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PubMed2000

In the steps of giants: the early geriatrics texts.

This article briefly reviews some of the major early geriatric textbooks of the last two centuries. Among the more important are books by George Day, Charcot, Nascher, Worcester, and Cowdry. Lord Amulree's book Adding Life to Years has become a watchword of modern geriatrics. It is of interest that during this time period the basic plea for high touch care of older patients and the lament that physicians have little knowledge of the needs of older patients has remained remarkably constant.

Geriatrics↗
PubMed2004

Operationalizing a frailty index from a standardized comprehensive geriatric assessment.

OBJECTIVES: To construct and validate a frailty index (FI) that is clinically sensible and practical for geriatricians by basing it on a routinely used comprehensive geriatric assessment (CGA) instrument. DESIGN: Secondary analysis of a 3-month randomized, controlled trial of a specialized mobile geriatric assessment team. SETTING: Rural Nova Scotia. Participants were seen in their homes. PARTICIPANTS: Frail older adults, of whom 92 were in the intervention group and 77 in the control group. MEASUREMENTS: A standard CGA form that accounts for impairment, disability, and comorbidity burden was scored and summed as a frailty index (FI-CGA). The FI-GCA was stratified to describe three levels of frailty. Patients were followed for up to 12 months to determine how well the index predicted adverse outcomes (institutionalization or mortality, whichever came first). RESULTS: The three levels of frailty were mild (FI-CGA 0-7), moderate (FI-CGA 7-13), and severe (FI-CGA>13). Demographic and social traits were similar across groups, but greater frailty was associated with worse function (r=0.55) and mental status (r=0.33). Those with moderate and severe frailty had a greater risk of adverse outcomes than those with mild frailty (unadjusted hazard ratio=1.9 and 5.5, respectively). There was no difference between frailty groups in mean 3-month goal-attainment scaling scores. Intrarater reliability was 0.95. CONCLUSION: The FI-CGA is a valid, reliable, and sensible clinical measure of frailty that permits risk stratification of future adverse outcomes.

Aged↗
PubMed2005

Evaluating immediate and long-range effect of a geriatric clerkship using reflections and ratings from participants as students and as residents.

This article describes a longitudinal study developed to assess perceived usefulness of a mandatory geriatric clerkship from the perspective of junior students completing the newly initiated program in 1998-1999 and 1999-2000 and these same students as second- or third-year residents. End-of-clerkship student evaluations were compared with follow-up resident surveys of those same students to identify the utility of information provided and strengths and weaknesses of the initial course experience. Students participated in hospice, outpatient clinics, nursing homes, and transitional care venues during their clerkship experience at the Donald W. Reynolds Department of Geriatrics, College of Medicine, University of Arkansas for Medical Sciences. Two hundred eighty-five student evaluations were collected, and 143 resident surveys were returned. Quantitative and qualitative data from students and residents corroborated each other in identifying strengths and weaknesses of the clerkship. Hospice information was successfully incorporated into residency practice. In contrast, outpatient clinic, nursing home, and transitional care segments of the clerkship were perceived as inadequate. Survey responses validated faculty changes that were initiated in the following years. These changes use settings and patients that more accurately mirror those seen in typical resident encounters.

Adult↗
PubMed2005

There is hope for the future: national survey results reveal that geriatric medicine fellows are well-educated in end-of-life care.

OBJECTIVES: To assess the status of geriatric medicine (GM) fellows' training experiences in end-of-life care via self-report. DESIGN: Anonymous surveys completed by mail, Web access, and telephone. SETTING: U.S. accredited GM fellowship training programs. PARTICIPANTS: Two hundred ninety-six surveys were sent to graduating GM fellows in 1- and 2-year programs across the Unites States. MEASUREMENTS: Measurements assessed self-reported attitudes, quantity and quality of end-of-life care education, preparation to provide care, and perceived value of caring for dying patients. RESULTS: Response rate was 74%. Ninety-five percent or more of respondents held positive views about physicians' responsibility and ability to help dying patients. Seventy percent of fellows had completed a rotation focused on end-of-life care. Fellows who had done such rotations rated their end-of-life care education as highly as their overall geriatrics training. Fellows frequently received teaching in many end-of-life care topics, with lower rates of teaching how to say goodbye and responding to requests for assisted suicide. Overall, fellows felt well prepared to care for dying patients. Four factors independently predicted such preparedness: having had a palliative or end-of-life care rotation, being female, having been taught how to say goodbye to patients, and perceiving that it is important to attending physicians that fellows learn to care for dying patients. CONCLUSION: GM fellows feel their end-of-life care education is excellent and feel prepared to take care of dying patients. It is critical that geriatricians in training have access to and take advantage of palliative and end-of-life care rotations.

Adult↗
PubMed2005

Quality of Internet geriatric health information: the GeriatricWeb project.

Many physicians report that Internet health information can affect their clinical decisions. Much of Internet geriatric health information (IGHI) is not controlled for quality, and there is no available process to assess the quality of IGHI used in clinical practice or in medical education. The objective of this project was to describe the development of an assessment process of IGHI and to report on the quality of existing IGHI through the GeriatricWeb project. The assessment was a trilevel process: identification, screening, and peer review. Medical librarians completed the identification of resources, and geriatric specialists conducted the screening and peer review. The peer-review process was accomplished using a developed tool (4 domains: credibility, accuracy, design, educational features; score 0-100, favorable assessment score > or = 75). More than 5,000 IGHI resources were identified, and 1,142 (22%) were advanced for screening. Of those, 246 (21%) were already peer reviewed, and 354 (31%) were advanced for peer review. Of those, 181 (51% or 20% of all those advanced for screening excluding those already peer reviewed) had a favorable assessment. Poor credibility and educational features contributed to this low quality. IGHI authored by national, federal, or academic organizations and targeted to higher academic levels was more likely to have a favorable assessment (P=0.01). Much publicly available IGHI is of suboptimal quality, particularly with regard to credibility and educational domains. Healthcare professionals need to be aware of how to locate high-quality IGHI and how to assess the quality of available IGHI.

Geriatrics↗
PubMed2005

Where does research occur in geriatrics and gerontology?

The International Plan of Action on Aging 2002 emphasized the need to promote and develop research on aging, especially in underdeveloped countries. This article aims at describing the current situation with regard to the international scientific production in the field of geriatrics and gerontology. All articles published in journals included in the categories "Geriatrics and Gerontology" of the Science Citation Index or "Gerontology" of the Social Science Citation Index in 2002 were analyzed. There is unquestionable predomination by the United States, which participates in 53.8% of the articles analyzed, followed by the United Kingdom (9.66%) and Canada (6.66%). The production of the 15 European Union countries together is 31.2%. When adjustments are made for economic or population factors, other countries show their importance: Israel and Sweden, for example. Authors from richer countries participate in more than 95% of the articles, whereas those in less-developed countries tend to publish less, and when they do so, it is through collaboration with more-developed countries. In general, only 10.5% of the articles are written in collaboration with institutions from different countries. One of the keys to stimulating research in less wealthy countries would seem to be precisely through collaboration. This would aid the transfer of knowledge and experience, allowing researchers in these countries to obtain autonomy to perform their own studies independently and to provide them with the ability to gain access for their publications at the international level.

Aged↗
PubMed2005

Antiaging medicine and mild cognitive impairment: practice and policy issues for geriatrics.

The claim that aging itself is treatable or even preventable has repeatedly been made over the centuries. Antiaging medicine is the current leader of approaches that even claim that geriatrics as a discipline will become increasingly unnecessary. The concept of mild cognitive impairment (MCI) as a condition intermediate between normal cognitive aging and Alzheimer's disease highlights the conceptual and practical difficulty of differentiating aging from disease. What should geriatricians and their organizations make of scientifically mainstream attempts to decelerate, arrest, or compress aspects of the normal human aging, including the brain aging process? This article reviews the political, philosophical, practice-related, and economical implications of antiaging medicine for geriatrics using MCI as a practical example. It concludes by suggesting actions that geriatricians should consider to strengthen their profession and to improve patient care in response to the challenges of longevity medicine.

Aged↗
PubMed2005

The state of chronic pain education in geriatric medicine fellowship training programs: results of a national survey.

A survey of U.S. geriatric medicine fellowship training programs was performed to assess the status of teaching about chronic pain evaluation and management and identify opportunities for improvement. After an initial e-mail query, 43 of 96 programs agreed to participate. A self-administered questionnaire, with items adapted from a 2002 consensus panel statement, was mailed to their 171 fellows-in-training and 43 fellowship directors. Thirty-two programs (33% of nationwide sample) including 79 fellows (30% of nationwide sample) and 25 directors (26% of nationwide sample) returned surveys; 21 institutions returned both faculty and fellow surveys. Overall, directors endorsed the 19 items identified by the consensus panel as essential components of fellowship training, but fellows identified deficiencies, both before and during fellowship training. Specific areas of undereducation included comprehensive musculoskeletal assessment, neuropathic pain evaluation, indications for low back pain imaging, the role of multidisciplinary pain clinics and nonpharmacological modalities, the effect of physical and psychosocial comorbidities in formulating treatment goals, and the effect of aging on analgesic metabolism and prescription. Both groups were generally positive about fellows' abilities to implement pain-related clinical skills. Discrepancies existed between fellowship directors' ratings of importance of teaching individual items and the degree to which teaching was actually done, as well as faculty versus fellow assessments of whether some of the 19 items were taught. Primary care training programs (e.g., internal medicine, family medicine, geriatric medicine) should pay more systematic attention to educating trainees about chronic pain to optimize patient care, decrease suffering, and diminish healthcare expenditures.

Aged↗
PubMed1996

Motivation in geriatric rehabilitation.

In this study, critical ethnography was used to explore the factors that help motivate people in a geriatric rehabilitation unit and factors that decreased motivation. Five key informants were chosen using purposeful selection. The participants were white women with an average age of 87. The women were interviewed within the first week of admission and follow up interviews were done at 3- to 5-day intervals. Each informant was interviewed at least three times and one informant was interviewed eight times. Additionally, participants were observed in therapy and on the nursing unit. The following themes emerged regarding factors that improved motivation -- goals, humor, caring, beliefs, encouragement, a motive disposition, and "power with" relationships. Several factors decreased motivation including feelings of domination and negative beliefs. The study helped identify ways in which clinicians can motivate older adults in a geriatric rehabilitation program.

Aged↗
PubMed1997

Emergency department evaluation of geriatric patients with acute cholecystitis.

OBJECTIVE: To estimate the frequency of abnormal clinical symptoms, laboratory tests, and diagnostic imaging studies in the ED assessment of elderly (> or = 65 yr) patients with acute cholecystitis, and to compare these factors in young-old (65-74 yr), middle-old (75-84 yr), and old-old (> or = 85 yr) population groups. METHODS: A retrospective, cross-sectional study was performed by review of ED records, hospital charts, and surgical operative reports of consecutive elderly ED patients determined at surgery to have acute cholecystitis. Records were reviewed between April 1990 and April 1995 at a large Midwestern tertiary care facility with 65,000 annual ED patient visits. Clinical signs and symptoms were compared in the young-old, middle-old, and old-old population groups. RESULTS: Of the 168 patients reviewed, 141 (84%) had neither epigastric or right upper quadrant abdominal pain, and 8 (5%) had no pain whatsoever. Only 61 patients (36%) had back or flank pain radiation. Ninety-six (57%) experienced nausea, 64 (38%) had emesis, and 13 (8%) had visible jaundice. Ninety-four (56%) patients were afebrile and 69 (41%) had no increase of white blood cell count. Twenty-two (13%) patients had no fever and all tests were normal. No statistical difference was noted in any symptom or laboratory factor for the 3 age groups, except jaundice was more common among the patients aged > or = 85 years. Ultrasonography was diagnostic for 91%, and CT was beneficial for only 1 patient. Eight patients had normal results on their ultrasonographic and CT studies. CONCLUSION: Classic symptoms and abnormal blood test results are frequently not present in geriatric patients with acute cholecystitis. Increasing age does not appear to affect the clinical and test markers used by clinicians to diagnose this illness. A high degree of awareness is essential for correct diagnosis of acute cholecystitis in geriatric patients.

Acute Disease↗
PubMed2000

Conducting geriatric dental research with cognitively impaired adults.

A growth in research focusing on the oral health of older adults has been evident in recent years. However, there are new and complex challenges for geriatric dental researchers studying the increasingly functionally dependent and cognitively impaired older adult population. Many geriatric dental studies have under-reported oral disease prevalence and incidence by excluding adults who are cognitively impaired and/or behaviourally difficult. To ensure representative samples of older adult populations are studied, traditional oral epidemiological protocols in studies with cognitively impaired adults, require additional components detailing: (1) communication and behaviour management strategies for cognitively impaired adults; and (2) methodologies to facilitate the completion of dental examinations. A description of such additional protocol components is presented, along with a discussion of the use of cognitive testing tools by dental researchers.

Adult↗
PubMed2006

The Yad Sarah geriatric dental clinic, a different model.

INTRODUCTION: There are not sufficient dental services for elderly people around the world. Yad Sarah is an Israel-wide network of volunteers aiding sick, elderly, isolated and housebound people with an array of services aimed at making home care possible. It provides medical and social services to more than 380 000 elderly persons per year and in addition, lends medical equipment free of charge, has day rehabilitation centres, legal aid council for seniors, provides transportation for the disabled, meal deliveries and geriatric dental services. MATERIALS AND METHODS: The latter are equipped with five dental units (one mobile unit) and a dental laboratory. During the 5 years from 2000 to 2004 the dental services provided dental care for 3890 elderly patients with the main clinic located in Jerusalem. Patients pay an average of 70% of the cost price of their dental care, with the difference being subsidised by Yad Sarah. Of the 515 patients who applied for treatment in 2004, 54% possessed natural teeth in both jaws, 28% were fully edentulous, 12% were edentulous in the maxilla and 6% were edentulous in the mandible. Females applied for dental treatment more often than the male population. Older patients (75-101 years old) required oral care at their homes or at old age residences, more frequently than the younger age groups (60-74 years old). CONCLUSION: Dental treatment was administered by 70 volunteer dental surgeons, two certified dental hygienists and dental hygienist students. The clinical staff was provided with a comprehensive in-service training in geriatric dentistry during the 3-year service learning period. A survey in 2004 showed that 83% of the selected patients were satisfied, compared with 14% who were not. The reasons for satisfaction were, mainly, the personal relationship with the attending staff (41%) and the professional ability of the dental team (46%).

Aged↗
PubMedDate not supplied

An analysis of the supply of and demand for continuing education in geriatric dentistry.

Continuing education directors at 158 sites were surveyed regarding their recent experience with geriatric dentistry courses. Of the 116 returns cited, 86 recorded offering courses with a total enrollment of 4,559 students. The courses tended to be of the survey type using a lecture format. Most directors thought that practitioner demand for such courses fell short of their need for education. Several suggestions emanated from this project for improving course attendance. They included: targeting courses to specific clinical areas; providing separate courses for each segment of the geriatric population; and educating both elders and dentists regarding the appropriateness of dental care for the elderly patient.

Curriculum↗
PubMedDate not supplied

Oral health needs of elderly short-term patients in a geriatric department of a general hospital.

The purpose of this study was to estimate the realistic dental needs of an elderly short-stay patient in a geriatric department. One segment of the elderly population at risk for whom surveillance would appear extremely important are those admitted temporarily to the hospital for acute or acute-on-chronic care. Little has been written about the oral needs of such patients. The study population was comprised of 468 patients of a geriatric department in a medical center examined by a dentist trained in gerodontics. An evaluation of the results showed that 65.3% needed direct oral hygiene assistance. Only 16.4% are able to participate in oral hygiene instruction; a few of them--6.6%--had a need of prosthodontic treatment. A once-weekly screening program was required to handle the oral problems, mainly Candida infections. Close cooperation with the ward staff is essential in order to develop and promote good oral hygiene for this very frail elderly population.

Acute Disease↗
PubMedDate not supplied

Delphi study to identify core competencies in geriatric dentistry.

The Delphi technique and an expert panel of general practitioners were used to identify geriatric dentistry core competencies--the necessary knowledge, skills, and values of new graduates to meet the oral health needs of older patients. Of the 74 dentists solicited, 50 dentists agreed to participate, and 40 dentists returned two questionnaires. Respondents were mostly male, white, in solo practice, with a mean age of 51.6 (SD 7.4) years. The first survey asked the participants to identify at least three topics in geriatric dentistry that they believed to be essential to a dental curriculum to graduate competent practitioners who can effectively treat older patients. The 45 unique responses were used in the second questionnaire that asked the practitioners to rate the importance of each topic for inclusion in a curriculum. For the 29 items describing skills, respondents indicated how often they performed the skill in their practices. Finally, the respondents considered all 45 items, and selected the five most crucial topics. Overall, participants achieved good consensus as to core knowledge, skills, and values needed to provide general dental care to older patients.

Clinical Competence↗
PubMedDate not supplied

Care of the geriatric patient in chronic renal failure.

Currently, there are around one million chronic dialysis patients worldwide. More than half of these are older than 65. For various reasons this is a fast growing population. When the indication is considered to start dialysis, a distinction must be made between biological age in the third and fourth decade on the one hand, and a specific geriatric profile on the other, which implies adequate gerontological knowledge. Besides the patient-directed choice of the best tolerated treatment technique, the specific treatment of age-linked polypathology as well as the appropriate approach of inter- and intradialysis related problems regarding access and haemodynamics are the best guaranties of success in this highest age dialysis group. By means of a multidisciplinary geriatric assessment, which makes it possible to carry out an objective analysis and observation from the somatic, psychic and social points of view, an ultimate objective is achieved: the improvement of quality of life by means of rehabilitation. The survival of elderly dialysis patients has favourably evolved since the 90's after the introduction of EPO, bicarbonate dialysate, the monitoring of dialysis adequacy and support of prognostic and comorbid factors. The problems surrounding dialysis drop-out is a sensitive and controversial matter in which well founded communication with the patient, the family, the dialysis team, domestic care and the general practitioner is vital. "Add life to years and not years to life" remains a challenge for every nephrologist.

Age Factors↗
PubMed2004

Emergence and spread of three clonally related virulent isolates of CTX-M-15-producing Escherichia coli with variable resistance to aminoglycosides and tetracycline in a French geriatric hospital.

Three types of multidrug-resistant Escherichia coli isolates, called GEN S, GEN R, and AMG S, according to their three different aminoglycoside resistance patterns, were responsible for urinary tract colonization or infection in 87, 12, and 13 new patients, respectively, in a French 650-bed geriatric hospital over a 13-month period. The three E. coli types belonged to the same clone and phylogenetic group (group B2) and had identical transferable plasmid contents (a 120-kb plasmid), beta-lactam and fluoroquinolone resistance genotypes (bla(TEM-1B), bla(CTX-M-15), and double mutations in both the gyrA and the parC genes), and virulence factor genotypes (aer, fyuA, and irp2). They disseminated in the geriatric hospital, where the antibiotics prescribed most often were fluoroquinolones and ceftriaxone, but not in the affiliated acute-care hospital, where isolation precautions were applied to the transferred patients. Thus, E. coli isolates, both CTX-M-type beta-lactamase producers and fluoroquinolone-resistant isolates, might present a new challenge for French health care settings.

Aged↗
PubMed1977

Geriatric medicine in Hull: a comprehensive service.

A partially age-related admission policy coupled with a "single-ward" scheme for treatment and rehabilitation was introduced by the Hull geriatric department in 1970. With rare exceptions, elderly patients needing hospital care have been admitted directly to the geriatric unit, and the proportion of the retired population admitted by the general physicians has been greatly reduced. The proportion of inpatients needing continuing care has been reduced to less than 20%, the mean length of inpatient stay has fallen to under 30 days, and separate long-stay wards are no longer needed. More than 91% of patients are admitted without preceding domiciliary assessment, and only 5-6% of admissions are transferred from other units within the area.

Age Factors↗