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PubMed1998

DRG reimbursement: geriatric hip fractures in the community hospital trauma center.

BACKGROUND: The purpose of this paper was to determine whether Medicare reimbursement for hip fracture reaches cost in geriatric patients. METHODS: We conducted a retrospective review using the hospital trauma registry. Demographics, operations, length of stay, clinical outcome, discharge disposition, hospital charges, and hospital costs were reviewed and compared with diagnosis-related group (DRG) reimbursement. RESULTS: The study included 153 Medicare patients. Mortality was 3.9%, 71% were discharged to a nursing home or rehabilitation unit, and 25% went directly home. DRG reimbursement constituted 58% of charges. Compared with costs, the DRG amount represented a mean loss of nearly $1,000 per patient. CONCLUSIONS: DRG reimbursement undercompensates the community hospital trauma center for treating a common malady among the geriatric population. A population shift toward the elderly, decreasing Medicare remuneration, and the advance of managed care will make correct identification and control of costs extremely important for the hospital caring for hip fractures in the geriatric population.

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PubMed2006

Serum albumin and comorbidity relative to rehabilitation outcome in geriatric stroke, and possible links with stroke etiology.

Factors that describe the disability status of the stroke patient on discharge are important when starting a rehabilitation program, both from a psychosocial and a financial point of view. The objective of this study was to assess how comorbidity and serum albumin levels relate to rehabilitation outcome in geriatric stroke patients. Another aim was to assess whether stroke etiology (ischemic or hemorrhagic) influences these links. Medical records of 80 patients (68 ischemic and 12 hemorrhagic strokes) older than 65 years, who had suffered their first stroke, were investigated. Functional performance levels at admission and discharge were evaluated using the Functional Independence Measure (FIM). Length of stay in hospital was recorded. Serum albumin levels and comorbidity scores on admission were noted. Correlations between these variables and differences between the groups categorized according to stroke etiology were analyzed. In the group of geriatric stroke patients as a whole, serum albumin level was correlated with FIM score at admission and discharge. Comorbidity score was negatively correlated with length of stay. In the ischemic stroke subgroup, serum albumin level was positively correlated with length of stay and with functional gain, and comorbidity score was negatively correlated with functional gain. Analysis of the data for the hemorrhagic stroke subgroup revealed none of these correlations. It was concluded that serum albumin level and comorbidity are useful indices in geriatric ischemic stroke patients for predicting functional outcome and time spent in rehabilitation.

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PubMed1982

Hemodynamic and metabolic effects of ketamine anesthesia in the geriatric patient.

The cardiovascular and metabolic effects of ketamine as the sole anesthetic agent for surgical correction of fractured neck of femur were studied in eight spontaneously breathing geriatric patients (mean age 83 years) before premedication, at the end of operation, and 15 min and 2 h after the end of anesthesia. Arterial blood pressure, cardiac index, left ventricular stroke work index and oxygen consumption increased during anesthesia but had returned to preoperative levels 15 min after the end of anesthesia. Vascular resistance, heart rate and stroke volume index were not significantly changed. During anesthesia, arterial carbon dioxide tension increased whereas arterial pH and arterial BE decreased. The levels of glucose and lactate increased in both blood and skeletal muscle during anesthesia and remained elevated throughout the period studied but the lactate:pyruvate ratio was unchanged. High energy phosphagen levels in skeletal muscle did not change. Ketamine anesthesia in the spontaneously breathing geriatric patient induces cardiovascular stimulation and metabolic changes indicative of an increased sympathetic stimulation, whereas respiration is slightly depressed. The magnitude of these changes is, however, small and it thus seems that ketamine can be safely used as the sole anesthetic agent for hip fracture surgery in the average geriatric patient.

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PubMed2006

Computerized condition-specific templates for improving care of geriatric syndromes in a primary care setting.

INTRODUCTION: As the U.S. population ages, primary care clinicians (PCCs) will encounter more patients with geriatric syndromes, such as urinary incontinence (UI) and falls. Yet, current evidence suggests that care of these conditions does not meet expected standards and that PCCs would benefit from tools to improve care of these conditions. Little is known about the role of computerized condition-specific templates for improving care of geriatric syndromes. AIM: We sought to develop and assess the usefulness of condition-specific computerized templates in a primary care setting. SETTING: A large academic Veterans Affairs medical center. PROGRAM DESCRIPTION: We developed and tested the usefulness of 2 condition-specific computerized templates (UI and falls) that could be added on to an existing electronic health record system. PROGRAM EVALUATION: Semistructured interviews were used to identify barriers to use of computerized templates. Usefulness and usability were assessed through a randomized-controlled trial involving standardized patients. DISCUSSION: Use of condition-specific templates resulted in improved history and physical exam assessment for both UI and falls (P < .05). Our computerized, condition-specific templates are a promising method for improving care of geriatric conditions in a primary care setting, but require improvement in usability before widespread implementation.

Academic Medical Centers↗

PubMed1966

A plan for regional medical health centers for the geriatric patient.

A rough plan is proposed which may facilitate the care of geriatric patients. The plan is to introduce pilot programs of geriatric regional centers attached to Veteran's Administration hospitals. Thus, at minimal cost, the problems of geriatric medicine would be under the supervision of our excellent university medical centers.

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PubMed1978

Evaluation of goal attainment in geriatric settings.

Determination of the impact of programs designed to enhance the functional independence of geriatric residents requires prior specification of goals in terms that clearly indicate the desired outcomes. The Geriatric Resident Goals Scale (GRGS) is a listing of specific goals developed to provide a systematic means of assessing resident status and program effectiveness. For male residents in a VA Nursing Home Care Unit, the obtained internal consistency reliability coefficient was .97 (N = 198), and the reliability coefficient reflecting a combination of test-retest and interrater consistency was .95 (N = 22). For a group of 178 residents, the GRGS was predictive of level of independence ratings (r = .82) and mental status (r = .71). The data showed the GRGS to be a highly reliable and valid means of assessing the functioning of geriatric residents, lending support to an assessment process based on a listing of specific goals. The GRGS can be viewed as a general procedure that is adaptable to a range of geriatic settings and programs.

Activities of Daily Living↗

PubMed1981

Consistency in patients' health and treatment expectations at a geriatric clinic.

This study focused on predictors of consistency and inconsistency in health and treatment expectations among 77 new patients (mean age, 73) at a geriatric outpatient clinic. Just before their first appointment, and again one week afterward, the patients were asked about their overall health status, their specific illness complaints, their reasons for visiting the clinic, and their expectations regarding treatment and the future outlook. Few predictors of consistency were found for such outcome measures as the number of health problems reported, present and future health status, and the duration, difficulty and benefits of treatment. Inconsistency and uncertainty were more evident in these geriatric outpatients' perceptions, especially among those with self-rated poor health and mobility. This study emphasizes: 1) the importance to the treatment context of geriatric patients' inconsistencies about their health, and 2) the additional burden clinicians must bear in dealing with such discrepancies.

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PubMed1984

Evolution of a geriatric evaluation clinic.

Multidisciplinary geriatric evaluation units are being established in hospitals and, to a lesser extent, as outpatient clinics. This paper presents results of a chart audit of 332 patients seen from 1978 to 1982 at a university based geriatric outpatient evaluation unit. The relationships of clinic staffing to types of referrals and other aspects of clinic operation are investigated. During the time under study, the proportion of patients whose problems were medical rather than psychiatric or social increased. Presenting problems varied by referral source. Family and self referrals were most likely to identify a medical presenting problem, while physician and community agency referrals were most likely to identify a psychiatric problem. Patients frequently received diagnoses in areas of function other than those identified as the presenting problems. For example, medical clinicians made at least one psychiatric diagnoses for 86 per cent of patients they evaluated. Important questions about the potential contribution of such geriatrics clinics to health care of the elderly remain to be answered.

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PubMed1984

Benefits of access to on-site acute and critical care for the residential section of a multi-level geriatric center.

Of 220 residents living in the residential unit of a multi-level geriatric center, 95 required a total of 131 transfers to other facilities over a one-year period. Fifty-three of these patients were transferred to the associated chronic-care hospital for short-term acute medical investigation or treatment. The average length of stay of 17 days was similar to that of patients of comparable age with comparable medical conditions admitted to an affiliated acute general hospital from the community. In addition to continuity of medical care and the social and psychologic advantages of remaining within the geriatric center, this transfer potential resulted in substantial financial savings. The cost of hospitalization in the general hospital would have been more than twice that of the geriatric unit.

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PubMed1984

Attitudinal stumbling blocks to geriatric rehabilitation.

Attitudes held by geriatric patients, their families, and hospital staff are frequent obstacles to successful rehabilitation following acute illness. These attitudes interfere with patients' motivation for increasing physical independence and result in patients' becoming stranded at a more dependent level of function. Three distinct attitudes frequently encountered in geriatric rehabilitation are identified: the prejudice of ageism, the right of dependency, and the apathy of fatigue. Recognition of these attitudinal syndromes permits effective treatment interventions to enable poorly motivated geriatric rehabilitation patients to progress towards functional independence.

Acute Disease↗

PubMed1987

Geriatric patient outcomes and costs in three settings: nursing home, foster family, and own home.

Forty-nine matched triads of geriatric patients were compared after three months in their respective placement settings: nursing homes, geriatric foster homes, and own homes with supportive services. Compared to similarly disabled patients in nursing homes, patients in the two community settings made greater improvements in self-care skills and mobility, expressed greater well-being, had similar types and amounts of morbidity, and entailed lower costs. The results support the expansion of home and community-based services as alternatives to institutional care for a substantial number of geriatric patients.

Activities of Daily Living↗

PubMed1989

Cutaneous-delayed hypersensitivity in nursing home and geriatric clinic patients. Implications for the tuberculin test.

Cutaneous-delayed hypersensitivity was studied by one and two-step Mantoux-type skin tests to four standard antigens in 33 elderly nursing home residents, 34 geriatric clinic patients, and 20 healthy young adult controls. Demographic and anthropometric data were collected to determine the effects of nutrition and other variables on cutaneous-delayed hypersensitivity. Anergy (a lack of response greater than 5 mm of induration when read at 48 hours) to any of the four antigens occurred in 34% of nursing home residents, 17% of geriatric clinic patients, and none of the healthy young adults. Mean and maximal responses were less in the nursing home residents than the clinic patients or controls, even if anergic individuals were excluded from analysis, suggesting both a qualitative and quantitative decline in cell-mediated immune function in this elderly population. Repeat testing with each antigen for which there was a negative initial response revealed a "booster" affect of 7 to 19% and occurred as commonly in the healthy young adults as in the nursing home residents or geriatric clinic patients. The mumps antigen elicited strong responses in the healthy young adults, but weak reactions in the nursing home residents. An unexpectedly high prevalence of positive tuberculin (PPD) responses occurred in the nursing home residents, suggesting recent exposure. Analysis of anthropometric and demographic characteristics show that neither nutritional status nor age alone can account for differences in cutaneous-delayed hypersensitivity observed between populations. Cutaneous-delayed hypersensitivity may vary widely between elderly populations and have important practical implications for the tuberculin test.

Adult↗

PubMed1992

Comparing proxy and patients' perceptions of patients' functional status: results from an outpatient geriatric clinic.

OBJECTIVE: To compare ratings of patients referred for geriatric evaluation and their proxies with respect to patients' ability to perform activities of daily living. DESIGN: Retrospective chart audit. SETTING: University-based Outpatient Geriatric Clinic. PATIENTS: Elderly medicine patients referred to a university-based outpatient geriatrics clinic for the first time. MAIN OUTCOME MEASURES: Modified Katz Physical Activities of Daily Living (PADL) and Instrumental Activities of Daily Living (IADL). RESULTS: With regard to PADLs, patients were generally rated as independent by both patients (91%) and proxies (87%); for IADLs, ratings of independence by both patients (68%) and proxies (51%) were significantly lower. Concordance between patient and proxy ratings was significantly (P less than 0.001) greater for PADLs (92%) than for IADLs (82%). When disagreement occurred, patients consistently rated themselves as more independent than their proxies, especially for IADLs. Moreover, concordance between patients and proxies regarding IADLs was significantly (P less than 0.001) worse for patients who had scores below 24 on the Folstein Mini-Mental State Examination (72%) compared with those scoring 24 or higher (95%). CONCLUSIONS: Patient and proxy ratings were concordant when rating patients' ability to perform PADLs. Moreover, concordance was extremely high on IADLs when patients' Folstein scores were 24 or higher. Concordance with respect to IADLs was relatively poor only among patients with Folstein scores below 24. In that case, patients had a more optimistic view of their independence, compared with their proxies.

Activities of Daily Living↗

PubMed1997

Diuretic usage and withdrawal patterns in a Dutch geriatric patient population.

OBJECTIVES: To describe diuretic usage and withdrawal patterns in a population of very old geriatric patients and to evaluate the long-term probability of remaining free from diuretic therapy after withdrawal. DESIGN: Retrospective analysis of medical records and 1-year follow-up study. SETTING: University Hospital Nijmegen and Rijnstate Hospital Arnhem, a non-academic teaching hospital, The Netherlands. PARTICIPANTS: All 1547 patients, aged 75 years or older, visiting geriatric medicine departments in the two hospitals for the first time in the years 1990 through 1993. MEASUREMENTS: Data on medical history, physical examinations, and medication use were obtained from medical records. Diuretic withdrawal and motivation was recorded as reported. Record review indicating diuretic withdrawal prompted a 1-year follow-up investigation and collection of additional updated information from family care and/or nursing-home physicians. RESULTS: A total of 593 three patients (38.3%) were using diuretics. Use of diuretics increased with age from 33.6% in patients aged 75 to 79 years to 47.4% in patients aged 90 years or older (P < .05). Diuretics were withdrawn in 218 patients (36.8%), in 101 patients because of doubts about the initial or persistent indication for diuretic use and in 91 patients because of adverse effects. No reasons for withdrawal were reported in 26 patients. Withdrawal of diuretics was attempted more often in cases of diuretic prescriptions for unknown reasons (51.2%) or ankle edema without heart failure (45.0%) than when prescriptions were for heart failure (28.5%) or hypertension (35.4%). The overall probability of remaining free of diuretic therapy for 1 year was 0.41. Success of diuretic withdrawal was significantly less when congestive heart failure was the initial indication for prescription (probability 0.24). We did not find other clinical parameters related to the success of withdrawal. CONCLUSIONS: Our study demonstrates that diuretic therapy can be withdrawn for at least a 1-year period in a substantial number of very old geriatric patients receiving these medications, regardless of the initial indications for prescription. However, withdrawal is performed without application of uniform criteria. Future prospective studies should be directed at developing clear guidelines for diuretic withdrawal in order to facilitate identification of eligible patients and to further improve the success of withdrawal attempts.

Age Factors↗

PubMed1999

Atrial natriuretic peptide levels in geriatric patients with nocturia and nursing home residents with nighttime incontinence.

OBJECTIVES: To determine if nocturnal polyuria in geriatric patients with nocturia and nocturnal incontinence is associated with elevated plasma atrial natriuretic peptide (ANP) levels. DESIGN: Case series. SETTING: Four nursing homes and two board and care facilities. PARTICIPANTS: Fifty-four nursing home residents and 26 board and care residents with a mean age of 86. MEASUREMENTS: Daytime (7:00 a.m. to 7:00 p.m.) and nighttime (7:00 p.m. to 7:00 a.m.) urine volumes of incontinent nursing home residents were measured over 3 days and 3 nights by reweighing preweighed adults diapers and toileting inserts emptied by research staff for the board and care group. Blood was drawn in the early morning (5:00 a.m. to 7:00 a.m.) before subjects arose and in the evening after an hour of lying in bed (8:00 p.m. to 11:00 p.m.), and plasma ANP levels were determined by radioimmunoassay. RESULTS: Forty-nine (61%) of the subjects had nocturnal polyuria as defined by night/total urine volume ratios > or = 50%. There was no significant difference between those with night/total ratios > or = 50% versus < 50% in plasma levels of ANP in the early morning (44.2+/-33.3, median 35.7 pg/mL vs 40.9+/-39.2, median 28.5; P = .36 by Mann Whitney U) or in the evening (43.4+/-28.8, median 36.4 pg/mL vs 49.6+/-53.1, median 34.4; P = .58). Nor was there any significant correlation between night/total urine volume ratio and morning or evening ANP levels (r = .01, P = .96 and r = .23, P = .31, respectively). CONCLUSIONS: In this sample of geriatric patients with nocturia and nursing home residents with nighttime urinary incontinence, ANP levels were elevated, but increased nighttime urine production was not associated with higher levels. Because of the variability in ANP levels, our power to detect such an association was low, and we cannot draw any definitive conclusions. Although high plasma ANP levels are unlikely to be a primary cause of nocturia and nighttime incontinence, they may, when combined with other factors such as low antidiuretic hormone levels, sleep disorders, and low functional bladder capacity, contribute to these symptoms in some geriatric patients.

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PubMed2000

Risk factors for symptomatic peripheral arterial disease in older persons in an academic hospital-based geriatrics practice.

OBJECTIVE: To investigate risk factors for symptomatic peripheral arterial disease (PAD) in older persons. DESIGN: A retrospective analysis of charts from all older persons seen from January 1, 1998, through June 15, 1999, 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 467 men, mean age 80 +/- 8 years, and 1444 women, mean age 81 +/- 8 years, were included in the study. MEASUREMENTS AND MAIN RESULTS: Symptomatic PAD was present in 93 of 467 men (20%) and in 191 of 1444 women (13%) (P = .001). Significant risk factors for symptomatic PAD by univariate analysis were: age (P = .021 in women); cigarette smoking, hypertension, diabetes mellitus, serum total cholesterol, serum high-density lipoprotein (HDL) cholesterol (inverse association), and serum low-density lipoprotein (LDL) cholesterol (P < .001 in men and women); obesity (P = .013 in men and .002 in women); and serum triglycerides (P = .027 in women). Significant independent risk factors for symptomatic PAD by stepwise logistic regression analysis were: age (odds ratio = 1.052 in men and 1.025 in women); cigarette smoking (odds ratio = 2.552 in men and 4.634 in women); hypertension (odds ratio = 2.196 in men and 2.777 in women); diabetes mellitus (odds ratio = 6.054 in men and 3.594 in women); serum HDL cholesterol (odds ratio = .948 in men and .965 in women); and serum LDL cholesterol (odds ratio = 1.019 in men and women). CONCLUSIONS: Significant independent risk factors for symptomatic PAD in older men and women were age, cigarette smoking, hypertension, diabetes mellitus, serum HDL cholesterol (inverse association), and serum LDL cholesterol.

Academic Medical Centers↗

PubMed2004

Effect of a comprehensive, multidisciplinary, educational program on the use of antibiotics in a geriatric university hospital.

OBJECTIVES: To assess the effect of a comprehensive, educational antibiotic management program designed to improve antibiotic use and reduce treatment costs in elderly patients with suspected urinary or respiratory tract infection. DESIGN: Interventional cohort study with 12 cross-sectional drug utilization reviews of antibiotic use before, during, and after the multifaceted intervention. SETTING: A 304-bed university hospital for geriatric patients. PARTICIPANTS: A total of 3,383 elderly patients. INTERVENTIONS: An educational program including distribution of guidelines on the diagnosis and treatment of urinary and respiratory tract infections; lectures on geriatric infectious diseases; weekly ward rounds for patients with suspected infection; and targeted, individual counseling on diagnosis and antibiotic treatment of infections. MEASUREMENTS: Antibiotic utilization data were collected from the patients' records. Antimicrobial costs were calculated using 1998 hospital wholesale prices. RESULTS: Of 3,383 screened patients, 680 (20%) received at least one antibiotic. During the study period, the mean number of prescribed drugs per patient increased from 5.9 to 7.6 (29%; P<.001). In contrast, a reduction of 15% was observed in the proportion of patients exposed to antibiotic agents (P=.08) and a drop of 26% in the number of antibiotics administered (P<.001). This resulted in a 54% decrease in cumulative daily antibiotic costs. In 83 (75%) of 110 surveyed patients, the guidelines were correctly implemented. The intervention had no measurable negative clinical effect. CONCLUSION: A comprehensive, multifaceted educational program for treating urinary and respiratory tract infections in the elderly was a safe and practical method to change physicians' antibiotic prescribing practice and significantly reduce the consumption and costs of antibiotics in a geriatric hospital.

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PubMed2004

Low testosterone is associated with decreased function and increased mortality risk: a preliminary study of men in a geriatric rehabilitation unit.

OBJECTIVES: To evaluate whether low testosterone levels are associated with greater depression or poorer function in a geriatric rehabilitation unit. DESIGN: Retrospective review. SETTING: Geriatric rehabilitation unit. MEASUREMENTS: Low testosterone levels were defined as total testosterone of 3.0 ng/mL or less or free testosterone of 9.0 pg/mL or less. Age, ethnicity, weight, depression, ambulation, length of rehabilitation, and 6-month rehospitalization and mortality rates were obtained. Overall illness severity was determined using the Cumulative Illness Rating Scale for Geriatrics. RESULTS: Low testosterone levels were present in 29 of 44 (65.9%) men. There were no significant differences between men with low and normal testosterone levels in ethnicity, age, weight, depression, and overall illness severity. Lower testosterone levels were correlated with decreased ability to ambulate and transfer (Spearman P>.34; P<.05). There were no significant differences between men with low and normal testosterone in length of stay on the rehabilitation unit (mean+/-standard deviation= 19.6+/-11.6 vs 17.7+/-17.5 days, P=.68) or rehospitalization rates (41.4% vs 26.7%; P=.34). Men with low testosterone had a trend toward increased 6-month mortality (31.0% vs 6.7%; chi(2)=3.3, P=.07) and shorter survival time (log rank=3.2; df 1, P=.07). After entering testosterone and variables with potential prognostic significance for mortality in a stepwise manner in a Cox regression analysis, there was a significant mortality risk associated with low testosterone (hazard ratio=27.9, 95% confidence interval=2.0-384.0; P=.01). CONCLUSION: Low testosterone levels were correlated with decreased physical function and increased risk for 6-month mortality. Prospective studies with larger sample sizes and better standardized testosterone measures are needed to confirm these findings.

Activities of Daily Living↗