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PubMed1999

Development and testing of a five-item version of the Geriatric Depression Scale.

OBJECTIVE: To develop and test the effectiveness of a 5-item version of the Geriatric Depression Scale (GDS) in screening for depression in a frail community-dwelling older population. DESIGN: A cross-sectional study. SETTING: A geriatric outpatient clinic at the Sepulveda VA Medical Center, Sepulveda, California. PARTICIPANTS: A total of 74 frail outpatients (98.6% male, mean age 74.6) enrolled in an ongoing trial. MEASUREMENTS: Subjects had a comprehensive geriatric assessment that included a structured clinical evaluation for depression with geropsychiatric consultation. A 5-item version of the GDS was created from the 15-item GDS by selecting the items with the highest Pearson chi2 correlation with clinical diagnosis of depression. Sensitivity, specificity, diagnostic accuracy, and positive and negative predictive values were calculated for the 15-item GDS and the new 5-item scale. RESULTS: Subjects had a mean GDS score of 6.2 (range 0-15). Clinical evaluation found that 46% of subjects were depressed. The depressed and not depressed groups were similar with regard to demographics, mental status, educational level, and number of chronic medical conditions. Using clinical evaluation as the gold standard for depression, the 5-item GDS (compared with the 15-item GDS results shown in parentheses) had a sensitivity of .97 (.94), specificity of .85 (.83), positive predictive value of .85 (.82), negative predictive value of .97 (.94), and accuracy of .90 (.88) for predicting depression. Significant agreement was found between depression diagnosis and the 5-item GDS (kappa = 0.81). Multiple other short forms were tested, and are discussed. The mean administration times for the 5- and 15-item GDS were .9 and 2.7 minutes, respectively. CONCLUSIONS: The 5-item GDS was as effective as the 15-item GDS for depression screening in this population, with a marked reduction in administration time. If validated elsewhere, it may prove to be a preferred screening test for depression.

Activities of Daily Living↗
PubMed1999

Prevalence of coexistence of coronary artery disease, ischemic stroke, and peripheral arterial disease in older persons, mean age 80 years, in an academic hospital-based geriatrics practice.

OBJECTIVE: To investigate the prevalence of coronary artery disease (CAD), ischemic stroke, and peripheral arterial disease (PAD), alone and in combination, in older persons. DESIGN: A retrospective analysis of charts from all older persons seen from April 1, 1998, through December 31, 1998, at an academic hospital-based geriatrics practice. SETTING: An academic hospital-based geriatrics practice staffed by fellows in a geriatrics training program and full-time faculty geriatricians. PATIENTS: A total of 474 men and 1328 women, mean age 80 +/- 9 years (range 60 to 102 years) were included in the study. MEASUREMENTS AND MAIN RESULTS: Of 1802 persons studied, 612 (34%) had CAD, 351 (19%) had ischemic stroke, 236 (13%) had PAD, and 816 (45%) had either CAD, stroke, or PAD. Three hundred twenty-eight (18%) of the 1802 persons had CAD alone, 128 (7%) had stroke alone, 50 (3%) had PAD alone, 123 (7%) had CAD + stroke and no PAD, 86 (5%) had CAD + PAD and no stroke, 25 (1%) had PAD + stroke and no CAD, 75 (4%) had CAD + stroke + PAD, and 986 (55%) had no CAD, PAD, or stroke. If CAD was present, coexistent PAD was present in 26% and coexistent stroke in 32% of persons studied. If stroke was present, coexistent CAD was present in 56% and coexistent PAD in 28%. If PAD was present, coexistent CAD was present in 68% and coexistent stroke in 42% of persons studied. CONCLUSIONS: These data showed that if CAD was present, ischemic stroke was also present in 32% and PAD in 26% of the population. If ischemic stroke was present, CAD was also present in 56% and PAD in 28% of the population. If PAD was present, CAD was also present in 68% and ischemic stroke in 42% of the population.

Aged↗
PubMed2000

A clinimetric evaluation of specialized geriatric care for rural dwelling, frail older people.

OBJECTIVE: To test Comprehensive Geriatric Assessment (CGA) as an adjunct to usual care. DESIGN: A randomized controlled trial with 3, 6, and 12 months follow-up. SETTING: Rural communities. PATIENTS: A total of 182 of 265 frail older patients (52 refused, 2 withdrawn, 27 ineligible, 2 deaths) referred by family practitioners with allocation to intervention (n = 95) or usual care (n = 87). INTERVENTION: Three-month implementation of CGA recommendations by a Mobile Geriatric Assessment Team (MGAT) with follow-up assessments at 3, 6, and 12 months. Geriatric nurse assessors, blinded to group assignment, performed each assessment. MAIN OUTCOME MEASURE: Goal Attainment Scaling (GAS). RESULTS: Baseline characteristics were comparable between groups. At 3 months, the intervention group was more likely to attain their goals (GAS total: chi = 46.4 +/- 5.9; GAS outcome chi = 48.0 +/- 6.6) compared with controls (total: chi = 38.7 +/- 4.1; outcome chi = 40.8 +/- 5.6) (P < .001). Standard assessments of function (Barthel index, instrumental activities of daily living), cognition (Mini-Mental State Examination), and quality of life (modified Spitzer quality of life index) showed no difference over 12 months. No difference in survival (intervention: chi = 320 days, SE = 6; control: chi = 294 days, SE = 6; P = .257) or time to institutionalization (intervention: 340 days, SE = 9; control: 342 days, SE = 8; log rank = 0.661; P = .416) were observed. CONCLUSIONS: A MGAT can target rural dwelling, frail older persons, perform in-home CGA, and develop an intervention strategy. Although the intervention did not prolong life or delay institutionalization, clinically important benefits were observed.

Activities of Daily Living↗
PubMed2004

Taking the next steps in goal ascertainment: a prospective study of patient, team, and family perspectives using a comprehensive standardized menu in a geriatric assessment and treatment unit.

OBJECTIVES: To examine the performance of an expanded menu of goals in a geriatric rehabilitation setting incorporating patient, family, and team perspectives. DESIGN: Prospective comparative study. SETTING: Inpatient geriatric rehabilitation unit. PARTICIPANTS: Nineteen consecutive eligible inpatients and their family members and seven unit team members. MEASUREMENTS: Each participant independently reviewed a standardized menu of medical, functional, psychosocial, spiritual, and future planning goals, which were compared with the goals set by the healthcare team. RESULTS: On average, patients and their family members agreed on goals about half the time; family members tended to have more goals than patients. Agreement between the team and patients and families was poor (kappas=-0.11-0.33). The team was less likely to identify functional, psychosocial, spiritual, and future planning goals. CONCLUSION: Patients and families have a broad range of goals that are not always identified by the healthcare team. A comprehensive standardized menu is feasible and may be helpful in setting goals in a geriatric rehabilitation setting.

Aged↗
PubMed2005

The intersection between geriatrics and palliative care: a call for a new research agenda.

Palliative care is interdisciplinary treatment focused on the relief of suffering and achieving the best possible quality of life for patients and their caregivers. It differs for geriatric patients from what is usually appropriate in a younger population because of the nature and duration of chronic illness during old age. In spite of the fact that death occurs far more commonly in older people than in any age group, the evidence base for palliative care in older adults is sparse. Over the coming years, the research foci in the field of geriatrics and palliative care that must be addressed include establishing the prevalence of symptoms in patients with chronic disease; evaluating the association between treatment of symptoms and outcomes; increasing the evidence base for treatment of symptoms; understanding psychological well-being, spiritual well-being, and quality of life of patients and elucidating and alleviating sources of caregiver burden; reevaluating service delivery; adapting research methodologies specifically for geriatric palliative care; and increasing the number of geriatricians trained as investigators in palliative care research. This article discusses specific methods to improve the current situation within each of these seven areas.

Caregivers↗
PubMed2005

Interventions from home-based geriatric assessments of adult protective service clients suffering elder mistreatment.

OBJECTIVES: To describe the interventions for adult protective service (APS) clients referred for geriatric assessment. DESIGN: Retrospective cohort study. SETTING: In-home geriatric assessments conducted in two New Jersey counties. PARTICIPANTS: Two hundred eleven APS clients; 74% female; mean age 77. MEASUREMENTS: Cognition, affect, nutrition, prevalence of selected medical diagnoses and functional conditions, and categories of interventions. RESULTS: Home health agency services were initiated for 46% of APS clients suffering from all forms of mistreatment. Institutional placements (36%) and guardianship interventions (36%) were correlated with caregiver neglect, especially in female APS clients and those diagnosed with dementia. Urgent medications (25%) were prescribed across all mistreatment classifications, and acute hospitalization (20%) was correlated with circumstances of physical abuse. CONCLUSION: An in-home geriatric assessment service was able to contribute at least one relevant intervention for 81% of referred APS clients to collaboratively help mitigate elder mistreatment circumstances.

Aged↗
PubMed2006

Diagnosis and characteristics of syncope in older patients referred to geriatric departments.

OBJECTIVES: To test the applicability and safety of a standardized diagnostic algorithm in geriatric departments and to define the prevalence of different causes of syncope in older patients. DESIGN: Multicenter cross-sectional observational study. SETTING: In-hospital geriatric acute care departments and outpatient clinics. PARTICIPANTS: Two hundred forty-two patients (aged>or=65, mean+/-standard deviation=79+/-7, range 65-98) consecutively referred for evaluation of transient loss of consciousness to any of six clinical centers participating in the study. Of these, 11 had a syncope-like condition (5 transient ischemic attack; 6 seizures), and 231 had syncope (aged 65-74, n=71; aged>or=75, n=160). MEASUREMENTS: Protocol designed to define etiology and clinical characteristics of syncope derived from European Society of Cardiology Guidelines on syncope. RESULTS: No major complication occurred with use of the protocol. Neurally mediated was the more prevalent form of syncope in this population (66.6%). Cardiac causes accounted for 14.7% of all cases. The neuroreflex form of syncope (vasovagal, situational, and carotid sinus syndrome) was more common in younger than in older patients (62.3% vs 36.2%; P=.001), whereas orthostatic syncope was more frequent in the older than in the younger group (30.5% vs 4.2%; P<.001). In only 10.4% of cases, syncope remained of unexplained origin. After initial evaluation, a definite diagnosis was possible in 40.1% of the cases, and a suspected diagnosis was obtained in 57.9%. Syncope of suspected cardiac origin after initial evaluation was confirmed in 43.7% of cases, and neuromediated causes were confirmed in 83.5% of the cases. CONCLUSION: The protocol is applicable even beyond the age of 90 in geriatric departments. The standardized protocol is associated with a reduction in the frequency of unexplained syncope to about 10%.

Age Factors↗
PubMed2003

Comparing various short-form Geriatric Depression Scales leads to the GDS-5/15.

PURPOSE: To compare three published short GDS scales and to identify a valid and reliable short-form alternative to the 15-item Geriatric Depression Scale. DESIGN: Comparative validation study via retrospective chart review of 816 acute care patients in an 830-bed academic medical center in the USA in 2001. METHODS: Data of the 15-item Geriatric Depression Scale, the Mini-Mental State Examination, and demographic data were extracted from medical records after patient discharge. Three scales: the D'Ath GDS-4, van Marwijk GDS-4, and Hoyl GDS-5, were compared to the 15-item Geriatric Depression Scale. RESULTS: The Hoyl 5-item version showed the highest sensitivity (97.9%). Concern for GDS-5 false positives when compared to the 15-item GDS (specificity 72.7%) led to re-ordering the 15 GDS items into a new two-tiered instrument, the GDS-5/15. In this study of 816 older adult inpatients, 60% were screened as "not depressed" using the first 5 items on the GDS-5/15, leaving 40% for continued screening and completion of all 15 GDS items. CONCLUSIONS: A shorter screening tool might encourage more providers to add depression screening to routine health care visits. The GDS-5/15 is an alternative screening tool.

Academic Medical Centers↗
PubMed2004

Nurse practitioners' and physicians' care activities and clinical outcomes with an inpatient geriatric population.

OBJECTIVE: Less is known about nurse practitioners' (NPs') effectiveness in acute care than about their effectiveness in outpatient settings. This study investigated care activities and clinical outcomes for hospitalized geriatric patients treated by NPs compared with those treated by intern and resident physicians. DATA SOURCES: A descriptive comparative research design involved random selection of 100 inpatient geriatric patients and a convenience sample of 17 professional providers who staffed three hospital units. A 1-month study period produced retrospective and prospective data for analysis. CONCLUSIONS: Self-reports concerning 10 primary activity categories indicated that NPs spent a higher percentage of time doing progress notes and care planning than did physicians (28% versus 15%, p = .011) and that physicians spent more time on literature reviews (5% versus 1%, p = .008). When prioritizing care activities, NPs ranked advance directive discussion higher than did physicians (2nd versus 7th, p = .036), a difference confirmed by medical record documentation. Physicians were more attentive to functional status (1st versus 3rd, p = .023), but medical record documentation showed NPs to be more attentive to physical and occupational therapy referrals (p = .001). Analysis of 13 independent organ areas revealed that NPs cared for more musculoskeletal (p = .036) and psychiatric (p = .005) problems. Physicians cared for more cardiac patients (p = .001). NPs' patients were older (p = .022) and sicker at admission (p < .001) and discharge (p < .001). Charges per length of stay were lower (p < .001) for the physician provider group, and patients in that group had shorter stays (p < .001). Readmission and mortality rates were similar. IMPLICATIONS FOR PRACTICE: NPs provide effective care to hospitalized geriatric patients, particularly to those who are older and sicker.

Adult↗
PubMed1993

The costs and experiences of caring for sick and disabled geriatric patients--Australian observations.

The costs and experiences of caring for geriatric patients and the effectiveness of a geriatric assessment team have been reviewed in this study from the New South Wales Central Coast. The findings were: that some clients who are referred for placement in nursing homes and who meet standard criteria for admission can be maintained in the community; the cost to the taxpayer of persons admitted to nursing homes was at least $449 to $776 per week (1991 prices), compared to an average cost of $89 per week to maintain at home those whose original assessment met all the criteria for nursing home placement; assessments of needs of some clients were being conducted by five or more separate agencies which led to increased costs and created distrust and confusion for the client; a key factor in the decision to maintain a client in the community was found to be the availability and motivation of carers. A geriatric assessment team has an essential role in mobilising expert assessment and facilitates access to community-based support services to obviate or delay admissions to nursing homes.

Aged↗
PubMedDate not supplied

Standardized patients for teaching geriatric dentistry.

Effectively managing geriatric dental patients requires behavioral, communication, and assessment skills which are not easily taught or evaluated by traditional methods. Standardized patients (SPs) are persons trained to simulate real patients. The advantages of using SPs instead of real patients are that student experiences can be realistic, yet predetermined and controlled. In a program at the University of Illinois College of Dentistry, SPs are used to provide practice and to evaluate dental students regarding their performance in managing specific geriatric dental patients. In the past three years, over 1500 student-SP interactions specific to geriatric dentistry have been conducted with a wide variety of cases, including examination, diagnosis, and treatment planning. Additionally, program outcomes are discussed.

Education, Dental↗
PubMed2001

[Detection of gram-negative bacteria in patients and hospital environment at a room in geriatric wards under the infection control against MRSA].

We prospectively surveyed gram-negative bacteria in patients and hospital environment in a room in the geriatric ward which was specifically under the infection control against MRSA once every two weeks between September and December 1996. We investigated the inpatients in an 8-bed room in the geriatric wards (190 beds) of AINO Memorial Hospital, affiliated with Nagasaki University. During the study period, we performed a total of 431 cultures. The number of specimens cultured was 116 from airways (nose, 42; pharynx, 42; sputum, 32), 24 from decubitus ulcer, 40 from urine, 42 from feces, a total of 125 from skin (head, 42; forearm, 42; inguinal region, 41), and 84 from the hospital environment (floor swab, 42; settled agar plate, 42), respectively. A total of 15 species were isolated from the hospital environment. Some species were the same as those which were recovered from the hospital environment were those observed on each body site. In the hospital environment, the isolation rates of Acinetobacter baumanii and Klebsiella pneumoniae were significantly high in the settled agar plate (A. baumanii, p < 0.01; K. pneumoniae, p < 0.05, respectively). Isolation rates of Pseudomonas aeruginosa, Citrobacter spp., and Enterobacter sakazakii were also high in the settled agar plate (p = 0.078, 0.078, 0.078, respectively). In conclusion, gram-negative bacteria in patients may be associated with the environmental bacteria in the room in the geriatric wards.

Aged↗
PubMed1979

Contribution from geriatric medicine within acute medical wards.

In 1977 a scheme of attachment to acute medical wards of consultants in geriatric medicine and associated junior medical staff was instituted in a large Edinburgh teaching hospital. The effect on admissions of patients aged 65 and over was examined for comparable periods before and during this arrangement. Mean and median stays were reduced for both sexes but more noticeably for women. The mean stay for all women aged over 65 was reduced from 25 to 16 days and for women aged over 85 from 50 to 19 days. The proportion staying under two weeks was significantly increased in both sexes, and the proportion discharged home also increased, correspondingly fewer patients being transferred to convalescent wards. These changes were not accompanied by increased transfers to the geriatric department, and probably the skills and extra resources available to the geriatric service were the factors mainly responsible for the changes in performance.

Acute Disease↗
PubMed1972

Making hospital geriatrics work.

The first year's work at a new geriatric department at Northwick Park Hospital shows that active policies revolutionize the geriatric service and result in high turnover of patients and no waiting list. Comparison with low turnover/waiting list departments shows the effects of a waiting list in terms of diminished therapeutic benefit and less favourable outcome for patients admitted. The requirements for elimination of the waiting list appear to be well directed policies and adequate and enthusiastic staff. Active geriatrics results in high morale and could be widely applicable within the present hospital bed resources given the necessary improvements in staffing.

Aged↗
PubMed1998

Autonomy and paternalism in geriatric medicine. The Jewish ethical approach to issues of feeding terminally ill patients, and to cardiopulmonary resuscitation.

Respecting and encouraging autonomy in the elderly is basic to the practice of geriatrics. In this paper, we examine the practice of cardiopulmonary resuscitation (CPR) and "artificial" feeding in a geriatric unit in a general hospital subscribing to jewish orthodox religious principles, in which the sanctity of life is a fundamental ethical guideline. The literature on the administration of food and water in terminal stages of illness, including dementia, still shows division of opinion on the morality of withdrawing nutrition. We uphold the principle that as long as feeding by naso-gastric (N-G) or percutaneous endoscopic gastrostomy (PEG) does not constitute undue danger or arouse serious opposition it should be given, without causing suffering to the patient. This is part of basic care, and the doctor has no mandate to withdraw this. The question of CPR still shows much discrepancy regarding elderly patients' wishes, and doctors' opinions about its worthwhileness, although up to 10 percent survive. Our geriatric patients rarely discuss the subject, but it is openly ventilated with families who ask about it, who are then involved in the decision-making, and the decision about CPR or "do-not-resuscitate" (DNR) is based on clinical and prognostic considerations.

Aged↗
PubMedDate not supplied

The roots of geriatric medicine: care of the aged in Byzantine times (324-1453 AD).

BACKGROUND: The search for the roots of geriatric medicine, which has been considered a relatively new branch. OBJECTIVE: The purpose of the study is the research of the original Byzantine medical texts and the contemporary historical sources so as to bring to light knowledge about ancient medical care. METHODS: The medical texts of Byzantine physicians were studied and analysed, as well as the Histories and Chronicles of their contemporary writers, so as to locate the extracts in the texts concerning geriatric care from the scientific point of view and that of the 'vox populi' which the historians and chroniclers express. RESULTS: The problems of old age occupied physicians from earliest Byzantine times. They had dealt with the characteristics, symptoms and accompanying diseases of the aged and endeavoured to confront all the medical problems faced by the elderly, providing a special healthy regimen for the third age and taking steps for the prevention of diseases of this age group and their treatment. Parallel to this, the research of contemporary historical texts proves the concern of all society for the special problems of the aged and the significant impact of scientific geriatric medicine on the population. CONCLUSION: The study and analysis of the original medical and historical texts of the Byzantine period (324-1453 AD), written in Greek language, prove that the roots of medical care of old age could be traced from ancient Greek and Byzantine medicine.

Byzantium↗
PubMed2006

Significant reduction of nosocomial pneumonia after introduction of disinfection of upper airways using povidone-iodine in geriatric wards.

We investigated the efficacy of disinfection of the upper airway using povidone-iodine against nosocomial pneumonia in geriatric wards. Cases of nosocomial pneumonia were retrospectively analyzed between January 1991 and March 1995 in geriatric wards (190 beds). Moreover, the relationship concerning methicillin-resistant Staphylococcus aureus (MRSA) isolates between patient and environment was investigated using pulsed-field gel electrophoresis (PFGE) with the SmaI restriction enzyme. The incidence of nosocomial pneumonia decreased significantly (p < 0.05). Major causative organisms of nosocomial pneumonia were MRSA and Pseudomonas aeruginosa, which significantly decreased. PFGE studies showed that the patterns of MRSA isolates show a strong association between patient and environment. Our study indicates that disinfection of the upper airways by povidone-iodine is very important in the prevention of nosocomial pneumonia in geriatric wards.

Aged↗
PubMed1995

Severity of symptoms in chronically institutionalized geriatric schizophrenic patients.

OBJECTIVE: The goal of this study was to characterize the symptoms of geriatric, chronically ill, institutionalized schizophrenic patients and investigate age-related differences in schizophrenic symptoms and cognitive performance from early adulthood to late senescence. METHOD: The Positive and Negative Syndrome Scale and the Mini-Mental State examination were used to assess the schizophrenic symptoms and cognitive performance, respectively, of 393 institutionalized schizophrenic patients stratified into seven groups designated by 10-year age intervals from 25 years to over 85 years. RESULTS: In the comparisons of the seven age groups, significant differences between groups in positive and negative subscale scores on the Positive and Negative Syndrome Scale and in Mini-Mental State scores were revealed. Significant correlations between Mini-Mental State scores and Positive and Negative Syndrome Scale negative symptom scores, but not positive symptom scores, were found for all age groups, except for the youngest patients studied. Current treatment with neuroleptics and prior treatment with ECT, insulin coma, or leukotomy could not account for the poor cognitive performance of the older schizophrenic patients. CONCLUSIONS: The older schizophrenic patients continued to experience psychotic and nonpsychotic symptoms in senescence. Their positive symptoms were moderately less severe and their negative symptoms and cognitive impairment were significantly more severe than those of the younger patients. Somatic treatment appeared not to be responsible for the severe cognitive impairment and negative symptoms of the older patients. These data are relevant to chronically hospitalized geriatric schizophrenic patients but not necessarily to all geriatric schizophrenic patients.

Adult↗