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PubMed2004

Executive dysfunction, heart disease burden, and remission of geriatric depression.

This study investigated the relationship of executive impairment and heart disease burden to remission of major depression among elderly patients. A total of 112 elderly subjects suffering from major depression received treatment with citalopram at a target daily dose of 40 mg for 8 weeks. Diagnosis was assigned using the Research Diagnostic Criteria and the DSM-IV Criteria after an interview with the Schedule for Affective Disorders and Schizophrenia. Executive dysfunction was assessed with the Initiation/Perseveration subscale of the Dementia Rating Scale (DRS) and the Color-Word Stroop test. Medical burden, including heart disease burden, was rated with the Cumulative Illness Rating Scale, and disability with Philadelphia Multilevel Instrument. Both abnormal initiation/perseveration and abnormal Stroop scores were associated with low remission rates of geriatric depression. Similarly, heart disease burden and baseline severity of depression also predicted low remission rates. The relationship of heart disease burden to remission was not mediated by executive dysfunction. Impairment in other DRS cognitive domains, disability, medical burden unrelated to heart disease did not significantly influence the outcome of depression in this sample. Executive dysfunction and heart disease burden constitute independent vulnerability factors that increase the risk for chronicity of geriatric depression. The findings of this study provide the rationale for investigation of the role of specific frontostriatal-limbic pathways in predisposing to geriatric depression or worsening its course.

Aged↗
PubMed2001

Medical dominance in multidisciplinary teamwork: a case study of discharge decision-making in a geriatric assessment unit.

AIM: To investigate the degree of medical dominance in multidisciplinary teams in a geriatric assessment unit by focusing on decision-making with regard to patient discharge. BACKGROUND: The persistence of medical dominance in multidisciplinary teamwork has been widely assumed but insufficiently researched, particularly through close observation of team practice. The present study seeks to rectify this by examining the extent of medical dominance in two multidisciplinary teams working in a hospital-based geriatric assessment unit. METHODS: Team practice was analysed by observing and audiotaping five case review meetings in each team and by semi-structured interviews with team members. RESULTS: In terms of level of contribution, the issues raised at meetings, and the team responses to discharge initiation, a lower than expected level of medical dominance was identified. This lower than expected level is related to consultants' views on the nature of rehabilitation, leading to a consensus amongst team members as to the purpose of geriatric assessment, and to a high level of team stability. CONCLUSION: Reducing the level of medical dominance encourages the contributions of all team members and thus enhances patient care. More training in team skills would also be beneficial, including interprofessional training.

Aged↗
PubMed2001

Clock drawing, clock copying, and physical abilities in geriatric rehabilitation.

OBJECTIVES: To determine whether clock drawing and clock copying assess domains that are critical for successful rehabilitation and to evaluate the use of these tasks in predicting physical abilities during rehabilitation. DESIGN: Observational survey study of geriatric cohorts. SETTING: Inpatient university hospital rehabilitation unit. PATIENTS: A total of 172 urban geriatric rehabilitation patients with orthopedic, neurologic, or medical diagnoses. MAIN OUTCOME MEASURES: Clock drawing and copying, FIM instrument, Mattis Dementia Rating Scale, and Neurobehavioral Cognitive Status Examination. RESULTS: Clock drawing and copying correlated highly with other measures of general cognitive ability. Classifying patients according to established cutoffs on clock drawing and copying revealed that patients with cognitive impairment had poorer physical abilities at discharge. CONCLUSION: Clock drawing can be used as a brief screening measure to determine cognitive integrity. Clock copying can yield valuable information about geriatric patients' potential acute rehabilitation course and discharge status.

Activities of Daily Living↗
PubMed2003

[Influence of institutional factors in neurological, medical and geriatric departments on length of stay in patients with stroke].

BACKGROUND: Length of hospital stay (LOS) is determined not only by medical procedures or complications but also by institutional factors. We examined the influence of various institutional factors in neurological, medical and geriatric departments on LOS in patients with ischemic stroke. METHODS: We used data of 12,410 patients from the Westphalian Stroke Register for the years 2000 and 2001. Forty-two centres including 24 neurological, 13 medical and five geriatric departments participated in the register. The register is based on a standardized data assessment, including patient-related sociodemographic and clinical items, diagnostic and treatment procedures, complications, and status at discharge. RESULTS: 7855 patients with ischemic stroke from 37 centres (median age: 73 years, 51 % female) were included in the analysis. In neurological departments, the LOS decreased with increasing numbers of stroke patients treated per centre and year, presence of a stroke unit or a rehabilitation unit. Conversely, the ratio beds to number of physicians was positively associated with LOS. In geriatric departments, a significant decrease in LOS with an increasing number of stroke cases and availability of a rehabilitation unit was also observed. In departments of medicine, no significant influence on LOS was found for the institutional factors analysed. CONCLUSIONS: Institutional factors have a significant influence on LOS in patients with stroke. In this analysis, the influence varied between the different medical specialties. Institutional factors gain importance in the management of stroke patients, when Diagnosis Related Groups (DRG) are introduced.

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PubMed2005

[Differences in the extent of diagnostic procedures after acute stroke in patients treated in departments of neurology, internal medicine and geriatric medicine].

BACKGROUND AND PURPOSE: In Germany, data about variations in acute stroke treatment between different facilities are lacking. The aim of the present study was to compare the extent of diagnostic procedures for acute stroke between departments of neurology, internal medicine, and geriatric medicine. METHODS: Stroke patients admitted to hospitals cooperating within the Westphalian Stroke Register between January 1, 2000 and December 31, 2001 were analyzed. Forty-two hospitals participated in the study including 24 departments of neurology, 13 of internal medicine, and 5 of geriatric medicine. The register is based on a standardized data assessment including sociodemographic and clinical characteristics of the patient, in the acute phase, as well as diagnostic and treatment procedures, complications, and status at discharge. The performance of brain imaging, Doppler, and echocardiography was defined as diagnostic standard for diagnosis and etiological classification of ischemic stroke. RESULTS: A total of 12,232 stroke patients were included. Mean age was 72 years, 49 % were men. In general, diagnostic procedures were administered more often in neurological departments compared to departments of internal or geriatric medicine. In all participating hospitals, the application of diagnostic techniques was less frequent in older patients. The defined diagnostic standard was performed more often in those neurological departments providing acute stroke unit services compared to neurological departments without stroke unit services. CONCLUSION: Our study detected variations in the extent of diagnostic procedures in acute stroke between different medical disciplines. However, further studies are required to clarify whether a more frequent performance of diagnostic techniques yields relevant therapeutic consequences.

Acute Disease↗
PubMed1979

Gerontology and geriatrics in medical education.

The elderly are receiving more attention because of their increasing numbers and because of the substantial public funding for their health and welfare. This article summarizes the findings of an Institute of Medicine committee, whose recently completed report concludes that gerontology (study of aging) and geriatrics (care of the aged) are not covered adequately in medical education. Suggested remedies include increased attention to these subjects in existing medical-school courses, establishment of a complementary required course integrating information from diverse disciplines and emphasis in house-staff training programs on continuous care of the aged in settings other than acute-care facilities. Although an academic discipline of geriatrics is necessary to enhance teaching, research, and specialized patient care, development of a practice specialty would be unwise. More funds for training and research in gerontology and geriatrics are essential to increase the science base and to encourage the development of knowledgeable faculty.

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PubMed1996

Plasma and erythrocyte thiamin concentrations in geriatric outpatients.

OBJECTIVE: The objective of this study was a) to determine the plasma and red cell thiamin levels in geriatric outpatients and b) to evaluate, using the rat model, the sensitivity of plasma thiamin concentration as an indicator of nutritional status for this vitamin. SUBJECTS: Thirty geriatric outpatients were evaluated for their plasma and erythrocyte thiamin levels. METHODS: Plasma and red cell thiamin levels were determined by a microbiologic assay using kloeckera apiculata. Sprague-Dawley rats were fed a thiamin deficient diet. Blood samples were obtained on specified days and the plasma and erythrocyte thiamin levels determined. RESULTS: Forty-three percent of the subjects studied had plasma thiamin levels below 2 SD of the mean of the younger-age group (20-60 yr) while 57% had a plasma thiamin below 10 ng/ml (the lower reference range of the younger age group). Twenty-seven percent were found to have red cell thiamin levels below 2 SD of the mean of the younger-age group, while 33% had red cell thiamin levels below 138 ng/ml (the lower reference range of the younger-age group). The rat study indicated that plasma thiamin concentration is a sensitive indicator of the nutritional status for this vitamin. CONCLUSION: About 50% of geriatric outpatients in this study had low plasma thiamin levels. The long-term effect of a low plasma thiamin level on cognitive functions remains to be investigated.

Adult↗
PubMed2000

Use of subjective global assessment to identify nutrition-associated complications and death in geriatric long-term care facility residents.

OBJECTIVE: The primary objective of this study was to assess the use of Subjective Global Assessment to identify nutrition-associated complications and death in a geriatric population. A secondary objective was to evaluate the ability of Subjective Global Assessment to identify geriatric residents of long-term care facilities who were undernourished or at risk for developing undernutrition. METHODS: Fifty-three consecutive residents who were > or = 65 years of age and had been residing in a long-term care facility for < 2 weeks were enrolled in the study. The Subjective Global Assessment Classification technique was performed according to the procedure outlined by Detsky and colleagues. Residents were classified as well-nourished (A), mild/moderately undernourished (B) or severely undernourished (C). In addition, a Subjective Global Assessment Composite Score was derived. Subjective Global Assessment measures were compared with two traditional objective measurements of nutritional status: serum albumin and serum total cholesterol. Outcome measurements of nutrition-associated complications were determined over a 3-month period by recording the incidence of major infections, decubitus ulcers, nutrition-related hospital readmissions, and mortality. RESULTS: Sixteen residents (30.2%) were categorized as Subjective Global Assessment class A, 28 residents (52.8%) were class B, and 9 residents (17%) were class C. A significant association was found between nutritional status as determined by Subjective Global Assessment Composite Score and nutrition-associated complications (p<0.05). Subjective Global Assessment Classification was related to death (p<0.05) with severely undernourished residents having the highest mortality rate. Hypoalbuminemia only demonstrated a significant relationship with nutrition-associated complications (p<0.05), whereas hypocholesterolemia was associated with death (p<0.05). CONCLUSIONS: Subjective Global Assessment of nutritional status appears to be a simple, noninvasive and cost-effective tool for assessing nutritional status of geriatric residents in long-term care facilities. This assessment tool is also beneficial for identifying patients with increased risk of nutrition-associated complications as well as death.

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PubMed2003

Evaluation and application of the General Motor Function assessment scale in geriatric rehabilitation.

PURPOSE: To test General Motor Function assessment scale (GMF) for concurrent validity, to analyse the distribution of scores and its clinical sensitivity in a setting of geriatric rehabilitation. METHOD: A descriptive and comparative study involving comparisons between GMF and Katz Index of ADL, analyses of GMF scores concerning distribution and comparisons between three geriatric care levels and between assessments pre- and post-intervention. One group of 20 in-patients and one group of 154 patients in three different care forms - institutional care, home rehabilitation and day care were included. Non parametric statistics were utilized, including a method which can separately measure the level of change for the group and for the individuals in that group. RESULTS: High correlation with r(s) = 0.80 (p < 0.001) between the subscale Dependence and the Katz Index of ADL verified that this part of the GMF measures variables related to ability in ADL. No floor effects in any of the subscales of the GMF were shown. The GMF was found to be sufficiently sensitive to demonstrate change from pre- and post-intervention assessments. CONCLUSION: This study indicates that GMF could be useful as a satisfactorily valid and sensitive tool for physiotherapists' standardized assessments in geriatric practice.

Activities of Daily Living↗
PubMed2001

The development and evolution of geriatric assessment teams over the past 25 years: a cross-cultural comparison of the US and the UK.

Findings from a literature synthesis and content analysis of the geriatric assessment team literature from the US and the UK over the past 25 years (1974-1999) are presented. Eighty-one geriatric assessment teams identified from the literature are analyzed (52 from the US and 29 from the UK). Geriatric assessment team characteristics are examined including team purpose, team setting, treatment link, team orientation, team composition, team size, and the client group targeted. The results show that teams in both the US and UK primarily have testing treatment effectiveness as their stated purpose, have strong treatment links, and are patient-oriented. Significant differences exist between the US and UK in terms of team setting, team composition, team size, and patients targeted by team. The US teams examined are more likely to operate in inpatient settings, include more disciplines and have more members on the team, and target specific subgroups of older people than those from the UK.

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PubMed2001

Evaluating geriatric medical outpatients with the Beck Depression Inventory-Fastscreen for medical patients.

To ascertain how effective the seven-item Beck Depression Inventory-FastScreen for medical patients (BDI-FS) was in screening geriatric (> 55 years old) patients for depression, the BDI-FS and the 15-item Geriatric Depression Scale (GDS-S) were administered to 33 (44%) male and 42 (56%) female outpatients who were scheduled for routine office visits by physicians specializing in geriatric medicine. The internal consistency of the BDI-FS was high (coefficient alpha = 0.83), and it was positively correlated with the GDS-S, r = 0.81, p < 0.001. The BDI-FS scores were not related to sex, age, ethnicity, or type of medical diagnosis, but were positively correlated with a diagnosis of depression (r = 0.49, p < 0.001) and being prescribed an antidepressant (r = 0.55, p < 0.001). A BDI-FS cut-off score of four and above had 100% sensitivity and 84% specificity rates, respectively, for identifying patients who were and were not diagnosed with depression.

Aged↗
PubMed2001

The prevalence and correlates of capacity to consent to a geriatric psychiatry admission.

In the UK the recent House of Lords ruling on the Bournewood case provided a statutory basis for admitting patients into psychiatric beds who lack the capacity to consent, but do not dissent, without recourse to detention under the Mental Health Act. A study to ascertain the prevalence and correlates of the lack of capacity to consent to geriatric psychiatry inpatient admission was undertaken. All consecutive acute inpatient admissions to a geriatric psychiatry unit over a six-month period were examined by an independent research psychiatrist (SM). Data on demography, diagnosis, severity of cognitive impairment, insight, the SM's assessment of capacity to consent to the admission and the consultant psychiatrists' assessment of the capacity to consent to the admission were ascertained. The overall prevalence of lack of capacity to consent to geriatric psychiatry inpatient admission was 48%. It was associated with a diagnosis of dementia, increased severity of cognitive impairment, reduced insight and detention under the Mental Health Act. The kappa concordance between SM's and the consultant psychiatrist's assessment of capacity was modest at 0.6. These findings require replication in a larger multi-centre study, perhaps using standardised instruments to measure capacity. A large number of psychiatric patients are informally admitted despite lacking the capacity to consent to the admission because they do not dissent. These patients do not enjoy the safeguards available under the Mental Health Act.

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PubMed2005

Gender comparisons of function-related dependence, pain and insecurity in geriatric rehabilitation.

OBJECTIVE: To evaluate possible gender differences regarding the effect of intervention in geriatric rehabilitation, expressed in terms of change in function-related dependence, pain and insecurity. DESIGN: Comparative study. PARTICIPANTS: A total of 110 women and 44 men undergoing geriatric rehabilitation. METHODS: Performance-based assessments with use of the General Motor Function assessment scale. Non-parametric statistics were mainly used. RESULTS: The women showed higher degrees of function-related dependence, pain and insecurity on admission than the men. Both women and men displayed significant improvement in all 3 variables during the rehabilitation period. However, the positive changes regarding pain and insecurity were according to the analyses of systematic group changes, at a low degree among the men, probably because of the low levels on admission. Gender comparisons of proportions with positive intervention outcome indicated that a significantly larger proportion of the women showed a positive treatment effect after intervention, with a difference in recovery of 19% in dependence, 23% in pain and 33% in insecurity (p<0.05). CONCLUSIONS: Gender differences in disability, with higher degrees of function-related dependence, pain and insecurity among women on admission for geriatric rehabilitation, can be diminished during the rehabilitation period. These promising results may have relevance for the public health of the elderly population.

Activities of Daily Living↗
PubMed1984

Upper gastro-intestinal endoscopy for Chinese elderly in an acute geriatric unit: a review.

From December 1982 to August 1983, a total of 242 oesophago-gastro-duodenoscopies were performed for 208 elderly patients in the Geriatric Unit, Princess Margaret Hospital, Hong Kong. These were done as part of an investigatory procedure in the Geriatric Unit, the first of its kind in Hong Kong. In the 9-month survey, it was found that upper gastro-intestinal endoscopy is a safe and useful diagnostic investigation. It also provides in-service training and stimulation for staff working in the unit to look at one of the many facets of geriatric medicine.

Aged↗
PubMed1985

Career aspirations of geriatric medicine trainees.

The views of trainees in geriatric medicine on preferred career styles were studied by questionnaire. As expected, the majority of respondents did not intend a career in geriatric medicine upon graduation. Whilst a majority would prefer a post wholly dedicated to the care of elderly patients, half the sample would prefer their service to be integrated with general medical services. The majority are optimistic for the future of geriatric medicine in the United Kingdom.

Age Factors↗
PubMed1988

The first year of a geriatric-orthopaedic liaison service: an alternative to 'orthogeriatric' units?

The use of orthopaedic beds by large numbers of elderly patients with multiple pathology will increase and already exceeds the provision of orthopaedic-geriatric rehabilitation units. A cross-specialty multidisciplinary ward round improved the quality of care of orthopaedic patients without requiring expenditure on equipment, facilities or staff, and abolished the need to transfer patients to geriatric beds for rehabilitation, this being achieved on the orthopaedic unit. The liaison service provided excellent medical training in acute and rehabilitative aspects of geriatric medicine, enhanced the role of other disciplines in the care of the elderly orthopaedic patient and facilitated communication between departments.

Geriatrics↗
PubMed1995

Reactivating occupational therapy: a method to improve cognitive performance in geriatric patients.

In this prospective treatment study, the effects of two different occupational therapy strategies were compared in two samples of long-term geriatric inpatients (n = 22 in each group) with slight to moderate dementia according to DSM-III-R. Psychometric ratings after 12 weeks and 24 weeks of treatment have demonstrated that the application of a reactivating occupational therapy programme in addition to functional rehabilitation is significantly more efficient than the application of functional rehabilitation alone on levels of cognitive performance, psychosocial functioning, and the degree of contentedness with life. These results support the assumption that geriatric patients, if stimulated for a longer time, are able to mobilize latent resources of cognitive and psychosocial performance. Reactivating occupational therapy has a place in the treatment of long-term geriatric patients.

Activities of Daily Living↗
PubMed1999

Factors predictive of outcome on admission to an acute geriatric ward.

AIM: To investigate which factors predict outcome of elderly patients on discharge and at 6 months. METHODS: A prospective study in an acute geriatric ward. Within 48 h of admission, patients were assessed for social factors, geriatric problems, admission diagnoses, medication, function and mental ability. Outcome measures were mortality, length of stay, institutionalization, readmissions and attendance at accident and emergency within 6 months. RESULTS: 353 patients were studied, with a mean age of 81.8 years. Logistic regression analyses showed that variables predicting hospital mortality were Barthel index on admission, pre-morbid disability and polypharmacy. The only variable independently predictive of prolonged stay in hospital was a Barthel score of <45 on admission. Functional disability on admission was predictive of institutionalization on discharge. Variables predicting mortality within 6 months of discharge were Barthel index on admission <65, presence of pressure sores, malnutrition and polypharmacy. Variables independently predictive of institutionalization were mental state and a low pension. Those who took more than five drugs on admission were more likely to attend accident and emergency and be readmitted. CONCLUSION: Limited activities of daily living and geriatric problems on admission are the strongest predictive factors of outcome, independent of diagnoses.

Aged↗