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PubMed1980

The combined approach to geriatrics and psychiatry: evaluation of a joint unit in a teaching hospital district.

A 25-bedded combined geriatric and psychogeriatric assessment unit in a District General Hospital (Teaching) is described. In the five years 1973-7 there were 1576 admissions. The turnover per bed was 12.6 per year, discharges 58% and deaths 22%. Results compare favourably with other geriatric and psychogeriatric units and with the treatment of elderly patients with psychiatric disorders in a general medical ward. The arrangement meets the needs of elderly patients very well, provides a valuable training ground, and ensures excellent liaison between geriatric and psychogeriatric services.

Age Factors↗
PubMed2004

Teaching physicians geriatric principles: a randomized control trial on academic detailing plus printed materials versus printed materials only.

BACKGROUND: We compared the effectiveness of academic detailing with printed materials, versus printed materials only, on promoting geriatric knowledge among physicians. METHODS: 31 physicians were randomly assigned to receive academic detailing plus printed materials (group 1 intervention, n = 16), or printed materials alone (group 2 control, n = 15), on 5 geriatric topics identified from a needs assessment survey. Two participants withdrew from group 2, leaving 13 in the control group. Both groups received printed educational materials between baseline and time 1, and at time 2. Only group 1 received an additional 15-minute, one-on-one education session with a geriatrician at time 2. The primary endpoint was knowledge retention, measured by the numeric score of a 5-item questionnaire (range 0 to 5), comprised of items from the Geriatrics Knowledge Test. Knowledge retention was measured at baseline, 1 week (time 1), and on average 29 weeks later (time 2). RESULTS: Most participants were postgraduate trainees. The mean knowledge score in all participants decreased from 3.6 +/- 1.2 at baseline to 3.1 +/- 1.2 at time 1 (p =.006). 19 participants (9 in group 1 and 10 in group 2) completed the knowledge questionnaire at time 2. At baseline, group 1 scored lower than group 2 (3.4 +/- 1.3 versus 3.8 +/- 1.1, p =.39); whereas at time 2, group 1 scored significantly higher than group 2 (4.7 +/- 0.7 versus 3.9 +/- 0.7, p =.034). Academic detailing plus printed materials produced higher mean score change from baseline (1.1 +/- 1.3) than printed materials alone (0.0 +/- 1.1, p =.053). CONCLUSIONS: Academic detailing plus printed materials improved knowledge retention among physicians, whereas printed materials only did not.

Education, Medical, Continuing↗
PubMed2005

Circulating acute phase mediators and skeletal muscle performance in hospitalized geriatric patients.

BACKGROUND: There is growing evidence for the significant involvement of inflammatory processes in the development of muscle wasting in old age. Therefore, any disease accompanied by inflammation can be threatening to the muscle function in geriatric patients. METHODS: Sixty-three hospitalized geriatric patients (42 female, 21 male; mean age 84.2 +/- 5.7 years) were monitored weekly for muscle function (grip strength, fatigue resistance, shoulder extension strength, and hip extension strength) and for concentration of circulating C-reactive protein (CRP), fibrinogen, interleukin 6 (IL-6), and tumor necrosis factor-alpha alpha (TNF-alpha). RESULTS: On the basis of circulating CRP and fibrinogen concentrations, 42 patients were categorized on admission as inflammatory and 21 as noninflammatory. Inflammatory patients presented significantly weaker grip strength, shoulder extension strength, and a worse fatigue resistance than did noninflammatory patients. These muscle functions were negatively correlated with the concentrations of circulating CRP and IL-6, but not with fibrinogen or TNF-alpha. In noninflammatory patients, the fatigue resistance improved significantly during the first week of hospitalization. In patients admitted with inflammation, no improvement of muscle function was observed. Patients who remained inflammatory for 2 weeks or more presented a significant worsening of fatigue resistance. CONCLUSIONS: Geriatric hospitalized patients presenting with inflammation show significantly worse muscle functions, which do not improve during hospitalization despite adequate treatment of the primary disease. Reduced strength and fatigue resistance are significantly related to the concentration of circulating CRP and IL-6. Standard treatment of the underlying illness and classic physical therapy are not sufficient to normalize the skeletal muscle strength and fatigue resistance in these hospitalized patients.

Aged↗
PubMed2006

Do geriatric interventions reduce emergency department visits? A systematic review.

BACKGROUND: Hospital emergency departments (EDs) serve an aging population with an increased burden on health resources. Few studies have examined the effects of comprehensive geriatric assessment interventions on ED use. This study aimed to systematically review the literature and compare the effects of these interventions on ED visits. METHODS: Relevant articles were identified through electronic databases and a search of reference lists and personal files. Inclusion criteria included: original research (written in English or French) on interventions conducted in noninstitutionalized populations 60 years old or older, not restricted to a particular medical condition, in which ED visits were a study outcome. Data were abstracted and checked by the first author and a research assistant using a standard protocol. RESULTS: Twenty-six relevant studies were identified, reported in 28 articles, with study samples obtained from EDs (9), hospitals (4), outpatient or primary care settings (10), home care (4), and community (1). The study designs included 17 randomized controlled trials, 3 trials with nonrandom allocation, 4 before-after studies, 1 quasi-experimental time-series study, and 1 cross-sectional study. Hospital-based interventions (mostly short-term assessment and/or liaison) had little overall effect on ED utilization, whereas many interventions in outpatient and/or primary care or home care settings (including geriatric assessment and management and case management) reduced ED utilization. Heterogeneity in study methods, measures of comorbidity, functional status, and ED utilization precluded meta-analysis of the results. CONCLUSION: Further research, using improved methodologies and standardized measures, is needed to address the effects of innovative geriatric interventions on ED visits.

Aged↗
PubMed1979

Geriatric evaluation unit of a medical service: role of a geropsychiatrist.

Psychiatric evaluation as a part of the complete geriatric workup was done on 143 consecutive patients transferred to a Medical Geriatric Evaluation Unit. The patients' age ranged from 48 to 94 years. The findings were: free of psychiatric problems--19.1%; organic brain syndrome--58.8%; dysphoria-depression--36.8%; paranoid--3.7%; alcohol abuse--8.1%; marital maladjustment 18.3% (of marrieds). The Geropsychiatrist diagnoses, participates in psychiatric management, consults, and supervises psychiatric evaluation by other team members. He is an esential member of the Geriatric team since proper recognition and treatment of psychiatric problems is necessary to complete treatment and to make optimum disposition.

Activities of Daily Living↗
PubMed1994

Interdisciplinary team training in geriatrics: reaching out to small and medium-size communities.

Since 1989, six teams in the state of Michigan have been involved in a team training program designed to promote the development of geriatric services in small to medium-size communities. The program was enthusiastically received by participants, but after 18 months, only half of the teams had implemented clinical services for older adults. Monitoring the progress of the teams over 18 months and analyzing the activities of two teams revealed that financially stable and supportive sponsoring agencies and the community were critical factors in the implementation of interdisciplinary clinical services in geriatrics. Future team training programs trying to promote the development of geriatric services in small to medium-size communities should try to address these issues through community organization interventions.

Community Participation↗
PubMed2001

E-mail versus conventional postal mail survey of geriatric chiefs.

PURPOSE: This study compared the response time, response rate, and cost of two types of survey administration techniques: e-mail/web-based versus conventional postal mail. The main aim of the survey was to collect descriptive information on the existence of Acute Care for Elders units and their characteristics by surveying geriatric division chiefs. DESIGN AND METHODS: Two randomized cohorts of geriatric division chiefs were formed to receive a survey either by electronic mail (n = 57) or by conventional postal mail (n = 57). If there was no response to the initial mailing, two follow-up mailings were sent to both groups using the original modality; a third follow-up was performed using the alternative modality. For each group, response rate and response time were calculated. The average total cost was computed and compared across two groups. RESULTS: The aggregate response rate was 58% (n = 31) for the e-mail group versus 77% (n = 44) for the postal mail group. The overall average response time was shorter in the e-mail group, 18 days compared with 33 days for the conventional postal mailing group. The cost comparison showed that average cost was $7.70 for the e-mail group, compared to $10.50 per response for the conventional mail group. IMPLICATIONS: It appears that although the web-based technology is gaining popularity and leads to lower cost per response, the conventional postal method of surveying continues to deliver a better response rate among the geriatric medicine division chiefs. The web-based approach holds promise given its lower costs and acceptable response rate combined with the shorter response time.

Aged↗
PubMed2004

Examination of the Philadelphia Geriatric Morale Scale as a subjective quality-of-life measure in elderly Hong Kong Chinese.

PURPOSE: We examine the psychometric properties of the Philadelphia Geriatric Morale Scale (PGMS) in an elderly Chinese population in Hong Kong. DESIGN AND METHODS: The study consisted of two cohorts: (a) 759 participants aged 70 years and older living in the community who were recruited as part of a territory-wide health survey and interviewed in 1993-1994; and (b) 388 participants living in long-term-care institutions in 1995-1996. Participants who were cognitively impaired (Abbreviated Mental Test score less than 7) or who could not answer questions for other reasons were excluded. The 15-item PGMS was administered. The Rasch dichotomous model was used to assess the validity of the PGMS, and the 15-item Geriatric Depression Scale, previously validated in Chinese, was also administered to examine the concurrent validity. RESULTS: A confirmatory factor analysis identified three underlying factors similar to findings among Caucasians; however, not all the goodness-of-fit indices were acceptable. An exploratory factor analysis using principal axis factoring and promax rotation revealed two underlying factors that explained 35% of the total variance: reconciled aging and unstrained affect. Some items were redundant when applied to the institutional sample. Concurrent validity was demonstrated by the good correlation between the reconciled aging and unstrained affect domains and the Geriatric Depression Scale (r = -0.72 and r = -0.56 respectively). Female gender, older age, and residence in institutions were associated with lower morale. IMPLICATIONS: The PGMS is a valid quality-of-life measure in elderly Hong Kong Chinese persons, but its psychometric properties are slightly different from those for Caucasians.

Aged↗
PubMed1981

Medical student attitudes toward geriatric medicine and patients.

This study examines the influence of factual knowledge of the aged, general attitudes toward the aged, and personal contact with the aged on first-year medical students' attitudes toward geriatric patients and geriatric medicine. Entering medical students indicated a preference for working with younger patients rather than aged patients. Students' attitudes toward the aged were associated positively with their knowledge of the aged, but their interest in geriatric medicine did not appear to be affected significantly by knowledge of, attitudes toward, or personal contact with the aged. The results suggest that factors beyond those considered in this study may need to be examined if there is to be an increase in the number of physicians wishing to care for the elderly.

Aged↗
PubMed1981

Geriatric medicine training in a family medicine residency.

While the need for training programs in geriatric medicine is widely recognized, there are substantial obstacles to developing such training. Obstacles include shortage of faculty members and negative attitudes toward geriatrics on the part of students. For the past two years, family medicine residents have participated in a required rotation in geriatric medicine at the Duke University Medical Center. The program has been successful as measured by regular monthly evaluations of the resident on the rotation, resident acceptance, requests by other learners in the university to participate, and career choices of graduates of the program.

Aged↗
PubMed1982

A study of geriatric training programs in the United States.

Training physicians in geriatrics is essential to improving health care for the elderly. The study reported here provides a detailed analysis of geriatric education at the undergraduate, graduate, and fellowship levels. The number of programs for medical students and residents has increased but is still relatively few; most are elective, and they are of variable quality. Both the number of fellowship programs (36) and positions (87) and the current number of yearly graduates (40) are quite small. Few of these programs have been thoroughly evaluated. Data are presented on the type of training sites, educational activities, and clinical interaction at different levels of training. Overall, the nursing home is most frequently used as a training site, and trainees have contact with many care providers. Information of this kind may be of value to those planning or conducting geriatric programs. The results suggest that there is a persistent need for high quality programs at all levels of educational continuum and that such efforts should be evaluated to ensure and improve quality.

Aged↗
PubMed1988

Home care services as teaching sites for geriatrics in family medicine residencies.

Evaluating the physical and psychological constitution of elderly patients and their social and cultural environments requires skills that should be taught to all physicians in training. A survey was conducted among all accredited U.S. residency programs in family medicine to examine training in geriatrics. The teaching sites most commonly used by the responding programs were the family practice center (used by 96.4 percent), nursing home (81.9 percent), family medicine inpatient ward (62.4 percent), and home care service (HCS) (48.2 percent). The professional most frequently in contact with the resident during training at an HCS was the attending physician. Longitudinal rotations (that is, long-term rotations involving part of each week for months or years) in geriatrics were used more often than block rotations. The HCS rotations ranked highest in residents' evaluations were those in which the resident followed patients long-term and discussed problems and management with a multidisciplinary team. A combined rotation involving a family practice center, a family medicine inpatient ward, and a home care service is discussed as an alternative method of teaching geriatrics in family medicine.

Evaluation Studies as Topic↗
PubMed1992

Scholarly productivity of geriatrics senior faculty members and faculty trainees compared with that of other health professions educators.

To compare the scholarly productivity levels of senior geriatrics educators and faculty trainees, and to compare their productivity with those of other faculty groups, the authors analyzed questionnaires completed in 1988 by 97 senior staff members of geriatrics education centers nationwide and in 1985-1989 by 91 faculty enrollees in the year-long professional development program of the Texas Consortium of Geriatric Education Centers. The chief difference between the two groups was that more senior educators (75%) than enrollees (40%) had published in the three years previous to completing the questionnaire. The authors conclude that the productivity levels of the two groups compare favorably with previously reported productivity levels of health sciences faculties in general.

Adult↗
PubMed2002

Teaching interdisciplinary geriatrics team care.

OBJECTIVES: Addressing the current fragmentation and lack of coordination of health care requires that health professionals be skilled and motivated towards interdisciplinary team care. The objectives of our program are to (1) enhance attitudes towards team health care and (2) improve group interaction skills among interdisciplinary health care learners. DESCRIPTION: We nested an educational intervention focusing on skills and attitudes in interdisciplinary team care within a one-month rotation in an interdisciplinary geriatrics clinic. One day each week, a morning is devoted to small-group seminars, and learners participate as members of an interdisciplinary geriatrics clinical team in the afternoon. Learners are from four disciplines and include an internal medicine resident, a nurse practitioner, a social worker, and pharmacy students. During the small-group seminars, eight hours are spent focusing on team care through facilitated discussions with assigned readings that include (1) motivational information and personal stories regarding the fragmented nature of current health care and personal attitudes and experiences with team care (2 hours), (2) a review of selected effective group communication skills (e.g., querying another learner about reasoning behind a statement before responding with a counter-opinion) (one hour), (3) case studies with team care planning and debriefing on group process behaviors (four hours), and (4) exploration of the potential relevance of team care to learners' own career paths (1 hour). The remaining seminars are devoted to topics in clinical geriatrics and managed care, and to reviewing patient files for the afternoon clinic. In the interdisciplinary clinic, learners spend an additional 18 hours seeing patients with a team that includes faculty from each of the four disciplines. Patients are seen jointly, and care plans are developed and implemented collaboratively. The primary outcome measures are pre- and post-rotation attitudes regarding interdisciplinary team care. Concurrent controls who do not participate in the program are also assessed. Additional measures include faculty observation of communication behaviors, review of written interdisciplinary care plans, and learner perceptions of the value of the rotation. After a one-year planning and pilot period, the educational program is now in its third month of operation. DISCUSSION: Previous team-care training programs for health professionals have demonstrated difficulty in fostering effective attitudes and skills. During the planning and pilot year, we identified barriers to success that included (1) negative baseline attitudes toward interdisciplinary team care, especially among medical residents, (2) unrecognized assumptions and behaviors by learners regarding authority and power relationships within the team, and (3) specific concerns by learners regarding the effectiveness and efficiency of health care teams. We hope to demonstrate success through a program that includes direct examination of learners' attitudes and their origins in a safe environment, immediate feedback regarding group behaviors, case-based learning, and direct role exposure to a well-functioning interdisciplinary team.

Attitude of Health Personnel↗
PubMed1990

Incidence of pulmonary embolism in elderly patients newly admitted to an acute geriatric unit: a prospective study.

To study the incidence of pulmonary embolism (PE) in elderly patients newly admitted to an acute geriatric unit, the authors carried out ventilation perfusion scans on 33 patients, 25 women and 8 men, mean age 79 years, consecutively admitted to the geriatric wards. The first scan was done within 5 days of admission and repeated between days 10 and 20. Where possible, patients with a positive second scan had a repeat scan at 2-3 months. Six (18%) patients were found to have a high probability of PE, 4 (12%) at the time of admission and two (6%) after admission. Three patients (9%) were considered to suffer from chronic pulmonary artery disease. Mortality was 5 for the whole group (15%) and 1 of 6 (17%) with a high probability of PE; this patient was suffering from carcinomatosis. The only patient who was anticoagulated suffered serious side effects. In no patient was PE clinically suspected. The authors conclude that PE is common in sick elderly patients newly admitted to acute geriatric wards, that rehabilitation with mobilization may precipitate new PE, and that nonanticoagulated PE does not seem to appreciably shorten the prognosis for life. Treatment with anticoagulants may be more dangerous than not treating PE in this older age group.

Aged↗
PubMed1999

Outcomes of critically ill elderly patients: is high-dependency care for geriatric patients worthwhile?

OBJECTIVES: To study the outcomes of elderly patients in a high-dependency care unit and to evaluate the costs and benefits of a geriatric high-dependency unit (GHDU). DESIGN: Prospective data collection and analysis. SETTING: Geriatric high-dependency unit. PATIENTS: One hundred fifty patients > or =70 yrs of age who had been admitted to the GHDU over a 10-month period were investigated during their treatment and rehabilitation. MEASUREMENT AND MAIN RESULTS: The patients' Acute Physiology and Chronic Health Evaluation (APACHE) II scores and Simplified Acute Physiology Scores (SAPS) were recorded. The APACHE II scores and SAPSs provided a close correlation with the patients' mortality (correlation coefficients were 0.97 and 0.92, respectively). The SAPS proved to have a better linear relationship with the elderly patients' mortality in comparison with APACHE II scores. Most of the elderly patients included in the study were suffering from multiple premorbid medical problems. Overall, the mortality rate up to 1 month after discharge from the hospital was 48%. For patients ranging in age from 70 to 84 yrs, the 1-month mortality was 39.6%; however, for patients > or =85 yrs of age, the 1-month mortality was 68.1%. The mortality ratio was 0.96 (for all patients), 0.88 (for those ages 70-84 yrs), and 1.05 (for those age 85 yrs and above). For patients with nil organ system failure, the mortality rate was 32%. For patients with one organ system failure, the mortality increased to 48%. For patients with two organ system failures, the mortality rate was 86%. Survival for patients with three or more organ system failures was unprecedented. Survivors and nonsurvivors were compared. Three poor-prognosis groups were identified: group 1, patients who had received preadmission cardiopulmonary resuscitation; group 2, patients with a recent history of malignant diseases; and group 3, patients who had been mechanically ventilated. All three groups had a significantly higher mortality than those without these factors (p<.05). Patients in the 85 yrs and above group had a significantly higher mortality rate than those in the 70- to 84-yr age group (p<.05). Patients with SAPS and APACHE II scores >20 and >30, respectively, had a poor prognosis. The geriatric outcome scoring system (GOSS) was used as the functional outcome test for the survivors. The GOSS has three components: activities of daily living, mobility status, and social condition. At 1 month after discharge, 66.7% of the survivors returned to their premorbid activities of daily living abilities, 79.5% maintained their mobility status, and 91.7% remained at the same social environment. No survivors deteriorated more than one grade in any of the three components measured by the GOSS. The severity-of-illness scores, percentage of mechanical ventilation utilization, mortality rate, length of GHDU stay, and total hospital stay were comparable with those of other intensive care units (ICUs). The cost of 1 GHDU bed-day was equivalent to 24% of 1 ICU bed-day. CONCLUSION: The prognostic information that we gathered from an unselected group of critically ill elderly patients is useful. The GHDU achieved treatment results similar to those achieved by an ICU and is therefore seen as an innovative way of treating critically ill elderly patients. High-dependency care for the elderly patient is worthwhile.

APACHE↗
PubMed2003

Improving geriatric care knowledge, competency, and resourcefulness of home care nurses and aides.

Home care nurses aides have opportunities to support families caring for frail elders; however, most lack specialized geriatric knowledge, competence, and resourcefulness skills essential to caring for vulnerable elders and assisting their families. This study compares the pretest and posttest intervention scores of a geriatric care continuing education program for nurses and aides. Specific participant outcomes include increased geriatric knowledge, competency, and resourcefulness.

Aged↗
PubMed1999

Cost-effectiveness of outpatient geriatric assessment with an intervention to increase adherence.

BACKGROUND: Comprehensive geriatric assessment (CGA) can be effective in inpatient units, but such inpatient settings are prohibitively expensive. If similar benefits could be obtained in outpatient settings, CGA might be a more attractive option. OBJECTIVES: To assess the cost-effectiveness (CE) of an outpatient geriatric assessment with an intervention to increase adherence. SUBJECTS: Three hundred fifty-one community-dwelling, elderly subjects with at least one of four geriatric conditions. MEASURES: In addition to the measures of functioning, we collected data on the costs of the intervention itself and on the use of medical services in the 64 weeks after the intervention. RESULTS: The intervention, which prevented functional decline, cost $273 per participant. The intervention group averaged three more visits than the control group in the first 32 weeks after the intervention, but only 1.2 extra visits in the next 32 weeks. We estimate that the costs of these additional medical services would be $473 for the 5 years after the intervention, leading to a total cost per Quality Adjusted Life Year (QALY) of $10,600. CONCLUSIONS: The CE of this program compares favorably with many common medical interventions. Whether investments should be made in health care resources on treatments that lead to modest improvements in the functioning of community-dwelling elderly people remains a societal decision.

Activities of Daily Living↗