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PubMed2005

The prevalence of undiagnosed geriatric health conditions among adult protective service clients.

PURPOSE: We sought to determine the prevalence of remediable health conditions from in-home geriatric assessments of referred adult protective service (APS) clients suffering elder mistreatment. DESIGN AND METHODS: We used a retrospective cohort study of 211 APS clients (74% female; age, M = 77 years) in two central New Jersey counties. RESULTS: Dementia was the most frequent diagnosis (62% prevalence) and was positively correlated with occurrences of financial exploitation (R =.199; p =.01) and caregiver neglect (R =.174; p =.03) among female APS clients. Depression (37% prevalence), hypertension (36%), involuntary weight loss (34%), pain (32%), and falling (26%) all appeared equally distributed, though urinary incontinence (23% prevalence) was strongly correlated with circumstances of caregiver neglect (R =.31; p =.003). IMPLICATIONS: This new effort to link APS workers with geriatric clinicians conducting in-home health assessments proved effective for identifying a high prevalence of remediable health conditions among APS clients suffering various manifestations of elder mistreatment.

Aged↗
PubMed1990

The importance of diagnostic procedures to ensure quality of health care in geriatric medicine. Examples from recent studies.

Within the health care of the elderly with prevention, diagnosis, therapy, rehabilitation, nursing care and social service, diagnostic procedures are of great importance to avoid under- and over-diagnosis. Many diagnostic difficulties exist in elderly patients such as changed reference values, changed normal values and changed signs and symptoms. Well-known examples of conditions which are likely to be under-diagnosed include depression and urinary incontinence. Examples are given from the cardiopulmonary field where e.g. dyspnoea showed to be very common, but in only 36% of males and 52% in females related to cardiac failure or pulmonary disease. The most common symptom of acute myocardial infarction in elderly patients was shown to be dyspnoea, whereas chest pain occurred in only one fifth of the cases. In another study of patients with ulcer disease loss of appetite and weight, nausea and anemia were more common than abdominal pain and heartburn. In peritonitis patients, abdominal pain was observed in only just more than half of the cases and guarding and/or abdominal rigidity in about one third. In patients with suspect age dementia a detailed investigation showed the prevalence of organic dementia to be 89% whereas 3% had treatable dementia and 8% non-dementia conditions. In geriatric long-term patients the mean hearing loss in the speech area was about 50 dB, in spite of the fact that only about 10% of the patients had hearing aids. The need for nursing diagnosis is also obvious. It is concluded that a detailed multidisciplinary diagnostic investigation procedure is very important in geriatric medicine.

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PubMed2006

Implementation of discharge management for geriatric patients at risk of readmission or institutionalization.

OBJECTIVE: To evaluate whether implementation of discharge management by trained social workers or nurses reduces hospital readmissions and institutionalizations of geriatric patients in a real-world setting. DESIGN: Quasi-experimental design. SETTING: Six general hospitals in Belgium. PARTICIPANTS: A representative sample of 824 patients, 355 of whom were assigned to the experimental group receiving comprehensive discharge management and 469 to the control group receiving usual care. Inclusion criteria were patients admitted to a geriatric, rehabilitation, or internal medicine ward, not residing in a nursing home, and showing risk of readmission or institutionalization on admission in the hospital. INTERVENTION: In-hospital discharge planning according to a case management protocol allowing for adjustment to participating hospitals' case mix and patients' and families' specific needs. MAIN OUTCOME MEASURES: Hospital readmission within 15 and 90 days post discharge; institutionalization at discharge and within 15 and 90 days post discharge. RESULTS: Discharge management resulted in fewer institutionalizations (n = 53; 14.9%) compared with usual care (n = 130; 23.7%) (adjusted odds ratio = 0.47; CI 95% = 0.31-0.70). Readmission rates between the intervention and usual care group were not significantly different. CONCLUSIONS: This implementation project showed that a discharge planning intervention can reduce institutionalization rates of elderly patients in real-life settings.

Aged↗
PubMed2000

Molecular epidemiology of an outbreak due to IRT-2 beta-lactamase-producing strains of Klebsiella pneumoniae in a geriatric department.

In February 1998, 195 patients in the geriatric department of a French hospital were screened for the presence of co-amoxiclav-resistant Klebsiella pneumoniae. Eleven co-amoxiclav-resistant isolates obtained all produced an identical IRT-2 beta-lactamase. These K. pneumoniae isolates were clonally related and harboured a c. 55 kb non-conjugative plasmid encoding a non-class-1 integron-located blaIRT-2 gene. This study underlines that geriatric departments may be a reservoir for antibiotic-resistant strains and that IRT beta-lactamase-producing strains may be nosocomial pathogens.

Amoxicillin-Potassium Clavulanate Combination↗
PubMed1992

Improvement in attitudes toward the elderly following traditional and geriatric mock clinics for physical therapy students.

The purpose of this study was to determine whether the attitudes of students in a physical therapy education program toward the elderly could be influenced positively by (1) having classroom discussion led by an individual with expertise in geriatrics and (2) having only individuals aged 65 years or older participate in a specially designed geriatric mock clinic (GMC). Subjects were 47 first-year students divided into a control group (n = 24) and an experimental group (n = 23). Students in the control group participated in two 4-week clinical rotations. Students in the experimental group participated in one 5-week clinical rotation and in one 3-week GMC. Students in both groups were given a pretest and a posttest administration of the Kogan Old People Scale to assess their attitudes toward the elderly. No significant difference was found between the two groups' overall attitude scores on the pretest or the posttest results. Overall, positive attitude scores increased significantly for both groups, although the increase was greater for the experimental group than for the control group. Negative attitude scores decreased significantly for the experimental group, but did not change for the control group. We concluded that both traditional clinical rotations and a specially designed GMC influenced the students positively. Suggestions have been made for the Clinical Instructor who wishes to influence physical therapy students' attitudes to meet the increasing needs of the elderly patient population.

Adult↗
PubMed2006

Experiences and views of specialist registrars in geriatric medicine on 'do not attempt resuscitation' decisions: a sea of uncertainty?

BACKGROUND: Recent cultural changes place doctors under increasing pressure to work with their patients to reach decisions about end-of-life care. AIM: To survey the experience, practice and opinions of specialist registrars (SPRs) in geriatric medicine regarding 'do not attempt resuscitation' (DNAR) decisions. DESIGN: Postal questionnaire survey. METHODS: A questionnaire was mailed to all members registered as trainees (n = 408) with the British Geriatrics Society in November 2003; a reminder was sent nine weeks later. Responses were analysed using both quantitative and qualitative (thematic) approaches. RESULTS: Response rate was 62% (251/408), of whom 235 were still SpRs. Respondents played a major role in DNAR decision-making in their day-to-day clinical practice. Over a third of respondents did not feel that locally available guidelines were helpful. More than half sometimes disagreed with their consultants' decision, and a fifth were concerned about the possibility of complaints regarding the decisions they made. The majority felt uncomfortable discussing the issue with the patient, and were more likely to discuss the issue with relatives than with patients. DISCUSSION: Further support and training may improve confidence and positive experiences in relation to DNAR decision-making among training-grade doctors in the UK.

Adolescent↗
PubMed2001

Hospitals, geriatric medicine, and the long-term care of elderly people 1946-1976.

This article investigates the development and interaction of the views of medical professionals and health officials on elderly care between 1946 and the early 1970s. It examines how the cultural and political context in which new ideas on the treatment of elderly people emerged in the early post-war period affected policy development in this area. The article argues that, in combination, the political and financial imperatives of health officials and the cultural prejudices of many in the medical profession created a situation in which progressive ideas about geriatric medicine and home care were used, not to improve the overall standard of care for elderly people, but to restrict their access to long-term medical and nursing care. The most important development in this respect, it will be argued, were efforts made by government from the mid-1950s to restrict the amount of provision for older people in hospitals, through the introduction of a geriatric bed norm. What lay at the heart of this question, the article concludes, was the reluctance of policy-makers to confront directly issues relating to the continuing care of old people with complex health problems. The reasons for this reluctance will be examined.

Aged↗
PubMed1995

Medical knowledge and medical practice: geriatric medicine in the 1950s.

This article examines the development of medical knowledge and practice with regard to sickness in old age in the early years of the National Health Service. It suggests that the creation of a speciality of geriatrics was inspired by the need to prevent hospital beds being blocked by long-stay patients. Thus, the efficient use of hospital provision required the diagnosis, treatment, and rehabilitation of elderly patients. The publication of medical texts on sickness in old age, provided the basis for a more interventionist approach to the care of sick, elderly people, but the development of geriatrics as a separate speciality was hindered by professional disputes over administrative responsibility, funding, private practice, and medical training. One key area of debate was whether sickness in old age was primarily a social rather than a medical problem. This needs to be considered with regard to the relationship between the hospital and the local community and the article examines the contribution of social and medical surveys of elderly people at home to the discourse on sickness and old age.

Geriatrics↗
PubMed1990

Teaching the multidisciplinary team approach in a geriatrics miniresidency.

The miniresidency program in geriatrics begun in 1985 at the University of California, San Diego, School of Medicine acquaints practicing health professionals with a multidisciplinary team approach to the care of geriatric patients. The two-week program features participation in a multidisciplinary outpatient clinic, home visits, social work and nutrition consultations, and conferences with patients and families. Miniresidency members also participate in neurologic and neuropsychological evaluations and attend day care for demented adults. The 71 health professionals who completed the program during its first 20 months showed significant improvement on their scores between the pre- and posttests: the mean of all scores in the pretest was 51 out of a possible 80 (SD 15); the mean of all scores in the posttest was 75 out of a possible 80 (SD 4); p less than .001. The 77% who returned post-program evaluation questionnaires found the program "useful" or "very useful."

Geriatrics↗
PubMed2002

Implementation of geriatric education into the first and second years of a baccalaureate-MD degree program.

OBJECTIVE: As the population ages with an increasing standard of good health, medical students must redefine their views on aging and their approaches to aging and medicine. Consequently, the UM-KC School of Medicine has introduced an innovative approach to geriatric education. The approach seeks to help students view aging as a multidimensional process, challenge stereotypes about aging, learn about factors in healthy aging, and explore medical conditions of older patients. DESCRIPTION: To fulfill these objectives, each first- and second-year medical student (n = 200) in a six-year BA-MD degree program is paired with a mentor on aging. The mentor is an older adult living independently and experiencing normal psychosocial issues of aging without major medical problems. Over two years, students converse with their mentors about aging, keep journals reflecting on their conversations, complete projects with their mentors, and write scholarly papers. Thus, students can experience aging through their mentor relationships, gain an appreciation of their mentors' lives, and sharpen communication skills. In small groups, students and a physician-facilitator discuss problem-solving exercises keyed to American Geriatrics Society competencies and participate in an empathic aging exercise. Students also attend lectures on the care of older women and primary prevention. DISCUSSION: Assessment of students' performances is ongoing. Mentors have rated their students positively for being interested in them, being good listeners, and being eager to learn. Facilitators have rated most students highly for small-group participation. Instructors have reviewed and commented on student journals that suggest students have changed their stereotypes about older adults and appreciated the uniqueness of their mentors' lives. A performance-based assessment of the students' abilities to elicit life histories from senior volunteers will be administered halfway into the second year, and the scholarly papers will be critiqued at the end of the second year. Program evaluation is also under way. A pre-test of knowledge and attitudes showed students had little knowledge of the aging process, held negative stereotypes of older people, and preferred to care for younger patients. After-measures will be administered at the close of the second year. Evaluating their experience, mentors have said their interactions with students were enjoyable and beneficial to both parties. Students, while initially hostile because the program shifted their focus from sickly to healthy older adults, have found the evolving bonds between them and their mentors to be a benefit of the program. They believe that the most important lessons learned involved seeing the vitality and courage of older adults and improving their communication skills. Nevertheless, students feel they need more training in leading conversations and conducting interviews. Structured communication training will be added as the program continues to be a required part of the curriculum. Students have also thought the problem-solving cases should be more medically focused. While cases in the second year will emphasize medical aspects of aging, the cases in the first year will continue to explore psychosocial issues. Finally, to highlight psychosocial issues of aging, a session will be added utilizing a panel of older adults to provide examples and insights and to answer questions.

Age Factors↗
PubMed2002

Senior mentor program: a geriatrics focused curriculum.

OBJECTIVE: To introduce medical students to a healthy elderly population and present the health care challenges in this population. DESCRIPTION: As medical education has begun to focus more on our aging population and their future health needs, the University of South Carolina School of Medicine has developed a senior mentor program. This program provides a longitudinal experience for undergraduate students with local elders. The program, currently in its second year, will provide multiple opportunities for students to follow their same senior mentors over a four-year period both in the home and in the clinical setting. In partnership with the division of geriatrics, healthy patients over 65 were recruited to serve as senior mentors. Students, mostly in pairs, were assigned either one senior mentor or a couple, whom they met for the first time at the beginning of the second semester of their first year. Using a multidisciplinary approach, modules have been developed so students can learn how their senior mentors function on a daily basis, thus assessing the whole person, their health, their medical needs, their life-styles, and their social and physical environments. During the first year, students meet with their senior mentors four times and complete modules that address the physiology of aging, medical history taking, mental status examination, and psychological issues involving growing old. The modules were designed to coordinate with other areas of the curriculum where these concepts are being taught so that the students have an opportunity to put them into practice. Students check their senior mentors' blood pressures and write up their findings and thoughts about aging during each visit. In the second year the students meet with their senior mentors six times. Modules include assessing the senior mentors' diets; developing a behavioral modification plan in the first semester; and performing an environmental safety check, physical examination, and medication evaluation. The modules are coordinated with the curriculum and involve student consultation with our nutritionist and pharmacists. As the students enter their third and fourth years they will be expected to continue to meet with their senior mentors, to discuss issues concerning death and dying and advance directives, and to accompany their mentors to a physician visit. DISCUSSION: The responses from students, senior mentors, and faculty have been overwhelmingly positive. Students have enjoyed the early clinical experience, senior mentors have enjoyed meeting and talking to the students, and the faculty are pleased with the ability to integrate classroom material into a clinical setting early in the curriculum. Difficulties have arisen as some of our senior mentors have become ill and in the coordination of schedules between senior mentors and students. The plan is to continue the program as a permanent part of the curriculum. The hope is that it will be seen as a model for increasing the focus on geriatrics and early clinical experiences in the curriculum.

Age Factors↗
PubMed1988

Perioperative care of the hemodynamically unstable geriatric patient.

The perioperative management of the geriatric patient with critical illness is a challenge for even the most skilled anesthesiologist. Careful preoperative assessment and preparation are essential. Optimal therapy requires application of appropriate monitoring, accurate interpretation of hemodynamic data, and appropriate selection and administration of anesthetics and therapeutic interventions. The hemodynamic compromise of critical illness is compounded by underlying pathophysiology in the aged. These factors lend a complexity to the treatment of the geriatric patient with hemodynamic instability that necessitates the anesthesiologist's implementation of the most current technological and pharmacological modalities in the operating room and intensive care unit.

Aged↗
PubMed1993

A double-blind study of paroxetine compared with fluoxetine in geriatric patients with major depression.

A 6-week, double-blind, parallel group study compared the efficacy and tolerability of paroxetine and fluoxetine in 106 depressed geriatric outpatients (age, > or = 65 years). Patients with an acute major depressive episode were randomized to receive either paroxetine (20 to 40 mg; N = 54) or fluoxetine (20 to 60 mg; N = 52) after a 3- to 7-day washout. Efficacy evaluations at weeks 1, 3, and 6 used the 21-item Hamilton Rating Scale for Depression (HAM-D). Cognitive function was assessed by use of the Mini-Mental State Examination (MMSE) and the Sandoz Clinical Assessment Geriatric Scale (SCAG). Tolerability was assessed by response to a nonleading question concerning adverse events. There were no significant differences between treatments at week 6 on the HAM-D total, change from baseline. However, there was a statistically significant difference (p < 0.05) at week 3 in favor of paroxetine. Results from the MMSE and SCAG showed that, during treatment, patients in the paroxetine group were characterized by greater improvement in cognitive function than were those in the fluoxetine group. This result was statistically significant at week 3 for both scales (p < 0.05). Adverse events occurred most frequently within the gastrointestinal and nervous systems for both drugs, with no significant differences between treatments.

Aged↗
PubMed1997

Substance use disorders in a geriatric psychiatry outpatient clinic: prevalence and epidemiologic characteristics.

This study was conducted to determine the prevalence of substance use disorders in a geriatric psychiatry outpatient clinic. The overall prevalence for any substance use disorder was 20% (N = 28). The prevalence of benzodiazepine dependence was 11.4% (N = 16); the prevalence of alcohol dependence was 8.6% (N = 12); and the prevalence of prescription narcotic dependence was 1.4% (N = 2). These findings suggest that substance use disorders in the geriatric psychiatry outpatient population exist to a significantly greater extent than previously reported. Descriptive statistics were used to characterize patients with benzodiazepine dependence, alcohol dependence, and no substance use disorder. These groups were compared on demographic and clinical variables using one-way analysis of variance (ANOVA) and chi-squared statistical techniques. Clinicians working in comparable outpatient settings may be in a better position to prevent, detect, and treat substance use disorders in their patients as a result of increased awareness of its epidemiologic characteristics in this population.

Aged↗
PubMed1997

Physician resource utilization after geriatric trauma.

OBJECTIVE: As health care resources become increasingly strained, the value of physician consultation has come under heightened scrutiny. This report reviews the value of early consultation by the physical medicine and rehabilitation (PMR) service to an integrated trauma service for geriatric patients with multiple trauma. METHODS: We retrospectively reviewed the records of 110 geriatric trauma patients (age > 60 years) with an Injury Severity Score > or = 15 to evaluate the effects of PMR consultation. Patients in group 1 were admitted to a general surgical service, and those in group 2 were admitted to a multidisciplinary trauma service. Demographic and physiologic factors, as well as short-term and long-term outcomes, were evaluated, and a subgroup analysis was performed to compare early (< or =3 days) versus late (>3 days) consultation by PMR. RESULTS: Although there were significant differences in Glasgow Coma Scale score and length of stay, no differences were found within groups in other demographic, physiologic, or outcome data. Focused review of PMR intervention based on early versus late consultation revealed no significant difference between the two groups. Furthermore, an after-discharge phone survey revealed no significant group differences in dependence on a care provider or nursing home placement, readmission to hospital, employment status, or current functional activity status. CONCLUSIONS: Long-term patient functional outcome and the in-house rehabilitation process are not affected by integration of PMR into a multidisciplinary trauma team or early PMR consultation.

Aged↗
PubMed1991

Characterization of geriatric drug-related hospital readmissions.

Although some factors placing geriatric patients at risk for hospitalization have been identified, little is known about drug-related problems that contribute to admissions. This study describes a protocol for characterizing drug-related problems that are associated with hospital readmissions. The protocol achieves significant improvements over other studies because geriatric readmissions to a community hospital are classified and the type of drug-related problem and relative contribution of the problem to the readmission are assessed. Thirty-five percent of study patients (n = 706) were readmitted within 6 months of their former discharge and 45 of the readmissions were drug-related. The assessments of three reviewers working independently agreed for 82% of the readmissions (kappa = 0.64). Eighteen percent of the cases identified as drug-related using the protocol were also classified as drug-related according to the hospital ICD-9 coding procedure. One percent of the readmissions classified according to the protocol as not drug-related received ICD-9 codes indicating drug-related problems. These findings suggest that the protocol identified drug-related hospital readmissions with good reliability and sensitivity. The most frequently identified drug-related problems were unexpected adverse drug reactions (n = 10), patient noncompliance (10), overdose (8), lack of a necessary drug therapy (6) and underdose (5). Drug-related factors were a major reason, rather than a contributory reason, for readmission in half of the cases. The study identifies specific drug-related problems that could become targets for preventive interventions. The majority (76%) of the problems identified were potentially preventable and the types of problems found indicate that interventions should be focused on both physicians and patients.

Adverse Drug Reaction Reporting Systems↗
PubMed1997

Disablement outcomes in geriatric rehabilitation.

Until recently, knowledge in the field of geriatric rehabilitation has been based largely on empirical findings. There is a need for greater conceptual clarity about major disablement outcomes to provide a foundation for future theoretical research. Disablement terms promulgated by the World Health Organization's (WHO) International Classification of Impairments Disabilities and Handicaps (ICIDH) are reviewed and compared with those of an alternative model proposed by Saad Nagi in 1965. Distinctions are drawn between the disablement concepts each system includes to refer to (1) inherent attributes of patients and (2) the interaction of the patient with the social and physical environment. The importance of a disablement model reflecting this distinction between inherent and relational concepts is emphasized. Areas for fertile research opportunities in which the disablement concepts could be used are discussed. It is suggested that improved understanding of disablement outcomes could be most readily achieved by application of an epidemiologic model separating the factors affecting outcomes into three sets of variables: the host factors representing intra-individual attributes; the agent factors, which are the external event or events causing the disability; and the environmental factors, which relate to the physical or social surroundings in which the disability occurs. In future research efforts, a more theoretical approach to studying disablement outcomes is advocated as a basis for improvements in geriatric rehabilitation.

Aged↗
PubMedDate not supplied

Geriatric clinical placements.

Recognizing that the profession must prepare individuals able and willing to work with the elderly, educators must consider the long-term care facility and geriatric clinical placement as part of the basic nursing curriculum. Data presented indicate that the geriatric clinical placement offers students opportunities to learn and practice a wide range of nursing skills and suggest that the long-term care facility is a valuable, underused clinical resource for intermediate and advanced students.

Clinical Competence↗