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PubMed1993

Causes of death in a hospitalized geriatric population: an autopsy study of 3000 patients.

Macroscopic and histological studies of 3000 consecutive autopsies (43.9% of the registered deaths) were performed by the same pathologist in a geriatric institution over a period of 20 years. Bronchopneumonia (42.9%), malignant neoplasms--mainly of the gastrointestinal tract and its annexae and the lungs (28.1%)-pulmonary thrombo-embolism (21.2%) and acute myocardial infarction (19.6%), were the most prevalent fatal conditions observed. Next, in decreasing order were: urinary tract infection (12.3%), acute cerebrovascular disease (6.5%), internal haemorrhage (5.5%), and congestive cardiac failure (3.3%). Some "rare" causes of death noted included trauma, metabolic disease, acute asphyxia from foreign body obstruction of the upper respiratory tract and degenerative neurological diseases. Some potentially treatable disorders which led to death were unsuspected clinically: for example, acute pyelonephritis (87%), pulmonary thrombo-embolism (74%), acute myocardial infarction (74%) and active pulmonary tuberculosis (61%). With advancing age there is an increased frequency of multiple pathological processes in a given subject and interactions play an important role in morbidity and mortality. We observed that two or more co-existing conditions often determine the fatal event. We also emphasize the relevance of post-mortem examination to prevention of disease and to therapeutic medicine in a hospitalized geriatric setting.

Aged↗
PubMed1995

A simple geriatric assessment measure to assist a consultative team decision for nursing home placement.

In this study, Barthel and Mini-mental State Examination scores were combined and examined for their ability to predict a geriatric assessment team's decisions for nursing home care. We examined cross-sectional data from a project of consultative geriatric assessment for nursing home applicants in a high socioeconomic status area of Sydney, Australia. The maximum combined score was 160, and a "grey zone" between 100 and 140 was identified where classification errors were greater than 30%. Above 140, most patients were assigned by the team to other care, and below 100, nursing home care was recommended for most. The effectiveness of a classification test will be increased by identification of a grey zone so that if patients fall within this zone, greater care can be taken in the decision-making process. Given the select nature of subjects in this analysis, the generalizability of the derived combined score will be limited. However, the study illustrates one approach that may be taken in the development of classification methods to aid decision-making in the clinical or screening settings.

Geriatric Assessment↗
PubMed2003

Adverse outcomes in older hospitalized patients: the role of multidimensional geriatric assessment.

BACKGROUND AND AIMS: This study was carried out to detect the incidence of adverse outcomes in hospitalized older patients and the role of multidimensional assessment in identifying predictors of adverse outcomes, which include in-hospital mortality and the need for admission to rehabilitation units or nursing homes after hospital discharge. METHODS: 923 patients at least 65 years old (mean age 78.7 +/- 7.2, 49% women) admitted to the acute care geriatric ward of an internal medicine department were included in the study. On admission, each patient underwent a comprehensive medical, functional, neuropsychological, sociodemographic and nutritional assessment. RESULTS: Incidence of mortality and other adverse outcomes was 6 and 16%, respectively. In-hospital mortality was independently predicted by older age (OR per year: 1.07, 95% CI: 1.02-1.12), male gender (OR: 3.97, 1.99-7.95), higher comorbidity (OR: 2.09, 1.01-4.33), higher heart rate (OR: 2.87, 1.30-6.35), lower systolic blood pressure (OR: 2.22, 1.03-4.81), lower serum albumin values (OR: 3.20, 1.63-6.29) and a lower MMSE score at hospital admission (OR: 5.51, 2.34-12.9). Adverse outcomes were independently predicted by older age (OR per year: 1.03, 1.01-1.06), higher comorbidity (OR: 2.00, 1.35-2.94), lower serum albumin values (OR: 2.57, 1.69-3.90) and a lower admission MMSE score (OR: 2.49, 1.68-3.71). CONCLUSIONS: A multidimensional geriatric assessment should be comprised of simple parameters available early, like serum albumin and MMSE score, that are predictive of adverse outcomes in older hospitalized patients, along with other health Indicators (comorbidity, heart rate and blood pressure).

Acute Disease↗
PubMed2004

Strength, mobility and falling in women referred to a geriatric outpatient clinic.

BACKGROUND AND AIMS: Mobility impairment and falling have a multifactorial etiology in frail older people. Muscle weakness is one of the risk factors and is accessible to intervention. The aim of this study was to determine the most important contributors of mobility and indicators of fall occurrence in women referred to a geriatric outpatient clinic. METHODS: Mobility was assessed using the Timed 'Get-Up-and-Go' test (TGUG) and the modified Coopertest (COOP). Falling was assessed retrospectively and isometric knee extension force was measured using fixed dynamometry. Habitual physical activity was quantified using a questionnaire for the elderly. Height, weight, medical conditions and current medication were recorded. RESULTS: Isometric knee extension strength and habitual physical activity, which consisted predominantly of household work, were independent variables of performance on TGUG and COOP and together explained 57% of the variance in TGUG (r=0.75, p<0.001), and 64% of that in COOP, (r=0.80, p<0.001). Age, total number of medical conditions, and presence of cardiovascular disease were not significant in the model. Women in the lowest tertile of knee extension strength had a significantly higher probability of falling (0.75, 95% CI 0.56-0.91) compared with women in the highest tertile (0.27, 95% CI 0.14-0.50). CONCLUSIONS: Knee extension strength remains a strong determinant of mobility and fall occurrence in women referred to a geriatric outpatient clinic. Performing light to moderate household work remains independently associated with functional mobility.

Accidental Falls↗
PubMed2006

Extradural motor cortex stimulation as a method to treat advanced Parkinson's disease: new perspectives in geriatric medicine.

Motor fluctuations not controlled by pharmacological therapy are often encountered in long-term Parkinson's disease (PD). Neurosurgery treatment represented by deep brain stimulation (DBS) was considered a valid alternative to pharmacological treatment. Unfortunately this method is most effective in patients under age of 70. Recently it has been suggested that extradural motor cortex stimulation (EMCS) could be a valid cost-effective alternative to DBS to control motor symptoms in patients affected by Parkinson's disease. The relevant non-invasive surgical technique makes this treatment particularly indicated in geriatric patients. Brain atrophy, cognitive impairment, psychiatric symptoms are not an absolute contraindication to the treatment. We submitted to EMCS an outpatient afferent to our geriatric department, a woman 68 yrs old. The patient showed an improvement of 35% as measured by the Unified Parkinson Disease Rating Scale (UPDRS) scale after the surgery. If our findings will be confirmed in larger series, a new dimension will be added to the treatment of PD.

Aged↗
PubMed2003

The significance of social network in a geriatric assessment population.

BACKGROUND AND AIMS: There has long been speculation that socially-involved individuals suffer less illness, overcome sickness more readily, and experience better health outcomes than more socially isolated persons. This study describes social network characteristics, and determines whether social network affects health outcomes in the geriatric population. METHODS: Data from 1270 consecutive patients seen in the outpatient Geriatric Assessment Clinic (GAC) of the University of Nebraska Medical Center between August 1988 and May 1999 were analyzed. Social network was measured by the Social Network Index (SNI). RESULTS: Younger age, higher income and higher education were related to a broader social network. A larger social network was generally associated with lower caregiver burden, higher functional status and better cognition. Men with the smallest social networks were found to be at significantly higher risk of death than women with larger social networks (HR 4). After adjusting for age (HR 1.04, CI 1.03-1.06), income (HR 1.00, CI 1-1), education (HR, NS), IADL (HR 0.97, CI 0.95-0.99), CIRS (HR 1.08, CI 1.05-1.10) and informal service use (HR, NS), the risk of death for subjects based on SNI is only significant in the comparison between SNI III and SNI I (HR 0.67, CI 0.50-0.91). CONCLUSIONS: SNI I males are at significantly increased risk of death compared with all other groups. The average number of years from initial visit to death for SNI I males is only 2.8 years. These results are consistent with the literature, which suggests men are more affected by social isolation and have decreased survival compared with females. The influence of SNI on mortality in this frail, elderly group appears to be diluted by the presence of functional disability and a high degree of comorbid illness.

Activities of Daily Living↗
PubMed2000

Geriatric assessment in the elderly cancer patient.

Lost and remaining functions are of special importance in geriatric medicine. The level of functional deficits ultimately determines the remaining quality of life and the patient's ability to continue independently. In contrast, the actual severity of a disease measured by common standards becomes less important. Geriatric assessment is increasingly used to describe the impact of disease and to focus on the functional losses and problems that are particularly relevant to the individual elderly patient. When developing a treatment plan for older cancer patients, it is essential to consider the functional deficits caused by age-related changes or comorbidity, the remaining compensation mechanisms and the patient's expectations. Cancer treatment has to be adapted to the individual needs of elderly patients. As the number of cancer patients is rising in all areas of medical practice, a close collaboration between oncologists and geriatricians will become increasingly important.

Affect↗
PubMed2007

[Relation between certain diseases and frequency of depression in geriatric patients].

The higher prevalence of depression in specific diseases and older persons is discussed. This prevalence varies greatly according to the method used to collect data. A risk group can only be defined if information on diseases and other influencing factors are collected uniformly. The target diagnoses Parkinson's disease, stroke, myocardial infarction, cancer, diabetes mellitus, chronic pain, multiple infarct syndrome, Alzheimer's and other dementia were recorded from 1208 geriatric patients of the ZAGF municipal hospital in Munich, Germany. Logistic regression was used to identify chronic pain as the main cofactor for an association with depression (clinical diagnoses by ICD-10) and depressive symptoms (via GDS [Geriatric Depression Scale]). This association was also found for multimorbid patients with chronic pain. Impairment of the activities of daily living and the clinical setting were important additional cofactors. Pain patients are therefore at higher risk for depression.

Activities of Daily Living↗
PubMed2004

[Effectiveness and efficiency of stationary geriatric treatment of old and very old patients].

In this study we compared characteristics and treatment results in patients of 60 to 79 (group I, n = 682) and of 80 to 100 years of age (group II, n = 593) treated in a geriatric hospital. Neurologic diseases (mainly stroke) predominated in group I (38%), and patients with fractures in group II (53%). Diabetes mellitus and hyperlipidemia were less frequent in patients of group II, but overt cardial insufficiency was more frequent than in group I. While the effectiveness of geriatric treatment was identical in both groups, the efficiency-defined as progress per day-was in some parts slightly higher in group II. There are three independent variables strongly related to the decision of transfer into a nursing home: 1) Barthel Index on discharge; 2) Household-Size (living alone/living not allone); 3) Age.

Accidental Falls↗
PubMed2000

[Evidence-based medicine--problems and application to geriatrics].

The use of evidence-based medicine (EBM) in the field of geriatrics faces some specific problems. Deficits in representation of older people in medical trials and the attitude of the majority of patients and their physicians considering disease as normal aging counteract successful implementation. EBM is also feasible in older patients after some adjustments without dropping the principles of the method or the preferences of patients, thus, resulting in improvement in diagnostic and therapeutic decisions. The methods are exemplified in the use of prophylactic antibiotics in endoscopic gastrostomy, a relevant geriatric problem with practical consequences.

Aged↗
PubMed2000

[Basic principles of exercise therapy in geriatric rehabilitation].

Physical therapy can support geriatric rehabilitation in contributing to better health status, mobility, and quality of life. However, the central focus of this contribution is not on illness-specific aspects of physical therapy but on power and stamina training. These two training methods are of special importance for geriatric rehabilitation since most patients are admitted due to related problems and these two methods do imply specific risk factors for the rehabilitation process. The spectrum of physical adaptation processes supported by power and stamina training is described and scientifically evaluated. Even in higher age groups positive training effects are possible. Adequate usage of these training methods contributes to increased competence and a minimization of risks in daily life.

Aged↗
PubMed2001

Predictors of favorable outcome in elderly stroke patients two years after discharge from geriatric rehabilitation.

This study was done to determine the independent predictors of long-term survival and long-term functional outcome in geriatric stroke patients with a high level of co-morbidity. We prospectively recruited 302 consecutive patients transferred from local hospitals of acute care to inpatient geriatric rehabilitation with a median of 23 days after stroke. The cohort with a mean age of 75.1 (range 60-90) years was followed up for 2 years after discharge from rehabilitation. The 24 month survival rate was 71.2%. Urinary continence (p = 0.000), younger age (p = 0.000), and absence of coronary artery disease (CAD) (p = 0.039) were predictors of survival. Independence in activities of daily living (Barthel Index (BI) > or = 85) 24 months after discharge was 43.2% and predicted by an admission BI > or = 50 (p = 0.000), urinary continence (p = 0.007), and absence of CAD (p = 0.018). Good functional outcome by the Modified Rankin Scale (MRS < or = 3) 24 months after discharge was 38.4%. It was predicted by absence of CAD (p = 0.001), first-ever stroke (p = 0.014), admission BI > or = 50 (p = 0.024), urinary continence (p = 0.025), mild motor paresis (p = 0.032), and good sitting balance (p = 0.039). Our study of a relatively aged and co-morbid stroke cohort confirmed most of the well-known predictors of outcome. A new result is that CAD also seems to be an important determinant of long-term outcome.

Aged↗
PubMed2001

[Conceptual and ethical questions in geriatric oncology].

Geriatric oncology concentrates on the field of cancer in the expanding aging population. Therapeutic goals are based on individual risk-assessment, comorbidities, and the specific tumor-biology. Good management of older cancer patients requires a multidimensional risk profile. Shared decision-making in geriatric oncology has to recognize a sometimes impaired autonomy. Possible conflicts between beneficence and autonomy are discussed and specific problems of the elderly patients are given. Informed consent requires competence, which might be lacking to some degree. It is the task of a responsible physician to promote autonomous decision-making as far as possible.

Aged↗
PubMed2003

Care of breast cancer in the elderly woman--what does comprehensive geriatric assessment (CGA) help?

Breast cancer is the most common cancer in women in Europe and Northern America. Its incidence and mortality rates are increasing with advance in age. Only few elderly women with breast cancer are treated in clinical trials. Elderly women with the same numerical age are very heterogeneous considering their biological age. Geriatric medicine has established comprehensive geriatric assessment (CGA) to get important information on elderly patients missed by a routine clinical history and physical examination. The data collected in CGA are of prognostic relevance for mortality, morbidity, maintenance of independence and utilisation of health care resources. Within the last few years, some research groups have demonstrated that the use of CGA in elderly cancer patients collects information missed by the currently established workup of these patients and that this information is of prognostic relevance concerning toxicity of chemotherapy and mortality. The use of CGA in a population of general elderly patients improves functional status and mental health, but so far no effect on mortality could be demonstrated. A subgroup analysis of the elderly cancer patients within this trial additionally demonstrated an improvement in pain control. Special data concerning the use of CGA within the group of elderly breast cancer patients are not published so far. The authors suggest areas of care for elderly women with breast cancer within which the CGA might be able to improve treatment and which should be a field of randomised controlled trials in the future.

Activities of Daily Living↗
PubMed2004

Validation of the 'Vienna List' as a proxy measure of quality of life for geriatric rehabilitation patients.

The reason for the study was to investigate the discriminative, content- and criterion-related validity of the 'Vienna List', a newly developed proxy-rating measurement for quality of life in very old and severely demented persons. The total population of patients of a geriatric rehabilitation clinic of one year (from November 2001 to October 2002; n = 687) was evaluated at admission and discharge by means of this proxy rating method together with the mini mental state examination, the timed up and go test, the Tinetti measure, the Barthel Index, and the Katz activities of daily living list. Differences, mainly on factors communication, mobility, aggression, and negative affect, appeared between seven diagnostic groups as well between several care-related categories and destination after discharge. The five factors of the measurement explained a significant amount of variance with a high specificity and more than 50% of the Barthel Index scores. The 'Vienna List', originally developed for the assessment of quality of life in severely demented patients, proved to be a useful, differentiating, less time-consuming and practical tool for the documentation of the outcome of geriatric inpatient rehabilitation, as well.

Activities of Daily Living↗
PubMed2004

The significance of subsyndromal depression in geriatrics.

Clinically significant non-major depression has been underinvestigated, despite its high prevalence and public health impact. Although there is increasing recognition of the importance of subsyndromal forms of depression, their nosologic boundaries and neurobiologic mechanisms remain largely unknown. This review discusses the literature pertaining to the current concepts, phenomenology, neurobiology, and treatment approaches for geriatric non-major clinically significant depression. The authors examine the similarities and differences between various subtypes of depressive disorders, and compare non-major clinically significant depression in the elderly with non-geriatric adult populations. The authors draw conclusions from the published literature and present clinical criteria for the diagnosis of clinically significant non-major depression in the elderly.

Age Factors↗
PubMed1992

Effect of two French nurses' strikes on mortality in a geriatric hospital.

PURPOSE: To study the influence of the 1988 French nurses' strikes on mortality in a geriatric hospital. MATERIALS AND METHODS: Two nurses' strikes affected the Charles Foix Hospital near Paris from June 29 to July 31 and from September 17 to October 22, 1988. Mortality was studied in nine geriatric wards of this hospital, including two rehabilitation units comprising 187 beds, and seven long-term care units comprising 1,132 beds. Monthly mortality rates were calculated from the hospital's administrative registers and expressed as deaths per 1,000 patient-days. These rates were calculated in each of the aforementioned nine units for the 36 months preceding the first strike (control period) and for the 12 months following it (study period). RESULTS: Over the control period, monthly mortality was significantly higher in rehabilitation units than in long-term care units (2.46 +/- 1.21 versus 0.83 +/- 0.47, p less than 0.001), but mortality rates among rehabilitation units, as well as among long-term care units, were comparable. Also, during the control period, large seasonal fluctuations in monthly mortality rates were observed in both rehabilitation units and long-term care units (peak in winter and nadir in summer). These rates tended to decrease from year to year in rehabilitation units but not in long-term care units. A statistical model based on time-series analysis of the control period data was used to calculate the expected monthly mortality rates for the study period in rehabilitation units and in long-term care units, respectively. Three of the 12 actual monthly mortality rates exceeded the upper limit of the 95% confidence interval of the 12 expected monthly mortality rates, in the units where the more severe care disruption occurred. A detailed analysis of discharge summaries of these units failed to identify a possible link between some of these deaths and a possible absence of care. CONCLUSIONS: The nurses' strikes did not induce a clear-cut increase in mortality in this population of elderly patients. However, we cannot exclude the possibility that these strikes had some negative effects on health. Our results fail to provide answers to the difficult ethical problems created by such stoppages.

Aged↗
PubMed1995

Psychosocial determinants of burnout in geriatric nursing.

The purpose of this study was to identify determinants of burnout using an adapted version of Kobasa's theoretical framework, considering work stressors, work support, coping strategies and hardiness. Data were collected through a questionnaire mailed to 1990 randomly selected geriatric nurses. A participation rate of 77.6% was achieved. T-test, variance analysis and multiple regression analysis were conducted. Hierarchical multiple regression analysis indicated that 49% of the variance was explained by the study variables. Hardiness and work stressors were the most important predictors of burnout. The findings are discussed in relation to Kobasa's framework, focusing on resources that reduce negative effects of geriatric work stressors. Implications for nursing practice, management, education and research are proposed.

Adaptation, Psychological↗