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PubMed1990

An exploratory use of the Symptoms Checklist-90 in a mixed geriatric study group.

There are currently no self-rating scales of general psychopathology in the older population. Such scales can be used to screen patients who may then be referred on for psychiatric assessment. The validity of the Symptoms Checklist-90 (SCL-90), a self-rating scale of general psychopathology widely used in the nongeriatric adult population, was explored in 44 older subjects. It was compared with the Sandoz Clinical Assessment Geriatric (SCAG) scale and a measure of functional disability, the London Psychogeriatric Rating Scale (LPRS). Caregivers to all subjects also rated the degree of difficulty experienced with their care on a four-point scale. Thirty of the subjects attended a geriatric day hospital, and the remaining 14 were waiting to go into long-term care facilities. Symptoms Checklist-90 was not significantly different between the two groups of subjects (day hospital and preinstitutional) after Bonferroni corrections, though SCAG scale and LPRS were (P less than .01 for both). Although SCL-90 was correlated significantly with the SCAG scale (r = .46), it was not significantly correlated with the LPRS. It showed good internal consistency but poor face validity and an inability to differentiate between levels of difficulty for the caregiver. It is concluded that the use of SCL-90 in older people may be limited because of the lack of sensitivity to functional disability and care difficulty. This nevertheless needs to be further explored, perhaps with some modification of the scale for older people.

Activities of Daily Living↗
PubMed1990

Prediction of independent functioning and behavior problems in geriatric patients.

Folstein's Mini Mental State Exam, a test assessing the capacity to perform novel and/or repetitive motor tasks (Behavioral Dyscontrol Scale) and a brief measure of working memory were used in a sample of 50 male Veterans Affairs geriatric clinic patients who ranged in age from 63 to 105 (mean, 80.1). The purpose of this study was to attempt to predict the patients' capacity to regulate their behavior independently. We hypothesized that frontal lobe disorders often impair a patient's ability to function autonomously and that the Behavioral Dyscontrol Scale, a measure of frontal lobe impairment, would best predict the capacity for independent regulation of purposeful behavior. Therefore, we examined the relationship of the Behavioral Dyscontrol Scale with spouses' and caregivers' ratings of patients' independent living skills, and with behaviors that interfere with independent functioning. The results of hierarchial regression analyses indicated that the Behavioral Dyscontrol Scale was the only predictor of functional autonomy and was the best predictor of both impulsivity and apathy among geriatric patients. The Behavioral Dyscontrol Scale appears to assess a different functional domain than do the MMSE and similar measures, which rely heavily on the evaluation of orientation and gross cognitive status.

Activities of Daily Living↗
PubMed1990

Caregiver burden should be evaluated during geriatric assessment.

This study examines the relationship between caregiver burden and use of long-term care services following geriatric assessment. One hundred nine older subjects underwent comprehensive assessment, which included a questionnaire completed by the primary caregiver to assess the sense of burden in providing care. Logistic regression was used to identify independent predictors of service use at 12 months. Among measures of the older person's cognitive and physical abilities, only activities of daily living predicted increased use of services. When the measure of caregiver burden was added, it also entered as an independent predictor, which significantly improved the prediction of service use (chi 2 = 5.9, P less than .02). In a separate analysis, caregiver burden predicted both the use of home services and nursing-home placement. During longitudinal follow-up, the measure of burden decreased over 12 months for the sample, with the greatest reduction in burden occurring for caregivers whose relative was placed in a nursing home. The fact that caregiver burden was the most important factor in determining who would use formal services suggests that burden should be evaluated as part of geriatric assessment.

Activities of Daily Living↗
PubMed1990

Candidates for the Certificate of Added Qualifications in Geriatric Medicine. Who, why, and when?

We surveyed physicians who took the examination for certification for Added Qualifications in Geriatric Medicine, physicians who only inquired about the examination, and physicians who expressed no interest in the examination to learn about practice characteristics of those who took the examination and their reasons for taking it. Based on a 72% response rate, we were able to demonstrate that those who took the examination took care of an older population of patients and disproportionately more of the oldest-old. These physicians were more likely to report the care of older people to be a professional focus and, in internal medicine, were more likely to have had formal training in geriatrics. Their reasons for taking the examination were primarily to obtain credentials but also frequently to improve their ability to care for older people. Nearly two-thirds of those who had inquired about the exam but did not take it in 1988 plan to do so at a later date.

Certification↗
PubMed1991

Outpatient geriatric assessment: associations between referral sources and assessment findings.

A review of 431 outpatient geriatric assessments conducted over 2 years examined the associations of referral problems, assessment diagnoses, and therapeutic recommendations with the source of patient referral, as well as that referral source's diagnostic accuracy in identifying the referral problems. Families referred 52% of patients, primarily for problems of memory and behavior, whereas social service agencies made 32.9% of all referrals, primarily for bladder control problems or safety-related concerns. Physicians made only 6% of referrals in this setting. Referral source was found not to be associated with any of the seven categories of medical diagnoses resulting from the assessment process and was associated with only two of the functional diagnostic categories. Therapeutic recommendations were also broadly distributed among referral sources, though social service agencies did refer more patients who required urgent nursing home placement, financial representation, or adult protective service involvement. The performance of family referral sources in accurately referring patients with dementia and psychiatric impairment was comparable to that of physicians, though all referral sources frequently missed patients with incontinence. Non-physician referral sources appear to serve as important and quite valid case-finders for outpatient geriatric assessment.

Aged↗
PubMed1991

Recommendations for a change in living situation resulting from an outpatient geriatric assessment: type, frequency and risk factors.

We analyzed the outcomes of 480 comprehensive outpatient geriatric assessments to determine the frequency of recommendations for home help or a change in residence and to determine whether simple clinical observations could predict such recommendations. Fifty-eight percent (280) of the patients received no recommendation for a change in the living situation. Of the 200 patients receiving a recommendation for a change in living situation, 97 (49%) were felt to be able to stay at home with increased in-home support and/or day care, and 51.5% (103) were advised to seek placement. After adjusting for age and gender, risk factors predicting a recommendation for change were dementia (odds-ratio = 9.98), vision deficits (odds ratio = 2.02), lower education level compared to college (odds-ratio = 1.88 high school, 1.42 for less than high school), an increasing number of medical diagnoses (odds-ratio = 1.49 per diagnosis), and a functional impairment on the Katz index (odds-ratio = 1.09). The presence of these risk factors should lead to consideration of further evaluation of the home environment in this study. We conclude that geriatric patients presenting for a comprehensive outpatient evaluation commonly need a change in home situation, though most can remain in their home, and that simple clinical observations can be helpful in screening patients for further evaluation of their home environment.

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PubMed1991

A geriatric-anesthesiologic program to reduce acute confusional states in elderly patients treated for femoral neck fractures.

The aim of this study was to evaluate the effect of a geriatric-anesthesiologic intervention program for the prevention and treatment of acute confusional states (ACS) in elderly patients treated for femoral neck fractures. The intervention program was based on the results of previous prospective studies in similar patient populations. The outcome of the intervention, comprising 103 patients, was compared with that of an earlier study comprising 111 patients. The intervention program consisted of pre- and post-operative geriatric assessments, oxygen therapy, early surgery, prevention and treatment of peri-operative blood pressure falls and treatment of post-operative complications. The incidence of ACS was lower, 47.6%, in the intervention study compared with 61.3% (P less than 0.05) in the control study. Furthermore, the ACS that occurred in the intervention study was less severe and of shorter duration than that in the control study. The incidence of post-operative decubital ulcers, severe falls, and urinary retention was also lower. The mean duration of orthopedic ward stay was 17.4 days in the control study and 11.6 days in the intervention study (P less than 0.001). It can be concluded that the intervention program reduced the incidence, severity, and duration of ACS which resulted in a shortened orthopedic ward stay.

Aged↗
PubMed1991

Geriatric evaluation and management units: experimental methods for evaluating efficacy.

A multi-site randomized controlled trial could most conclusively establish the efficacy of geriatric evaluation and management units, but many questions must be answered to design such a trial. First, the research questions needs to be rigorously specified. This will facilitate decisions concerning the types of patients to be included in the study. Second, the intervention requires a clear definition, including its component parts, to improve replication across multiple sites. Third, the type of randomization (ie, by hospital or by patient) and the timing of randomization (ie, at admission or at some later point during care) need to be considered. Fourth, because this type of intervention cannot be administered in a blind fashion, bias is a critical concern. Outcome measures must be selected carefully so that those least susceptible to bias are given the highest priority. Despite the need to address all of these questions, the time is upon us to conduct a multi-site trial of geriatric evaluation and management programs.

Bias↗
PubMed1991

Research strategies for geriatric evaluation and management: conference summary and recommendations.

In this paper, we present the consensus statement from a national conference on research priorities and methodologies for studying geriatric evaluation and management (GEM) programs. These conclusions, discussion points, and recommendations resulted from discussions of plenary papers, working group deliberations, and a final session in which findings were synthesized by the conference co-chairmen and presented to conference participants for final review. Major conclusions included: (1) The importance of linking geriatric evaluation with care management in future studies; (2) The need for multi-center trials of inpatient units to establish efficacy; (3) The importance of studying criteria for targeting GEM care on patients who are most likely to benefit; (4) The need for further developmental studies of outpatient GEM clinics; (5) The importance of assessing a range of outcomes including mortality, patient function, satisfaction, caregiver burden, and cost; and (6) The need to define more carefully the nature of the intervention that is being studied to aid in comparing and extrapolating findings. The following research priorities for GEMS were formulated based on the conference: (1) Within the VA health care system, a multi-site randomized trial of inpatient GEM units should be initiated; (2) Multi-site studies of inpatient GEM units and consultation teams linked to outpatient care should be initiated in non-VA settings; (3) Studies should identify the components of GEM that are most critical to outcome; (4) Studies should explore efficacy of GEM in settings that have not been well studied to date such as nursing homes; and (5) Studies are needed to test screening methods and targeting criteria for GEM in all settings.

Geriatric Assessment↗
PubMed1992

An interdisciplinary approach to the assessment and behavioral treatment of urinary incontinence in geriatric outpatients.

OBJECTIVE: To test the effectiveness of an interdisciplinary assessment and behavioral treatment of persistent urinary incontinence in geriatric outpatients. DESIGN: Prospective case series in which frequency of incontinence was measured before and after intervention. SETTING: We established an interdisciplinary continence program within an existing academic center, the Benedum Geriatric Center. PATIENTS: Convenience sample of 70 non-demented outpatients aged 56 to 90 years. Behavioral treatment was provided to 29 patients including many with multiple medical problems (Mean = 6.0 problems). INTERVENTION: Behavioral treatment consisted of biofeedback, pelvic floor muscle exercise, scheduled voiding, and other strategies for preventing accidental urine loss. OUTCOME MEASURE: Outcome of treatment was measured by comparing bladder diaries completed in the 2 weeks immediately following treatment to those completed in the pretreatment phase. RESULTS: Following an average 5.6 treatment sessions, the mean weekly frequency of accidents was reduced from 16.9 to 2.5 (P less than 0.01). Individual reductions ranged from 30.8% to 100% with an average of 81.6% improvement. Ten patients achieved continence. Patients with mixed incontinence had greater improvement than those with urge incontinence alone (P less than 0.05), and patients who reported previous evaluation or treatment had a poorer outcome than those coming for their first evaluation (P = 0.05). Degree of improvement was not significantly related to age, duration of symptoms, baseline frequency of accidents, number of treatment sessions, number of other medical diagnoses, or urodynamic findings. CONCLUSION: We conclude that older adults who are able and willing to participate in behavioral treatment can benefit significantly despite other health problems or disabilities.

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PubMed1994

Reducing hospital costs for the geriatric patient admitted from the emergency department: a randomized trial.

OBJECTIVE: To test the impact of a geriatric evaluation and management model on the costs of acute hospital management of emergently admitted older adults. DESIGN: Randomized controlled trial. Patients were followed in the acute hospital from admission through discharge. Results based on both univariate and multiple regression analyses. SETTING: Private, nonprofit, academic medical center in a densely populated urban area. PATIENTS: Adults 70 years of age and older admitted from the Emergency Department to the medicine service (non-ICU admission) who did not have an internist on staff at the admitting hospital. Of 141 randomized patients, 111 (78.7%) met eligibility criteria. INTERVENTION: Assignment of a geriatrician and a social worker as the primary managing team during the hospital stay. MAIN OUTCOME MEASURES: Length of stay, total cost of acute hospital care, cost of laboratory, pharmacy, and rehabilitation services. RESULTS: Patients in the intervention group had 2.1 fewer days of hospitalization, but this shorter length of stay was not statistically significant (P = 0.108). There were no differences in mortality or discharge disposition. In risk-adjusted, multiple regression analysis the intervention group had a statistically significant lower predicted total cost per patient than the usual care group (-$2,544, P = 0.029); assignment to the intervention group was associated with a lower predicted cost per patient for laboratory (including cardiology graphics) services (P = 0.007) and pharmacy costs (P = 0.047). CONCLUSIONS: When controlled for important predictors of expected resource use, care provided by a geriatric management team resulted in a significant reduction in the cost of hospitalization. A reduction in the cost of laboratory, cardiographic, and pharmacy services is consistent with the team's philosophy of defining the services needed based on goals related to functional outcomes.

Academic Medical Centers↗
PubMed1994

Geriatric home assessment after hospital discharge.

OBJECTIVES: To evaluate the feasibility of an intervention involving post-discharge geriatric home assessment and follow-up and to describe the spectrum of significant clinical problems identified during the home assessment. DESIGN: Prospective observational study nested within a randomized controlled trial. SETTING: Inpatient service of a large academic medical center in Southern California. PATIENTS: There were 152 adults aged 65 or greater who had one or more specific risk factors for functional decline or increased mortality, who were awaiting discharge from the hospital, and who were assigned to the intervention arm of a randomized controlled trial of post-discharge comprehensive geriatric home assessment. MAIN RESULTS: During the home assessment, the gerontologic nurse practitioner (GNP) identified new or worsening problems in 150 patients (99%); 61 problems (eg, serum sodium 125 mg/dL; severe orthostatic hypotension) were considered by a reviewing physician to require urgent medical attention. Older age, non-white race, and new incontinence were associated independently with a greater number of findings (P < 0.05). Based on the findings, an interdisciplinary team made an average of 3.4 recommendations per patient; only two of 111 requests for written approval of recommendations were rejected. CONCLUSIONS: Post-discharge visitation by a GNP to patients at high risk is capable of detecting a high yield of important and potentially reversible clinical problems. This multidisciplinary approach is acceptable to physicians. Research is needed to identify additional links between short hospital stays, impairment or instability at discharge, and adverse outcomes.

Academic Medical Centers↗
PubMed1994

Is geriatrics a primary care or subspecialty discipline?

OBJECTIVE: To determine how much of the clinical care provided to older persons by geriatricians is primary versus consultative. DESIGN: National Survey. PARTICIPANTS: Candidates for the 1988 certifying examination in geriatrics, physicians who expressed interest in the examination but did not register for the examination, and physicians who expressed no interest in the examination (comparison group physicians). RESULTS: Based on a 72% response rate, 78% of the care rendered by certified internal medicine geriatricians and 90% of the care rendered by certified family practice geriatricians to older persons was primary care. Internal medicine geriatricians spent a greater percentage of their care of older persons providing primary care compared with internists with no interest in geriatrics. Although internist geriatricians who were formally trained or had additional subspecialty certification provided less of their care as primary care compared with geriatricians who had no formal training, the majority of care (approximately 70%) provided by each of these two subgroups was primary care. CONCLUSIONS: The vast majority of care provided to older persons by geriatricians is primary care, and these physicians should be considered as generalists for health policy and educational purposes.

Adult↗
PubMed1995

The role of gerontological advanced practice nurses in geriatric care.

GAPNs have a significant role to play in the care of older people. They provide focused health screening, counseling, crisis intervention, and comprehensive care to this population. They serve as important advocates in directing appropriate utilization of resources and making referrals that promote continuity of care geared to the needs of older adults. GAPNs provide essential educational services to older clients, their families, and other nursing and health care professionals involved in their care. They are innovators in the field of gerontological nursing and geriatric care and initiate or collaborate in research aimed at improving the health status of older persons. GAPNs are true providers of geriatric care, with great potential for serving an increasingly aging society.

Aged↗
PubMed1996

Nutritional assessment: a primary component of multidimensional geriatric assessment in the acute care setting.

OBJECTIVE: To test the prognostic role of nutritional variables as a component of geriatric multidimensional assessment and to study the effect of hospitalization on nutritional status. DESIGN: Validation cohort study: multidimensional assessment on admission and at discharge and a weekly nutritional assessment. SETTING: General Medicine and Geriatrics wards in an acute-care university hospital. PATIENTS: A consecutive sample of 302 patients aged 79 +/- 6 years, range 70-96 years. MAIN OUTCOME MEASURES: Mortality, longstay (> 29 days), loss of lean body mass as expressed by a negative change in mid-arm muscle circumference (MAMC). RESULTS: Incidence of mortality, longstay, and decreased MAMC was 6.9%, 24.8%, and 64.2%, respectively. According to logistic regression analysis, mortality was independently predicted by preadmission dependency in at least one Activity of Daily Living (odds ratio = 2.08, confidence limits = 1.19-3.65), clinical diagnosis of malnutrition (OR = 1.89, CL = 1.11-3.21), serum albumin < 3.5 g/dL (OR = 1.82, CL = 1.06-3.14). This predictive model allowed us to recognize 75% of the patients at risk of death by targeting 23% of the population. Longstay was independently predicted by stroke (OR = 1.54, CL = 1.01-2.35), clinical diagnosis of malnutrition (OR = 1.41, CL = 1.04-1.93), and more than five comorbid diseases (OR = 1.39, CL = 1.01-1.94). Dependency in at least one ADL was the only independent predictor of decreased MAMC (OR = 1.71, CL = 1.27-2.30). CONCLUSIONS: Nutrition variables are a cardinal component of multidimensional assessment in the acute-care setting. Nutritional status deteriorates during the hospital stay, mostly in physically dependent patients.

Activities of Daily Living↗
PubMed1997

Functional outcome of cognitively impaired hip fracture patients on a geriatric rehabilitation unit.

OBJECTIVES: To compare outcomes (physical functions and discharge destinations) of cognitively impaired and intact older hip fracture patients, and to identify cognitive skills related to functional gains. DESIGN: Prospective longitudinal study of hip fracture patients treated on an acute inpatient rehabilitation service, with evaluation of functional performance and living status determined at admission and discharge. SETTING: A specialized inpatient geriatric rehabilitation program at Wesley Woods Geriatric Hospital, which is affiliated with Emory University School of Medicine. SUBJECTS: Fifty-eight hip fracture patients, 35 with and 23 without cognitive impairment. MEASUREMENTS: Cognitive functioning measured by the Mattis Dementia Rating Scale (MDRS); functional outcome assessed by the Functional Independence Measure (FIM); comparison of pre-fracture with discharge living environments. MAIN RESULTS: Both cognitively impaired and intact hip fracture patients exhibited similar overall FIM motor improvements as well as functional gains in specific FIM areas measuring self-care, sphincter control, and locomotion (e.g., walking). Cognitively intact patients, however, displayed significantly greater gains in mobility (e.g., transfers) at discharge. Cognitively impaired patients who lived in the community were as likely as intact patients to return to the community. Patients who entered the program at a modified dependence level (FIM 3-5) and achieved motor independence at discharge (FIM 6-7) had higher MDRS initiation/ perseveration and memory scores. CONCLUSIONS: Hip fracture patients with cognitive impairments can achieve positive outcomes as defined by functional improvement and discharge destination. Intensive post-fracture rehabilitation in the early phase of recovery may promote functional independence and a return to the community for older patients at risk for nursing home placement. Future research should examine the long-term maintenance of these improvements and explore how rehabilitation interventions can be altered to enhance outcome.

Aged↗
PubMed1997

Determinants of functional status in healthy Italian nonagenarians and centenarians: a comprehensive functional assessment by the instruments of geriatric practice.

OBJECTIVE: To evaluate the physical ability and psychocognitive status of a population more than 90 years of age with regard to sociodemographic, behavioral, and biomedical variables known to affect functional status in old age. DESIGN: A survey design was used. SETTING: Emilia Romagna, Northern Italy. PARTICIPANTS: Eighty-four healthy community-dwelling subjects aged 90 to 106 years. MEASUREMENTS: Sociodemographic variables, health behavior, anthropometric indices, and serum DHEAS levels were recorded. Functional assessment was performed by instruments currently used in geriatric practice: the Mini-Mental State Examination (MMSE), Geriatric Depression Scale (GDS), and Activities of Daily Living (ADL) scale. A stepwise multiple regression analysis was performed. RESULTS: GDS scores correlated directly with MMSE scores and inversely with ADL severity scores. Poor education, institutionalization, sensory impairment, muscular mass loss, and lower DHEAS levels were the variables with the highest correlation to functional impairment. Smoking, alcohol consumption, and marital status were relatively unimportant. An inverse association was found between DHEAS levels and dependency scores of single ADLs (continence, mobility). CONCLUSION: Impaired cognitive and physical ability with no increase in depression prevalence was found in a sample of subjects more than 90 years of age free of major age-related disease. Muscular mass and DHEAS levels seem to play a role in maintaining physical independence. In turn, physical independence, as well as social and cultural factors, strongly affect the compliance of long-lived subjects with psychocognitive tests currently used in the clinical evaluation of younger old people, suggesting that these instruments are not reliable for screening for cognitive impairment and depression in the oldest old subjects.

Activities of Daily Living↗
PubMed1998

Pharmacologic treatment of geriatric depression: key issues in interpreting the evidence.

OBJECTIVE: A framework for critical appraisal of antidepressant trial literature involving geriatric subjects is presented. Among older adults, treatment decisions are complicated by comorbid medical and cognitive illness, the variable course of recovery, and the overlap of depressive symptoms with other disease symptoms. Consumers of the literature on competing antidepressant therapies for older adults must consider disease and population-specific outcome assessment issues. DESIGN: An appraisal guide, adapted for geriatric depression, is developed from literature on methodological challenges of outcome assessment and published clinical trials comparing competing antidepressant therapies in older subjects. CONCLUSIONS: The clinical utility of pharmacologic treatment of depression can be difficult to assess because depression scales in current use provide an important but limited perspective on treatment outcome and because the scales vary in actual content and ability to detect change. The use of indicators of function, independence, and self-perceived well-being as outcomes offers additional patient relevance and should be included. Key considerations involve (1) general characteristics: whether the depression outcome measure is valid and reproducible for the aged population under study, whether the outcome measure is sensitive to treatment-related change, and whether the time-frame of outcome assessment is appropriate for the treatment goal; (2) cognitive impairment: how subjects with dementia are assessed, and whether the impact of the intervention on caregivers and healthcare systems is considered as a relevant outcome; (3) pharmacologic issues: whether the comparator agent is a reasonable usual-care standard in the older adult and whether ascertainment for adverse effects is similar for all agents under study; and (4) broader general health status issues: whether functional or quality of life measures are used as outcome indicators.

Aged↗