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PubMed1984

Dr. Marjory Warren and the origin of British geriatrics.

The life and works of the pioneer British geriatrician, Marjory Warren, are worthy of closer examination. The transformation of a Public Assistance Institution into her unit at the West Middlesex Hospital in 1935 represented the first organized geriatric medicine service in the United Kingdom. She promoted multidisciplinary rehabilitation and holistic appreciation of elderly patients, and emphasized the economic, social, and moral problems associated with their care. She was particularly concerned with the rehabilitation of hemiplegics and amputees, preventive medicine, patient responsibility, and home nursing. She underscored the need for geriatrics to maintain a close link with general medicine and its training programs. Her innovative methods, influential writings, committee work, and personal force were instrumental in the evolution of modern British geriatrics and rehabilitation medicine.

England↗
PubMed1984

Geriatric consultation: a functional approach.

Eighty-one geriatric consultations conducted on behalf of 71 patients (mean patient age 78 years, range 59-99; M34 , F37 ) at San Francisco General Hospital were analyzed. Seventy-nine per cent of requests were for medical or psychiatric evaluation; 19 per cent social; and 3 per cent rehabilitation. The authors made 50 new diagnoses, many of which identified conditions that adversely affected patients' functional levels, including cardiovascular disorders (8), medication effects (8), malnutrition (7), misdiagnosis of dementia (7), and gait disorders (4). Recommendations focused on treating those conditions whose alleviation could improve self-care ability: medication adjustment (62 per cent), management of dementia, delirium, or depression (59 per cent), rehabilitation (32 per cent), and treatment of malnutrition (30 per cent). Geriatric consultations resulted in rerouting 18 patients (51 per cent) from nursing homes to lower levels of care. Fourteen of these eventually returned home. By focusing on reversible conditions that affect patients' functional levels, geriatric consultation can improve the management of elderly patients and prevent unnecessary nursing home placement.

Activities of Daily Living↗
PubMed1985

Geriatric education: what the medical schools are doing now.

For a survey of geriatric education in medical schools in the United States in 1983, data were received from one hundred schools. Increasing numbers of schools are providing required geriatric curriculum, and over 80 per cent of schools offer fourth-year electives. Ninety per cent of schools have physician faculty in geriatrics, affiliated with major departments, for an average of 2.5 full-time equivalents per school. Training sites are expanding to include many noninstitutional settings. Issues of curriculum content and impact, as well as faculty development, require further investigation.

Curriculum↗
PubMed1985

Geriatric consultation teams in acute hospitals: impact on back-up of elderly patients.

Back-up of elderly patients in hospital awaiting long-term placement has become a major problem in some areas of the United States and elsewhere. In 1982, geriatric consultation teams (physician, nurse, and social worker) were introduced into six acute hospitals in Monroe County, New York, to help alleviate the problem through more attention to restoration of patient function and comprehensive discharge planning. Over a six-month period, 4,328 newly hospitalized patients aged 70 or older were screened, and geriatric consultations were provided for 366 (8.5 per cent) who were judged to be at risk of requiring prolonged hospital stays. During this period, the mean monthly census of elderly patients backed up in hospital declined 21 per cent, a reversal of previous rises that could not be explained by any other identifiable factors. The impact was on length of stay on back-up status rather than rate of entry to that status. A variety of medical, rehabilitative, and social interventions accounted for this outcome. A number of health care system barriers to expeditious rehabilitation and discharge of hospitalized elderly patients were identified. Geriatric consultation was deemed useful for implementation in acute hospitals in other settings.

Aged↗
PubMed1989

Geriatrics: an updated bibliography.

This is the author's fifth revision of a geriatrics bibliography. Approximately one-third of the previous references have been replaced by more current or more delimited 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 reference data from the past four years. Some articles were selected to highlight current controversies or changes in viewpoint. 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 are primarily concerned with medical ailments of the elderly; legal, ethical, and sociological topics receive more limited coverage. The references are divided into categories. The first set (I) deals with some possible causes of aging; the second (II) with physiologic decline accompanying aging; the third (III) with the atypical and nonspecific characteristics of illness among geriatric patients; the fourth (IV) with the elderly and society; and the fifth (V) 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↗
PubMed1990

What practicing physicians in North Carolina rate as their most challenging geriatric medicine concerns.

We recently surveyed a random sample of 500 physicians in family practice, general practice, and internal medicine in North Carolina, to discover their most challenging geriatric concerns. Using a three-stage survey technique, respondents were asked to answer two open-ended questions about the most challenging geriatric problems they face and what specific geriatric content areas would attract their participation in an educational program. They were then asked to rank 34 topics on which they would like more information. A total of 242 responses were received for a 55% response rate (63 of the 500 were undeliverable). Responses indicated that physicians are more concerned with management than diagnosis and revealed considerable evidence of empathy and concern. The top three topics had to do with the management of dementia, multiple problems, and depression. Approximately 25% of physicians consider problems of financing health care as among the most challenging problems.

Adult↗
PubMed1990

The Senior Care Study. Does inpatient interdisciplinary geriatric assessment help the family caregivers of acutely ill older patients?

Comprehensive geriatric assessment has emerged as an effective strategy for improving outcomes for frail older patients in the hospital setting. Attention, however, has not been given to determining whether this process has any effect on their family caregivers. As part of a randomized controlled clinical trial designed to test the efficacy of early interdisciplinary geriatric assessment for acutely ill hospitalized patients 75 years of age or older, their family caregivers were studied to determine if the process had a positive effect on caregivers' self-reported health and emotional well-being. One hundred forty-two caregivers were approximately evenly distributed between experimentals (n = 69) and controls (n = 73). By three months after the patients' hospitalization, experimental caregivers were more likely to report good general health (81% vs 63%, P = .049) than were controls. The positive effect persisted after statistical adjustment for confounding variables. Experimental caregivers were not significantly more likely to have good emotional health at follow-up than were controls (65% vs 58%, P = .43), even after statistical adjustment. Although the findings are modest, they suggest that the acute hospital setting may be an ideal place to develop interventions designed to enhance family caregivers' well-being during the early months following hospitalization. This may be particularly true when the interventions with caregivers are coupled with a geriatric assessment and care plan process.

Aged↗
PubMed1991

Working group recommendations: targeting criteria for geriatric evaluation and management research.

To maximize the cost effectiveness of geriatric evaluation and management (GEM) programs, criteria need to be established for selecting patients most likely to benefit. A working group was convened to define appropriate patient selection (targeting) criteria for each type of GEM program and to consider research questions for future targeting studies. The group outlined targeting criteria for the spectrum of GEM program types and locations. GEM program types included: inpatient GEM units; hospital geriatric consultation service; GEM programs in nursing homes; outpatient GEM programs for functionally impaired persons; and geriatric community outreach/screening programs for functionally independent elders. For each program type, the group outlined targeting criteria based on current literature and experience. Because research has not yet established the effectiveness of many of these patient targeting strategies, the group drafted a set of research questions, pertinent to targeting, that require attention: (1) For each identifiable population of elderly people, who are most likely to benefit from GEM? (2) How should these people best be identified/targeted? (3) What criteria should be used for targeting? (4) How and how often should population screening be performed to identify persons in need of GEM?

Aged↗
PubMed1991

Working group recommendations: methods for geriatric evaluation and management research.

Methodological issues relating to multi-site studies of inpatient geriatric evaluation and management units were the focus of this working group's deliberations. The group favored a randomized clinical trial in which the inpatient geriatric evaluation and management unit was coupled with outpatient geriatric care. Inclusion of a broad spectrum of patients stratified according to risk for poor hospital outcomes was proposed in order to obtain information on the types of patients that would be most likely to benefit. The need for a detailed definition and description of care in the unit and of "usual care" was emphasized. Serious concerns were raised about including both VA medical centers and private hospitals in the same trial due to differences in the implementation of such a program. Furthermore, fears of contamination of the control group suggested that hospitals could be randomized either to provide usual care or have a GEM unit. However, this strategy would necessitate that hospitals that have already developed inpatient GEM units would be excluded from the trial and could be costly because of the number of hospitals that would be required.

Geriatric Assessment↗
PubMed1992

Predictors of two-year post-hospitalization mortality among elderly veterans in a study evaluating a geriatric consultation team.

OBJECTIVE: To determine predictors of 2-year post-hospitalization mortality in a cohort of elderly hospitalized patients originally assembled to assess the impact of a Geriatric Consultation Team (GCT). DESIGN: Two-year follow-up of an inception cohort. SETTING: University-affiliated tertiary care VA Medical Center. PATIENTS: One hundred sixty-seven veterans age 75 or older discharged following hospitalization on medical, surgical, or psychiatry services but not intensive care units. INTERVENTION: None specifically studied here though cohort was previously part of randomized control trial of a Geriatric Consultation Team. MEASUREMENT: Mortality during 2 years of post-hospitalization follow-up. RESULTS: Two-year post-hospitalization mortality was 28 percent with no difference between the original GCT and control groups. For the entire sample, age, mental status, admission or discharge ADLs (but not change in ADL status), number of admission problems, number of discharge diagnoses, and discharge site were significant predictors of mortality in univariate analysis. Only discharge ADLs and discharge site remained significant in multivariate analysis. CONCLUSION: Measures of ADLs during hospitalization are stronger predictors of mortality following hospitalization than disease diagnoses. Impaired ADLs and placement other than at home are significant predictors of mortality, suggesting that the decision for nursing home placement contains other independently predictive information within it and/or that the subsequent nursing home period produces excess mortality. As had been indicated in short-term follow-up, there was no survival advantage for the Geriatric Consultation Group.

Activities of Daily Living↗
PubMed1993

The problems of pain and its detection among geriatric nursing home residents.

OBJECTIVE: To assess physicians' detection of pain among geriatric nursing home residents and to determine if there are factors that may interfere with their ability to do this. DESIGN: Chart review and patient interview. SETTING: Geriatric nursing home. PARTICIPANTS: One hundred nursing home residents age 65 or older. Seventy-six were communicative. MEASUREMENTS: Demographic information, diagnoses, and medication use were compared for several groups of residents to determine their effects on the detection of pain. RESULTS: Sixty-six percent of the communicative residents were identified as having chronic pain. Treating physicians did not detect this problem in 34% of these residents. Those whose pain was not so identified were more likely to have a neurologic disorder other than dementia. When non-communicative residents were compared with those who were communicative, the physicians were found to have identified pain less frequently in the former cohort. CONCLUSIONS: Chronic pain is a common problem among geriatric nursing home residents and is frequently undetected. Identification of this problem among communicative residents may be markedly improved by direct questioning about this problem at frequent intervals. New methods of assessing pain need to be created to assist in its detection among the non-communicative population.

Aged↗
PubMed1993

Inpatient community-based geriatric assessment reduces subsequent mortality.

OBJECTIVE: To evaluate the effect of an Inpatient Geriatric Consultation Team on patient outcome. DESIGN: Randomized controlled clinical trial. SETTING: A non-academic-affiliated 503-bed community hospital. PATIENTS: All inpatients over the age of 70 years. Sixty-two patients received multidimensional geriatric assessment, and 58 patients received no intervention. INTERVENTION: Team assessment, leading to formal recommendations to the attending physician. MEASUREMENTS: Data were collected on hospital length of stay, referrals to community service, discharge destination, hospital readmissions in 6 months, number of post-discharge physician visits, and change in functional status. Mortality at 6 months and at 1 year was determined for each patient. MAIN RESULTS: At 6 months, 12/58 patients (21%) had died in the control group versus 3/62 (6%) patients in the experimental group (P = 0.01). During hospitalization, the length-of-stay was 10.1 days for the control group versus 9.0 days for the experimental group (P = 0.20). The control group had significantly more readmissions (0.6 per patient vs 0.3 per patient, P = 0.02). A higher number of experimental patients, 22% (13/59), showed improvement in ADL scores compared with 7% (4/46) of control patients, P = 0.07. At one year for all randomized patients, 7/68 (10%) of experimental patients and 13/64 (20%) of control patients had died. CONCLUSIONS: Short-term mortality can be reduced in community inpatient acute hospital settings by comprehensive geriatric consultation teams. Important differences in mortality remain at 1 year of followup. Trends towards improved functional status and fewer hospital readmissions favor the intervention group.

Activities of Daily Living↗
PubMed1993

A randomized, controlled trial of outpatient geriatric evaluation and management in a large public hospital.

OBJECTIVE: To study the effect of outpatient geriatric evaluation and management on physical function, mental status, and subjective well-being. DESIGN: Prospective randomized controlled trial with a 1-year study period. SETTING: Large medical school-affiliated public hospital in an urban community. SUBJECTS: Patients at least 70 years old admitted to the medicine service were screened, randomized, and completed a 1-year follow-up interview. INTERVENTIONS: Comprehensive geriatric evaluation and an outpatient care management program. MAIN OUTCOME MEASURES: Mental status (SPMSQ), ADL (Katz Index), IADL (Five-Item OARS Scale), Life satisfaction (LSI-Z), and self-perception of health status (physical health section of OARS). RESULTS: No significant differences were found for cognitive status, ADL functioning, life satisfaction, nursing home placement, or mortality. The experimental patients reported significantly higher function in IADL and more favorable self-perception of health status compared with controls. CONCLUSION: Outpatient comprehensive geriatric evaluation and management appears to be a useful model for providing care to medically frail elderly patients.

Activities of Daily Living↗
PubMed1997

Validation of multi-frequency bioelectrical impedance analysis in detecting changes in fluid balance of geriatric patients.

OBJECTIVES: Multi-Frequency Bioelectrical Impedance Analysis (MFBIA) is a quick, simple, and inexpensive method to assess body fluid compartments. This study aimed at determining the validity of MFBIA in detecting clinically relevant changes of fluid balance in geriatric patients. DESIGN: A prospective, observational study. SETTING: The 22-bed Geriatric Department of the University Hospital Nijmegen. PARTICIPANTS: Hospitalized patients were eligible if they did not have a pacemaker, were not suffering from terminal illnesses, and did not have psychogeriatric diseases likely to interfere with capacity to consent or comply. During a 16-months period, 218 patients were admitted, of whom 78 patients were eligible and 53 consented to participate. MEASUREMENTS: Each subject's fluid balance was diagnosed twice a week as dehydrated, overhydrated, or euvolemic, based on standardized physical examination, laboratory tests, and weight evaluation. Changes in fluid balance were quantified by measuring total body water (TBW) and extracellular fluid (ECF) applying deuterium- and bromide-dilution techniques. Impedance at 1, 5, 50, and 100 kHz and body weight were measured daily. Sensitivity and Guyatt's responsiveness indexes of MFBIA in detecting dehydration and overhydration were determined. RESULTS: In total, 1071 MFBIA measurements were performed, during which 14 transitions from dehydration to euvolemia and 13 transitions from overhydration to euvolemia were monitored. Rehydration of dehydrated patients caused an increase in TBW and ECF of 3.4 +/- 1.8 L and 1.9 +/- 1.9 L, respectively, which resulted in significant decreases in impedance of 133 +/- 67 omega at 1 kHz and 93 +/- 61 omega at 100 kHz (P = .001). Treatment of overhydrated patients caused a TBW and ECF loss of 3.8 +/- 4.2 L and 3.1 +/- 3.8 L, respectively, which resulted in significant increases in impedance of 104 +/- 72 omega at 1 kHz and 81 +/- 68 omega at 100 kHz (P < .001). Sensitivity of a single MFBIA in diagnosing dehydration and overhydration was 14% and 17%, respectively. Responsiveness indexes of weighing and MFBIA for dehydration and overhydration were similar at all frequencies and greater than one. CONCLUSION: The sensitivity of a single impedance measurement in detecting dehydration and overhydration was low. However, responsiveness of serial measurements to intra-individual changes in fluid balance was good. Therefore, this noninvasive technique may be used in clinical practice to improve monitoring fluid balance in geriatric patients, especially when daily weighing is difficult.

Activities of Daily Living↗
PubMed1998

Prevalence of coronary artery disease, atherothrombotic brain infarction, and peripheral arterial disease: associated risk factors in older Hispanics in an academic hospital-based geriatrics practice.

OBJECTIVE: To investigate the prevalence of coronary artery disease (CAD), atherothrombotic brain infarction (ABI), and peripheral arterial disease (PAD) in older Hispanics and the association with risk factors in this population. DESIGN: A retrospective analysis of charts from all Hispanics seen during January 1996 through July 1997 at an academic hospital-based geriatrics practice. SETTING: An academic, hospital-based, primary care geriatrics practice staffed by fellows in a geriatrics training program and by full-time faculty geriatricians. PATIENTS: One hundred sixty women and 53 men, mean age 80 +/- 8 years (range 64 to 100), were included in the study. MEASUREMENTS AND MAIN RESULTS: Of 213 Hispanics in the study, 59 (28%) had documented CAD, 43 (20%) had ABI, 34 (16%) had PAD, and 90 (42%) had either CAD, ABI, or PAD. Serum total cholesterol and triglycerides were measured in 202 of 213 subjects (95%). Serum high-density lipoprotein cholesterol was measured in 137 of 213 patients (64%). Other risk factor data were documented in all patients. Multiple logistic regression analysis performed in 202 patients using the variables age, gender, cigarette smoking, hypertension, diabetes mellitus, obesity, serum total cholesterol, and serum triglycerides showed statistically significant associations between prevalent CAD, ABI, or PAD and age (P = .002, odds ratio (OR) = 1.083), cigarette smoking (P = .002, (OR) = 3.865), hypertension (P = .007, (OR) = 2.749), diabetes mellitus (P = .028, (OR) = 2.386), obesity (P = .014, (OR) = 2.608), serum total cholesterol (P < 0.001, (OR) = 1.025), and serum triglycerides (P = .017, (OR) = .993). CONCLUSIONS: Either CAD, ABI, or PAD was present in 42% of 213 older Hispanics. There were statistically significant associations between prevalent CAD, ABI, or PAD in older Hispanics and risk factors, including age, cigarette smoking, hypertension, diabetes mellitus, obesity, and serum total cholesterol.

Academic Medical Centers↗
PubMed1998

That was the year that was: an evidence-based clinical geriatrics update.

BACKGROUND: Physicians are faced with an ever-growing information base in medical practice. Studies regularly show a disparity between science and patient care, with scientifically validated practices often taking 20 years and more to enter mainstream clinical practice. OBJECTIVES: To review the recent medical literature for high quality studies that practicing geriatricians should be aware of, either because they provide evidence that might lead to a change in clinical practice or because they provide insight into common geriatric syndromes. DESIGN: Overview. DATA SOURCES: All articles abstracted or noted in ACP Journal Club, Evidence-Based Medicine, or The New York Times from July 1996 to June 1997. STUDY SELECTION: Studies that met the standards for inclusion in ACP Journal Club. STUDY DESIGN: Sampling plan (including eligibility criteria), sample size, response rate, data analysis plan, proportion available for follow-up, main outcomes and measures, main results. RESULTS: Review of the 98 articles that met criteria resulted in the identification of several themes of importance to geriatricians, including the hazards of hospitalization, the prevention of NSAID-induced peptic ulcers, and the treatment and prevention of Alzheimer's disease. The results of these studies expand the therapeutic armamentarium of practicing geriatricians, provide new insights into geriatric syndromes, and raise cautions about the use of certain therapies in older adults. CONCLUSIONS: Many methodologically rigorous studies relevant to the medical care of older people have recently been published. Evidence-based medicine and the use of journals of secondary publication are useful tools to enhance the efficiency of journal reading for geriatric practitioners whose interests span the journals of several disciplines and subspecialties.

Aged↗
PubMed1998

Development and validation of a geriatrics attitudes scale for primary care residents.

OBJECTIVE: To develop and validate an instrument measuring attitudes toward older persons and caring for older patients. DESIGN: Cross-sectional and longitudinal studies. SETTING: An academic medical center. PARTICIPANTS: Initial Study: 121 primary care residents (n = 96), fellows (n = 14), and faculty (n = 11) participated in instrument development in 1995. Longitudinal Study: 95 residents (n = 87) and fellows (n = 8) of the initial cohort participated in the 1996 follow-up study, and 61 of the initial cohort (57 residents and 4 fellows) participated in the 1997 follow-up study. Cross Validation Study: 96 first-year residents (n = 78) and fellows (n = 18) participated in this study. MEASUREMENTS: A 14-item geriatrics attitudes scale was developed. The items were selected from a pool of 37 items administered to the 121 participants in the initial study. RESULTS: The instrument demonstrated high reliability (Cronbach's alpha = .76) and known-groups and construct validity. Attitudes were progressively more positive with more medical training (P < .001), and residents with greater career interest in geriatrics scored higher than those less interested (P = .007). Cross validation results supported the reliability and validity of the instrument. Longitudinal data showed significantly different trends of attitude changes among groups of residents and fellows over a 2-year period. CONCLUSIONS: The 14-item geriatrics attitudes scale developed in this study shows sound reliability, validity, and sensitivity to change among primary care residents. The performance of other groups of medical trainees and the relationship of attitude changes to specific medical training warrant further investigation.

Aged↗
PubMed1999

A randomized clinical trial of outpatient comprehensive geriatric assessment coupled with an intervention to increase adherence to recommendations.

BACKGROUND: Although comprehensive geriatric assessment (CGA) has been demonstrated to confer health benefits in some settings, its value in outpatient or office settings is uncertain. OBJECTIVE: To assess the effectiveness of outpatient CGA consultation coupled with an adherence intervention on 15-month health outcomes. DESIGN: A randomized controlled trial. SETTING: Community-based sites. PATIENTS: 363 community-dwelling older persons who had failed a screen for at least one of four conditions (falls, urinary incontinence, depressive symptoms, or functional impairment) INTERVENTION: A single outpatient CGA consultation coupled with an intervention to improve primary care physician and patient adherence with CGA recommendations. MEASUREMENTS: Medical Outcomes Study Short Form-36 (MOS SF-36), restricted activity and bed days, Physical Performance Test, NIA lower-extremity battery. RESULTS: In complete case analysis (excluding the five control group subjects who died during the follow-up period), the adjusted difference in change scores (4.69 points) for physical functioning between treatment and control groups indicated a significant benefit of treatment (P = .021). Similar benefits were demonstrated for number of restricted activity days and MOS SF-36 energy/fatigue, social functioning, and physical health summary scales. In analyses assigning scores of 0 to those who died, these benefits were greater, and significant benefits for the Physical Performance Test and MOS SF-36 emotional/well being, pain, and mental health summary scales were also demonstrated. CONCLUSIONS: A single outpatient comprehensive geriatric assessment coupled with an adherence intervention can prevent functional and health-related quality-of-life decline among community-dwelling older persons who have specific geriatric conditions.

Accidental Falls↗