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PubMed1979

An alternative model in geriatric care.

An analysis is presented of one long-term care facility's attempt to develop a comprehensive geriatric program including care of the patient in a hospital, a skilled nursing home, a day hospital, or a clinic for care of the ambulatory aged. The goal was to raise issues for debate and discussion, especially in terms of the evolving role of medical directors in long-term care. The need for group professionalism in cooperation with the Board of citizens in community geriatric practice is emphasized.

Aged↗
PubMed1981

Improved care for patients on a new geriatric evaluation unit.

An analysis is presented of a geriatric evaluation unit (GEU) established at the Sepulveda VA Medical Center in 1979 to provide comprehensive interdisciplinary assessment and treatment of geriatric inpatients. The data on 74 patients admitted during the first year show that major improvements can occur in several outcome areas. Placement location was improved over expectations in 48.4 percent of patients, thus permitting a higher level of independence with a lower level of care requirements. Functional status (Katz ADL scale) improved in two-thirds of the patients who could have shown improvement. An average of almost four new treatable disorders not noted by previous physicians were diagnosed per patient. The mean daily number of prescribed drugs was reduced by 32 percent per patient, and the total number of drug doses by 43 percent. Though limited by the unique aspects of the vA situation and by lack of a control group, the findings lend support to the efficacy and value of the GEU concept. (A randomized controlled study is in progress.)

Activities of Daily Living↗
PubMed1982

Medical care in a geriatric psychiatry unit: impact on psychiatric outcome.

The medical care of 49 randomly selected patients admitted to a geriatric psychiatry evaluation unit was assessed to determine the impact on psychiatric care and outcome. Medical factors were identified as directly causing psychiatric symptoms in 12 of the 49 cases, whereas psychiatric decompensation was precipitated by medical illness in 25. Previously undiagnosed significant medical problems were found in ten patients. In 25 cases concomitant medical illness had a major effect on psychiatric treatment, and in 23 the course of the medical illness affected psychiatric outcome. Seventy-nine per cent of the patients had at least moderately improved at the time of discharge, and most were able to return to their homes. Improvement in medical condition was correlated significantly with psychiatric improvement. Implications for the care of geriatric psychiatry patients are discussed.

Adult↗
PubMed1982

Geriatric medicine: a multidisciplinary training and education model in an acute care medical center.

A description of a comprehensive multidisciplinary education and training program in geriatrics in an acute care hospital is presented. A brief review of the history of medical education in geriatrics is examined, and the need for and potential of a hospital-based training program is discussed. The methods used in implementing an education program that attracts house staff physicians and other health professionals are described. The program incorporates the application of a multidisciplinary team model of patient assessment and treatment, which is augmented by clinical bedside teaching and a broad-based educational program. Using hospital-wide faculty, the program includes a geriatrics/gerontology lecture series incorporating presentations on the biopsychosocial aspects of aging and a diversity of subjects relevant to aging. Other programs such as weekly house staff topic sessions on aging, interdisciplinary research seminars, orientations, and special symposia are all part of the education program.

Acute Disease↗
PubMed1983

A geriatric special-care unit: experience in a university hospital.

Responding to a perceived need for specialized care for the acutely ill elderly, a 14-bed geriatric special-care unit was established in the University of Massachusetts Hospital in January 1980. Patients were selected for admission after assessment of their potential to benefit from restorative care. Most patients were admitted from the emergency room or outpatient clinics or were scheduled admissions; a few were in-hospital transfers. This report deals with a retrospective analysis of the first 514 admissions (431 patients) to the unit. Admissions by major service were: Medicine, 64 per cent; Surgery, 14 per cent; Neurology, 10 per cent; Orthopedics, 7 per cent; and other, 5 per cent. Approximately 64 per cent of patients were between the ages of 70 and 84. The overall average length of stay per admission was 11.5 days. Mortality rate of patients undergoing surgery (n = 125) was 4 per cent. The percentage of admissions that were discharged home was 78.7 per cent. Only 7.3 per cent of admissions were discharged to a nursing home, when those that were admitted to the unit from a nursing home are excluded. The authors conclude that a special nursing unit for acutely ill elderly patients may serve several purposes in a university hospital: overall patient care may be improved; length of hospital stay may be shortened; and medical students, housestaff, and attending physicians may gain an opportunity to learn the fundamentals of geriatric medicine as demonstrated by the staff of the unit.

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PubMed1983

Success with an inpatient geriatric unit: a controlled study of outcome and follow-up.

To assess the worth of a newly established geriatric unit, outcomes for 50 subject patients cared for on this unit were compared with outcomes for 50 control patients. Both groups of patients were hospitalized in Highland View Hospital, the chronic illness and rehabilitation section of a major teaching hospital in Cleveland, Ohio. Analysis of admission data showed the two groups to be closely comparable. All patients were managed by multidisciplinary teams, and the length of stay of both groups was comparable. The discharge data showed that the subject patients were more independent, with significantly greater numbers improving in ambulation and significantly more subject patients being discharged to a home setting. Although the patients in the control group were discharged at lower levels of function, they showed improvement at follow-up. Follow-up data also showed that both groups largely remained in their discharge environments. Explanations for these findings are discussed. The results of this study support the establishment of geriatric inpatient units.

Activities of Daily Living↗
PubMed1984

A randomized trial of intra-hospital relocation of geriatric patients in a tertiary-care teaching hospital.

Growing numbers of aged patients are being cared for in both acute care and chronic care settings. It is often necessary to relocate elderly patients within the institution. Relocations are generally considered to increase mortality and morbidity among the elderly and to be detrimental to activities of daily living. Effects of relocation on long-term patients in an acute care institution are examined. Thirty-six (36) patients were assigned to experimental and control groups. The experimental group (n = 20) was relocated for nine weeks, while members of the control group (n = 16) remained in their original units. The two groups were evaluated for differences in mortality, morbidity, activities of daily living, and drug management. The experimental group was managed by a geriatrics team during the nine-week relocation period, while the control group remained under the supervision of a general medical surgical team. No statistically significant (P less than 0.05) differences were found with respect to mortality and morbidity, activities of daily living, or drug management. Some clinical improvements were noticed in the experimental group under the geriatrics team's supervision. The authors conclude that if careful consideration is given to the relocation of long-term patients in an acute care setting, detrimental outcomes can be avoided.

Activities of Daily Living↗
PubMed1985

Extending the extenders. Compromise for the geriatric specialization-manpower debate.

This pilot study reports on issues germane to the geriatric specialization-manpower debate. The study found that a large amount of the functional responsibility required by older adults in an urban clinic setting could be delegated to physician extenders. Other findings included shorter hospitalizations, increased feelings of well-being, and high patient satisfaction with physician extended care. The implications are that rather than develop a new physician specialty, more geriatric manpower needs could be met by delegating responsibility to appropriately trained and supervised physician extenders.

Aged↗
PubMed1985

OARS methodology. A decade of experience in geriatric assessment.

The Older Americans Resources and Services (OARS) methodology was designed to assess functional capacity in five dimensions (social resources, economic resources, mental health, physical health, and activities of daily living) and to measure use of and need for 24 types of generic services. The OARS questionnaire now has been used in more than 150 research and practice settings. Recent refinements in the OARS methodology include new information about validity and reliability, computerized summary ratings for the five dimensions of functional status, and eleven scales that measure specific aspects of functioning within the five dimensions. This paper describes the conceptual foundation, appropriate uses, psychometric properties, and recent refinements in the OARS methodology. Empirical data from a geriatric clinic population are used for purposes of illustration. The paper presents an assessment of the strengths and limitations of the OARS methodology based on more than a decade of experience. Particular attention is paid to the degree to which the measures of functional status can be related to health service use measures to inform geriatric research and practice.

Activities of Daily Living↗
PubMed1986

Relevance of readmission of elderly patients discharged from a geriatric unit.

Eight percent of the elderly patients discharged from a geriatric unit in one year were readmitted within three months. Forty-six percent had been living alone and nearly all of these had received full community support at the time of discharge. Recurrent problems were the reason for readmission in 59% of cases, mainly due to falls, incontinence, and confusion. Only 54% of the readmitted patients were discharged home again--those with new additional problems tended to die in hospital, whereas those with recurrent problems often required institutional long-term care. It is concluded that even with careful discharge planning, a proportion of patients will require readmission, some of which will also require long-term institutional care. This number is quite small in terms of the total number of patients discharged from a geriatric unit and should not be a reason for seeking nursing home care at an early stage.

Accidents↗
PubMed1987

Trial of a geriatric consultation team in an acute care hospital.

A controlled trial was conducted to examine the effects of superimposing an interdisciplinary geriatric consultation team upon the conventional patterns of care in medical wards of an acute care hospital. Two hundred and twenty-two patients, aged 69 years of age or older, admitted from the emergency room to two trial wards and 182 similar patients admitted to two control wards where the team did not work, were followed. Evaluations at admission, two and four weeks, and three and six months postadmission by independent evaluators allowed comparisons between the care groups with reference to survival, length of stay, disposition, physical, mental, and social functional levels, and use of services after discharge. Data from charts and treatment logs allowed the care processes to be compared. Findings determined that patients in the two groups were alike on socio-demographic and clinical characteristics at entry. Results demonstrated that patients in the trial and control groups fared similarly on the outcome measures at each evaluation point, although a trend toward better survival among team patients was noted. It was concluded that the addition of a consultative geriatric team to the medical wards failed to show a significant impact on patient outcomes.

Aged↗
PubMed1988

Beyond caring: the challenge to geriatrics.

Geriatrics has established itself in the past decade as a recognized part of health care, but several issues remain unsolved about its place in the system. It has been addressed as both an approach to primary care of the elderly and a specialty in its own right. It relies excessively on the technology of assessment. Although geriatrics responds to a pervasive need for coordinating clinical and social care for a subset of the elderly, its potential contributions to this challenge have not yet been well modeled. As it comes of age, there is a need for greater conceptual clarity and a series of demonstrations that its abilities fit the needs identified.

Aged↗
PubMed1989

The yield of a home visit in the assessment of geriatric patients.

Elderly patients often have problems not easily detected during an office visit. We investigated the yield of a home visit by a geriatric nurse specialist as part of an interdisciplinary assessment process. Compared with the findings of an office-based assessment by a general internist, the home visit resulted in up to four new problems (median = 2, mean = 1.7, 95% confidence interval = 1.5-1.8) and one to eight new recommendations (median = 4, mean = 3.6, 95% confidence interval = 3.4-3.9). Twenty-three percent of the problems could have resulted in death or significant morbidity. The most frequent problems related to psychobehavioral difficulties (23.1% of problems involving 38.3% of patients), safety (21.6% of problems involving 35.7% of patients), and caregiver related problems (20.4% of problems involving 33.8% of patients). The most common recommendations related to safety (30.7% of recommendations involving 81.8% of patients), caregiver well-being (19.8% of recommendations involving 52.6% of patients), and social issues (12.7% involving 33.8% of patients). Baseline clinical information did not predict the yield of the home visit in this sample. We conclude that an in-home assessment contributes unique and meaningful information to the geriatric assessment process.

Activities of Daily Living↗
PubMed1989

The first certifying examination in geriatric medicine.

On April 22, 1988, the first Certifying Examination in Geriatric Medicine was administered jointly by the American Board of Internal Medicine and the American Board of Family Practice to 4,282 diplomates (ABIM = 2,202; ABFP = 2,080). This paper addresses both an analysis of the examination and the relationship between performance on that examination and a group of characteristics of the examinees, collected as part of the registration process. The pass rate was 56%. Performance on the examination was positively correlated with scores on the general certifying examinations and with training in geriatric medicine. Data provided by the candidates in an addendum to the application were also available for analysis and were used to derive correlations with groups of questions. The performance of candidates was positively correlated with seeing large numbers of elderly in hospitals, nursing homes, or home settings, working in a University Hospital, teaching and research, and the size of the community in which the candidate practiced. Physicians from long-term care settings did exceptionally well. Working in a solo practice setting was negatively correlated with performance on the examination as was working in a for-profit setting.

Certification↗
PubMed1989

Physician Payment Reform. Implications for geriatrics.

A consensus has developed on the need for a major revision of physician reimbursement in the Medicare program. The Physician Payment Review Commission has recommended to Congress a series of far-reaching changes in the payment system, based on the development of a fee schedule using a Resource Based Relative Value System (RBRVS). This article explores the rationale for the recommendations and the probable impact on Medicare beneficiaries and their physicians if the changes are enacted. Special consideration is given to unique aspects of geriatric medicine, including comprehensive geriatric assessment.

Fee Schedules↗
PubMed1990

The Senior Care Study. A controlled trial of a consultative/unit-based geriatric assessment program in acute care.

Successful models of inpatient geriatric assessment have often involved long hospital stays, specialized interdisciplinary care, and prolonged follow-up, which are difficult to achieve within a prospective payment system. A randomized clinical trial was undertaken to evaluate the efficacy (maintenance or improvement in mental, emotional, and physical function) of using a geriatric assessment process in acute hospital care without increasing hospital charges or lengths of stay. Four hundred thirty-six patients greater than or equal to 75 years of age were randomly allocated to treatment (n = 221) or control (n = 215) conditions. Patients in the treatment group were admitted to a special unit and evaluated on admission by an interdisciplinary team, which developed a care plan. Although primary care was provided by the patient's own physician, the team followed the patients as consultants on the unit in the hospital, and by telephone for 2 months after discharge. The control group was placed on other units and received usual hospital care. The treatment and control groups were similar at study entry. At follow-up, there were no significant differences between the groups with respect to lengths of stay, hospital charges, mortality, change in physical function, or change in mental function. The treatment group changed more often in measured emotional function (chi 2 = 6.213, P = .045). This study indicates that it is feasible to implement consultative interdisciplinary team care in the acute-care hospital, but that its efficacy may be limited when applied to an unselected group of older patients.

Activities of Daily Living↗
PubMed1990

Characteristics of an elderly driving population referred to a geriatric assessment center.

A retrospective, case-control study was performed to determine the characteristics of elderly drivers referred to an outpatient geriatric assessment center. It was hypothesized that the driving population was operating at a higher cognitive and functional level than nondrivers. One hundred eighty-two subjects meeting the entry criteria were studied. Twenty-three percent of the subjects were driving at the time of their assessment. Compared to nondrivers, drivers were younger (P = .0001), were more likely to be male (P = .003), scored higher on a mental status examination (P = .0001), and were more independent in Physical and Instrumental Activities of Daily Living (P less than .0001). Despite these findings, the mean Folstein Mini-Mental score for drivers (23.7) was below normal; 40% of drivers were diagnosed as having Alzheimer's dementia at the time of their evaluation, and over 26% of the drivers needed help with either dressing or bathing. The frequency of impaired elderly drivers in this referral setting was high. The authors conclude that conditions that affect the driving task are common in geriatric assessment centers. Prospective studies of elderly drivers are needed to answer the difficult question of who among the elderly should drive.

Activities of Daily Living↗
PubMed1990

Formal geriatric assessment instruments and the care of older general medical outpatients.

To improve identification of cognitive, affective, gait, and nutritional problems in older medical outpatients, non-physician clinic personnel administered formal geriatric assessment tools to 183 medical outpatients age 70 years and older. Definite impairments were demonstrated in 7% to 23% of patients (depending on the function being assessed), and borderline abnormal results were common as well. Overall, 56% of patients had at least one meaningful impairment identified. Few of these problems had been recognized before the survey. Assessment required 10 to 15 minutes of interviewer time per patient (approximately 22 minutes for each problem newly uncovered). A simple education and information intervention led to physicians addressing the newly identified problem in 30% to 55% of cases. These results suggest that formal geriatric assessment instruments provide an efficient mechanism for case finding in older medical outpatients. Further studies are necessary to determine whether such interventions will lead to improved outcomes in older medical outpatients.

Aged↗