Living↗
PubMed2004

Achieving goals in geriatric assessment: role of caregiver agreement and adherence to recommendations.

OBJECTIVES: To determine predictors of recommendation adherence and goal attainment of family caregivers of patients at a geriatric assessment center. DESIGN: One-year prospective cohort study. SETTING: Outpatient geriatric assessment center in Connecticut. PARTICIPANTS: Two hundred consecutive new patients and their family caregivers. MEASUREMENTS: : Family caregivers were interviewed after geriatric assessment to ascertain their treatment goals for the patient. Medical records were reviewed to identify treatment recommendations. Family caregivers were interviewed 1 year later to assess adherence to recommendations and attainment of goals. RESULTS: Follow-up interviews were completed with 176 (88%) family caregivers. Common recommendations pertained to physician referral (71%), medications (46%), counseling/education (31%), diagnostic tests (30%), residential planning (26%), healthcare planning (21%), and community services (21%). Goal attainment was reported in 44% to 67% of the patient cases, depending on goal category. Caregiver agreement with recommendations predicted adherence to recommendations (adjusted relative risk (ARR)=1.99, 95% confidence interval (CI)=1.04-5.92) after adjusting for available clinical and demographic factors. In addition, adherence to recommendations predicted goal attainment in adjusted analyses (ARR=1.70, 95% CI=1.09-2.64). CONCLUSION: This study revealed a broad range of treatment recommendations in geriatric assessment and suggests that agreeing with recommendations can promote adherence and that adherence can promote goal attainment. Taken together, the results imply that articulating shared treatment recommendations may improve the quality of health care.

Aged↗
PubMed2004

Curricular framework: core competencies in multicultural geriatric care.

Strategies to reduce the documented disparities in health and health care for the rapidly growing numbers of older patients from diverse ethnic populations include increased cultural competence of providers. To assist geriatric faculty in medical and other health professional schools develop cultural competence training for their ethnogeriatric programs, the University of California Academic Geriatric Resource Program partnered with the Ethnogeriatric Committee of the American Geriatrics Society to develop a curricular framework. The framework includes core competencies based on the format of the Core Competencies for the Care of Older Patients developed by the Education Committee of the American Geriatrics Society. Competencies in attitudes, knowledge, and skills for medical providers caring for elders from diverse populations are specified. Also included are recommended teaching strategies and resources for faculty to pursue the development of full curricula.

Aged↗