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PubMed2003

Evaluation and management of geriatric depression in primary care.

Geriatric depression is a common but frequently unrecognized or inadequately treated condition in the elderly population. Manifestations of major depression in elderly persons may hinder early detection; anxiety, somatic complaints, cognitive impairment, and concurrent medical and neurologic disorders are more frequent. Like major depression, minor depression, which is often ignored, produces morbidity for elderly persons. Both major and minor depression are associated with high mortality rates if left untreated. This article reviews the important aspects of geriatric depression for the nonpsychiatric clinician: the etiology of depressive conditions in the elderly population, the unique clinical features of depression in older people, important evaluation considerations in a population with many medical and neurologic comorbidities, and the nonpharmacological and pharmacological treatment options for managing depression in the geriatric population.

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PubMed2003

General internal medicine and geriatrics: building a foundation to improve the training of general internists in the care of older adults.

Internists--"doctors for adults"--provide most of the medical care given to older Americans, especially those with serious chronic disease. Nonetheless, the United States lacks an adequate physician workforce with mastery in caring for older persons and with expertise in building knowledge about how best to provide this care. This supplement aims to strengthen the physician workforce by fostering incremental and sustained improvements in the training of internal medicine residents in the care of older adults and in the development of geriatrics-oriented general internal medicine faculty. It identifies 3 major barriers to these improvements: lack of adequately trained teachers and mentors, the belief that explicit training in geriatrics has little to offer the generalist, and inadequate funding. Three strategies offer particular promise in overcoming these barriers: engaging directors of internal medicine residency programs, funding centers to promote collaboration between teaching and research programs in general internal medicine and geriatrics, and providing substantial incremental funding on the national level to pay for the time required to care for frail older patients and to teach and do research about this care. The barriers and strategies identified in this supplement may also inform efforts to enhance the skills of practicing physicians and improve training and faculty development in family medicine and other disciplines.

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PubMed1979

Geriatrics and internal medicine.

If medical education is to respond adequately to the growing number of citizens encompassed by the field of geriatric medicine, it must intensify its commitment to the special health and health-related problems of the elderly at every level, from student to certified specialist. This paper discusses the various intellectual, epidemiologic, economic, and attitudinal factors related to the teaching and practice of geriatric medicine. The emergence of a positive philosophy emphasizing coping and possible reversibility of disease is vital. The recent report of the Institute of Medicine on Aging and Medical Education is also reviewed, as well as graduate training opportunities and ways in which the American Board of Internal Medicine could play a leading role in this process by providing increased emphasis on geriatrics in its training programs and certifying examinations. The medical profession must continue its self-evaluation to ascertain how it can most effectively contribute to improving the lives of the elderly, perhaps our greatest national resource.

Attitude of Health Personnel↗
PubMed2000

Dermatophyte test medium culture versus mycology laboratory analysis for suspected onychomycosis. A study of 100 cases in a geriatric population.

Onychomycosis is the most frequently encountered condition in podiatric practice in the United States. A variety of modalities are available to confirm the presumptive diagnosis of onychomycosis. This study was conducted to compare the results of in-office dermatophyte test medium cultures with those of mycology laboratory analysis for 100 cases of suspected onychomycosis in a geriatric population. The results demonstrated that 20% of the patients had dermatophyte involvement, 56% had saprophyte involvement, and 19% had yeast involvement. Only 50% of positive dermatophyte test medium cultures correlated with a positive microscopic fungal culture for dermatophytes. Given these results, it is questionable whether in-office dermatophyte test medium cultures should be routinely used in geriatric patients for the diagnosis of onychomycosis. The authors believe mycology laboratory testing with fluorescent potassium hydroxide preparations and microscopic fungal cultures to be superior to in-office dermatophyte test medium cultures for the diagnosis of onychomycosis in geriatric patients.

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PubMed1992

Geriatric nutrition assessment: comparison of a screening tool to a dietitian assessment.

A priority in nutrition care is early identification of patients at risk of developing nutrition disorders. Simple identification measures such as nutrition screening on admission must be demonstrated to be as effective as the more lengthy traditional nutrition assessment. This study compares a nutrition screen to a clinical assessment in a geriatric setting. Seventy-two consecutive admissions to a geriatric assessment unit were both screened and individually assessed by different staff dietitians. Results of the assessment and the screen corresponded in classifying those at nutrition risk 92% of the time and those not at nutrition risk 77% of the time. The screen was found to be highly sensitive (88%) and specific (83%). A geriatric nutrition screen that has a high degree of agreement with a lengthier assessment may be a useful tool for the clinical practitioner in early identification of patients at nutritional risk.

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PubMed1988

The acute geriatric psychiatry service: a suggested model.

In general hospitals, especially on acute medical-surgical, and general psychiatric units, geriatric patients are often exposed to attitudes of resentment or rejection. Individuals with treatable mental illnesses may be relatively neglected or dismissed as "senile," and their special needs not attended to. This tends to occur when the particular psychological issues of elderly patients are not shared by most of the other patients, and also when staff members are prejudiced about old people, either because of fear about their own aging or because of unresolved difficulties with parents or grandparents. The authors believe that age-specific geriatric units are the most effective treatment format for the elderly in need of psychiatric care. One example of such a unit opened in 1980, the Geriatric Psychiatry Unit currently in operation at the Johnston R. Bowman Health Center for the Elderly, a part of Rush-Presbyterian-St. Luke's Medical Center in Chicago, is described.

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PubMed1999

Depressive symptoms, cognitive impairment and functional impairment in a rural elderly population in India: a Hindi version of the geriatric depression scale (GDS-H).

OBJECTIVE: To measure depressive symptomatology in a largely illiterate elderly population in India, using a new Hindi version of the Geriatric Depression Scale (GDS-H), and to examine its distribution and associations with age, gender, literacy, cognitive impairment and functional impairment. DESIGN: A Hindi version of the Geriatric Depression Scale was developed and administered to participants along with measures of demographic characteristics, cognitive functioning and functional ability. SETTING: The rural community of Ballabgarh in northern India. PARTICIPANTS: A community sample of 1554 mostly illiterate Hindi-speaking residents of Ballabgarh aged 55+. MEASURES: The Hindi version of the Geriatric Depression Scale (GDS-H); the Hindi Mental State Exam (HMSE); the Everyday Abilities Scale for India (EASI); age, gender and literacy. RESULTS: The GDS-H had high internal consistency and a factor structure comparable to the original English language version. The overall distribution of scores was higher than reported from other populations. Greater numbers of depressive symptoms, as measured by higher scores on the GDS-H, were associated with older age and illiteracy. Among the illiterate, there was no gender difference while among the literate, higher GDS-H scores were found among women. Cognitive impairment and functional disability were independently associated with higher scores on the GDS-H after adjustment for age, gender and literacy. CONCLUSION: A reliable and valid Hindi version of the GDS has been developed. Depressive symptoms as measured by the GDS-H were prominent in this elderly illiterate northern Indian population and strongly associated with both cognitive and functional impairment.

Activities of Daily Living↗
PubMed2000

[Does geriatric rehabilitation need a psychosocial foundation?].

In view of the differentiality and multidimensionality of ageing, especially with regard to geriatric rehabilitation, a look at psycho-social and also the environmental context is indispensable. Above all there are mental and social components that hide the physical consequences of acute incidents and that lead to a reduction in the quality of life. Yet it is a widespread opinion that expansion and the level of health care, in geriatry and in rehabilitation, are nowadays oriented toward what is seen to be medically necessary and economically feasible. Increasing mechanization, rationalization, standardization, and economizing are unambiguous indicators. All the other mental and social needs are problems ranking much lower in the health provision policy as well as in geriatric rehabilitation, and are still far behind the medical and economic requirements set by professional therapists, the health provision policy and the question of who pays for the benefits. However, in consideration of the available knowledge of gerontology, rehabilitation as well as health and nursing sciences and--above all--for humanitarian reasons a psycho-social foundation for geriatric rehabilitation seems to be indispensable.

Activities of Daily Living↗
PubMed2000

[Geriatric medicine at European universities].

The demographic data of industrialised nations predict an unavoidable shift towards an increase of the ratio of old people to total population. Thus, senescence presents a challenge to sociology, psychology and medicine. The latter responds by the holistic approach of geriatrics and medical gerontology. The diversity of European nations and their medical schools lead us to assess the respective incentives in the field of geriatric medicine. By means of a questionnaire with a response rate of 41%, by direct contact and personal communication and by consulting published and unpublished papers we obtained a survey of current geriatric activities in European universities. The results of this investigation are summarized.

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PubMed2001

Hospitalization of nursing home residents in an acute-care geriatric department: direct versus emergency room admission.

BACKGROUND: Transfer to an emergency room and hospitalization of nursing home residents is a growing problem that is poorly defined and reported. OBJECTIVES: To assess the clinical effectiveness of a pilot project involving hospitalization of nursing home residents directly to an acute-care geriatric department. METHODS: We retrospectively compared the hospitalization in an acute-care geriatric unit of 126 nursing home residents admitted directly to the unit and 80 residents admitted through the emergency room. The variables measured included length of stay, discharge disposition, mortality, cause of hospitalization, chronic medical condition, cognitive state, functional status at admission, and change of functional status during the hospital stay. Follow-up data were obtained from medical records during the 2 years study. RESULTS: No significant differences between the groups were found for length of stay, mortality, discharge disposition and most characteristics of the hospital stay. The only significant difference was in patients' mean age, as emergency room patients were significantly older (86 vs. 82.9 years). The most common condition among nursing home patients admitted via the emergency room was febrile disease (36.9%), while functional decline was the most common in those coming directly from the nursing home (32.5%). The prevalence of functional dependence and dementia were similar in both groups. Functional status did not change throughout the hospital stay in most patients. CONCLUSIONS: Treatment of selected nursing home residents admitted directly from the nursing home to an acute-care geriatric unit is feasible, medically effective, results in the safe discharge of almost all such patients and provides an alternative to transfer to an emergency room. This study suggests that quality gains and cost-effective measures may be achieved by such a project, although a randomized controlled trial is necessary to support this hypothesis.

Activities of Daily Living↗
PubMed2002

Reduced serum concentrations of riboflavine and ascorbic acid, and blood thiamine pyrophosphate and pyridoxal-5-phosphate in geriatric patients with and without pressure sores.

BACKGROUND: Patients with pressure sores have as part of their treatment been reefed with energy and proteins with varying result. It has been uncertain, however, to what an extent these patients also were depleted of micronutrients which might be critical for ulcer healing. OBJECTIVE: To study the nutritional intake and nutritional status of a number of micronutrients in geriatric pressure sore patients and in matched controls. DESIGN: The nutritional intake and nutritional status as anthropometric measures, serum conc. of albumin, zinc, and of vitamins (ascorbic acid, riboflavin, calcidiol), were measured. Thiamin pyrophosphate and pyridoxal-5-phosphate were determined in whole blood from 11 geriatric in-patients with pressure sores and 11 matched controls. RESULTS: The serum conc. of ascorbic acid was significantly (p< 0.05) more reduced in pressure sore patients (mean+/-S.D.) 4.2+/-3.4 (ug/ml) than in control patients 7.4+/-5.4 (ug/ml) which still was lower than in a reference group (10.9+/-1.9) (ug/ml). In all the geriatric patients compared to the reference group, the conc. of serum-riboflavin was reduced to about 15 %, thiamine-pyrophosphate and pyridoxine-5-phosphate in whole blood and serum calcidiol to about 50 %, without any differences between the pressure sore patients and the matched controls. CONCLUSION: Refeeding of pressure sore patients who often are catabolic and have increased needs for protein and energy, should include micronutrients not only to cover recommended dietary allowances, but sufficient to reach normal nutritional status for the individual micronutrient.

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PubMed2001

Critical role of functional decline in delayed discharge from an acute geriatric unit.

INTRODUCTION: Delayed hospital discharge of elderly patients after an acute illness poses significant problems, including bed-blockade, iatrogenesis, and increase in morbidity, dependency and social isolation. The aim of this study was to determine the factors associated with delayed discharge from an acute geriatric unit. MATERIALS AND METHODS: This was a prospective cohort study involving 172 consecutive non-institutionalised patients, 65 years and older, admitted to an acute geriatric unit. The medical, functional, psychological and social variables of each subject were documented and any decline in functional status recorded. Based on the discharge status, patients were dichotomised into the "delayed" and "non-delayed" groups. Initial bivariate analyses of the variables were performed to select those associated with the "delayed discharge" group at the P < 0.05 levels. These variables were in turn entered into a multivariate logistic regression model to identify factors significantly associated with delayed discharge. RESULTS: Forty-eight patients (27.9%) had their discharge from the acute geriatric care unit delayed despite clinically fit to be so. Variables significantly associated with delayed discharge in the multivariate model were: 1) decline in basic activities of daily living (ADL) status [P < 0.001; adjusted odds ratio (AOR), 3.63; 95% confidence interval (CI), 1.33 to 9.86] and 2) need for skilled nursing [P = 0.012; AOR, 4.57; 95% CI, 1.88 to 11.14]. CONCLUSIONS: The study demonstrates the central importance of effectively identifying elderly patients who are at risk of delayed discharge after acute hospitalisation through a multidisciplinary focus on illness-induced functional decline. It is likely therefore that proactive approaches to rehabilitation and caregiver training, and adequate community-based services, may facilitate early and effective return of these patients to their homes, thereby reducing inappropriate use of acute beds.

Activities of Daily Living↗
PubMed1998

[Geriatric dentistry in dental education].

Geriatric patients have both special medical problems (problems with aging and general health problems) and specific dental problems. This requires special skills of dentists who are treating these patients. The medical problems require a dentist with a wide medical education and a friendly attitude towards his patients. The dental problems require a dentist who is more problem orientated on his way of treatment. Both aspects are present in the theoretical teaching in most of the dental schools. For treatment of institutionalized geriatric patients it is advocated to train specialists in geriatric dentistry taking into account the need for a multidisciplinary and specific approach.

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PubMed2002

Community and social interventions at a geriatric medical OPD.

Health and social services in Ireland tend to be relatively poorly coordinated. Surveys confirm the perceptions of older people with disability that access to and availability of both health and social services are limited. Multi-disciplinary geriatric medical clinics may provide a focus for better utilization and coordination of these services. The purpose of this study was to measure not only the existing service use but also the potential for community and social-care intervention with older people living in the community when using multi-disciplinary geriatric medical clinics. A sample of 60 consecutive patients aged over 65, attending our geriatric medical OPD for the first time, were interviewed using a semistructured questionnaire on the current and potential use of community and social care services. Our service arranged for 229 interventions or referral to services, an average of 3.8 interventions per patient. Ninety-six services were already in place (an average of 1.6 per patient) and 455 services were not applicable, an average of 7.6 per patient. A combined health and social care response is critical to a successful strategy to disease and disability in later life. Although this study describes a relative utilitarian approach to increase community and social care support, it shows there is significant scope to improve uptake of basic community and social care services by a focussed approach to the care needs of older people.

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PubMedDate not supplied

Subspecialty certification in geriatric psychiatry.

OBJECTIVE: The authors describe the development of certification and recertification processes for geriatric psychiatry, the American Board of Psychiatry and Neurology's second subspecialty in psychiatry. METHODS: Authors referenced databases of the certifying organizations and consulted published surveys of examinees. RESULTS: Since the first certification examination was administered in 1991, 2,595 certificates have been awarded. Because the certificates are time-limited, diplomates must sit for recertification every 10 years. Thus far, about 63% of the diplomates who have needed to do so have been recertified. CONCLUSION: It is estimated that 5,000 geriatric psychiatrists will be needed to meet future healthcare needs. Thus, the demand for this expertise will be increasing, and it is anticipated that board-certified geriatric psychiatrists will continue to play leading roles in educating practitioners from multiple disciplines.

Certification↗
PubMed2003

Postgraduate diploma courses in geriatric psychiatry.

BACKGROUND: Training in geriatric psychiatry constitutes a fundamental element toward further development of this relatively new branch of medicine. However, it varies both in quantity and quality among different countries, healthcare providers and medical schools. OBJECTIVES: To describe the demographic and professional characteristics of participants in postgraduate diploma courses in geriatric psychiatry, and the perceived contribution of the courses, and to compare these variables among the participants in 1 year and 3 year courses, and between psychiatrists and non-psychiatrists. METHODS: A retrospective self-administered questionnaire was mailed to the 153 physicians who participated in the two courses. The 60 questionnaires completed and returned were analyzed. RESULTS: Participants in the courses constituted a heterogenous group in terms of demographic and professional characteristics, with no differences between 1 year and 3 year course participants, or between psychiatrists vs. non-psychiatrists (with the exception of more involvement of non-psychiatrists and 1 year course participants in old-age homes). Most responders indicated both the theoretical and practical benefits and application to daily practice of the material learned. Similarly, most responders indicated that after the courses they definitely used general assessment scales to a much greater extent, particularly cognitive scales, as well as operational diagnostic criteria for dementia. Participants in the 3 year course reported more significant use of assessment scales compared with 1 year participants, and 3 year participants and psychiatrists used the cognitive scales more often. There were no other significant differences between 1 year and 3 year participants and between psychiatrists' and non-psychiatrists' reports regarding general and more specific contributions of the courses. CONCLUSION: Postgraduate diploma courses in geriatric psychiatry seem to have a favorable effect on participants, irrespective of course duration or specialty. However, course duration positively influenced the implementation of assessment scales in general, and cognitive scales in particular. A prospective comparative study on this subject is warranted, with stricter definitions of participants' pre-course and postcourse background, attitudes, knowledge and benefits.

Adult↗
PubMed2003

Administering the "AHSP Questionnaire" (appetite, hunger, sensory perception) in a geriatric rehabilitation care.

BACKGROUND: Frail elderly people, living in nursing homes, usually show a malnutrition state caused by an increased need of energy or an inadequate food intake. Among the causes leading to reduction of food intake in elderly people and consequently to malnutrition, is the loss of appetite, often marker of depression and alterations of taste and smell perception. OBJECTIVE: The aim of this research is to verify the application of the AHSP Questionnaire and relate its score to nutritional state of a frail elderly population hospitalized in a geriatric rehabilitation care. SETTING AND SUBJECTS: All patients of the "3rd Rehabilitation Department" of the Istituto Geriatrico "Villa delle Querce" Nemi (Rome-Italy). METHODS: Informations, number and type of medical conditions, prescribed drugs, other parameters that can affect taste, smell, hunger and nutritional status, mood, cognitive and nutritional status have been collected from the clinical folders. To assess appetite, hunger smell and taste perception had been submitted the AHSP Questionnaire. RESULTS: The AHSP Questionnaire had been administered only to 44 of the 103 patients present at the survey because of the high prevalence of cognitive impairment. AHSP score is lower in presence of malnutrition assessed with MNA (Mini Nutritional Assessment). MNA, expressed as proportional score, seems to present a clear correlation with AHSP's (r=0.59; p=0.000). CONCLUSION: The results achieved show the scarce adaptability of the AHSP Questionnaire to frail elderly people living in geriatric rehabilitation care. MNA is at the moment the most reliable tool to single out dietary deficiency on geriatrics population.

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