Comprehensive geriatric assessment for older hospital patients

Short-term Resource Utilization and Cost-Effectiveness of Comprehensive Geriatric Assessment in Acute Hospital Care for Severely Frail Elderly Patients

OBJECTIVE

The objective of this study was to estimate the 3-month within-trial cost-effectiveness of comprehensive geriatric assessment (CGA) in acute medical care for frail elderly patients compared to usual medical care, by estimating health-related quality of life and costs from a societal perspective.

DESIGN

Clinical, prospective, controlled, 1-center intervention trial with 2 parallel groups.

INTERVENTION

Structured, systematic interdisciplinary CGA-based care in an acute elderly care unit. If the patient fulfilled the inclusion criteria, and there was a bed available at the CGA unit, the patient was included in the intervention group. If no bed was available at the CGA unit, the patient was included in the control group and admitted to a conventional acute medical care unit.

SETTING AND PARTICIPANTS

A large county hospital in western Sweden. The trial included 408 frail elderly patients, 75 years or older, in need of acute in-hospital treatment. The patients were allocated to the intervention group (n = 206) or control group (n = 202). Mean age of the patients was 85.7 years, and 56% were female.

MEASURES

The primary outcome was the adjusted incremental cost-effectiveness ratio associated with the intervention compared to the control at the 3-month follow-up.

RESULTS

We undertook cost-effectiveness analysis, adjusted by regression analyses, including hospital, primary, and municipal care costs and effects. The difference in the mean adjusted quality-adjusted life years gained between groups at 3 months was 0.0252 [95% confidence interval (CI): 0.0082-0.0422]. The incremental cost, that is, the difference between the groups, was -3226 US dollars (95% CI: -6167 to -285).

CONCLUSION

The results indicate that the care in a CGA unit for acutely ill frail elderly patients is likely to be cost-effective compared to conventional care after 3 months.

Quality indicators for in-hospital geriatric co-management programmes: a systematic literature review and international Delphi study

OBJECTIVE

To find consensus on appropriate and feasible structure, process and outcome indicators for the evaluation of in-hospital geriatric co-management programmes.

DESIGN

An international two-round Delphi study based on a systematic literature review (searching databases, reference lists, prospective citations and trial registers).

SETTING

Western Europe and the USA.

PARTICIPANTS

Thirty-three people with at least 2 years of clinical experience in geriatric co-management were recruited. Twenty-eight experts (16 from the USA and 12 from Europe) participated in both Delphi rounds (85% response rate).

MEASURES

Participants rated the indicators on a nine-point scale for their (1) appropriateness and (2) feasibility to use the indicator for the evaluation of geriatric co-management programmes. Indicators were considered appropriate and feasible based on a median score of seven or higher. Consensus was based on the level of agreement using the RAND/UCLA Appropriateness Method.

RESULTS

In the first round containing 37 indicators, there was consensus on 14 indicators. In the second round containing 44 indicators, there was consensus on 31 indicators (structure=8, process=7, outcome=16). Experts indicated that co-management should start within 24 hours of hospital admission using defined criteria for selecting appropriate patients. Programmes should focus on the prevention and management of geriatric syndromes and complications. Key areas for comprehensive geriatric assessment included cognition/delirium, functionality/mobility, falls, pain, medication and pressure ulcers. Key outcomes for evaluating the programme included length of stay, time to surgery and the incidence of complications.

CONCLUSION

The indicators can be used to assess the performance of geriatric co-management programmes and identify areas for improvement. Furthermore, the indicators can be used to monitor the implementation and effect of these programmes.

Comprehensive geriatric assessment pilot of a randomized control study in a Swedish acute hospital: a feasibility study

BACKGROUND

Comprehensive geriatric assessment (CGA) represent an important component of geriatric acute hospital care for frail older people, secured by a multidisciplinary team who addresses the multiple needs of physical health, functional ability, psychological state, cognition and social status. The primary objective of the pilot study was to determine feasibility for recruitment and retention rates. Secondary objectives were to establish proof of principle that CGA has the potential to increase patient safety.

METHODS

The CGA pilot took place at a University hospital in Western Sweden, from March to November 2016, with data analyses in March 2017. Participants were frail people aged 75 and older, who required an acute admission to hospital. Participants were recruited and randomized in the emergency room. The intervention group received CGA, a person-centered multidisciplinary team addressing health, participation, and safety. The control group received usual care. The main objective measured the recruitment procedure and retention rates. Secondary objectives were also collected regarding services received on the ward including discharge plan, care plan meeting and hospital risk assessments including risk for falls, nutrition, decubitus ulcers, and activities of daily living status.

RESULT

Participants were recruited from the emergency department, over 32 weeks. Thirty participants were approached and 100% (30/30) were included and randomized, and 100% (30/30) met the inclusion criteria. Sixteen participants were included in the intervention and 14 participants were included in the control. At baseline, 100% (16/16) intervention and 100% (14/14) control completed the data collection. A positive propensity towards the secondary objectives for the intervention was also evidenced, as this group received more care assessments. There was an average difference between the intervention and control in occupational therapy assessment - 0.80 [95% CI 1.06, - 0.57], occupational therapy assistive devices - 0.73 [95% CI 1.00, - 0.47], discharge planning -0.21 [95% CI 0.43, 0.00] and care planning meeting 0.36 [95% CI-1.70, -0.02]. Controlling for documented risk assessments, the intervention had for falls - 0.94 [95% CI 1.08, - 0.08], nutrition - 0.87 [95% CI 1.06, - 0.67], decubitus ulcers - 0.94 [95% CI 1.08, - 0.80], and ADL status - 0.80 [95% CI 1.04, - 0.57].

CONCLUSION

The CGA pilot was feasible and proof that the intervention increased safety justifies carrying forward to a large-scale study.

TRIAL REGISTRATION

Clinical Trials ID: NCT02773914. Registered 16 May 2016.

Comprehensive geriatric assessment in patients undergoing transcatheter aortic valve implantation - results from the CGA-TAVI multicentre registry

Background

In older patients with aortic stenosis (AS) undergoing TAVI, the potential role of prior CGA is not well established. To explore the value of comprehensive geriatric assessment (CGA) for predicting mortality and/or hospitalisation within the first 3 months after transcatheter aortic valve implantation (TAVI).

Methods

An international, multi-centre, prospective registry (CGA-TAVI) was established to gather data on CGA results and medium-term outcomes in geriatric patients undergoing TAVI. Logistic regression was used to evaluate the predictive value of a multidimensional prognostic index (MPI); a short physical performance battery (SPPB); and the Silver Code, which was based on administrative data, for predicting death and/or hospitalisation in the first 3 months after TAVI (primary endpoint).

Results

A total of 71 TAVI patients (mean age 85.4 years; mean log EuroSCORE I 22.5%) were enrolled. Device success according to VARC criteria was 100%. After adjustment for selected baseline characteristics, a higher (poorer) MPI score (OR: 3.34; 95% CI: 1.39–8.02; p = 0.0068) and a lower (poorer) SPPB score (OR: 1.15; 95% CI: 1.01–1.54; p = 0.0380) were found to be associated with an increased likelihood of the primary endpoint. The Silver Code did not show any predictive ability in this population.

Conclusions

Several aspects of the CGA have shown promise for being of use to physicians when predicting TAVI outcomes. While the MPI may be useful in clinical practice, the SPPB may be of particular value, being simple and quick to perform. Validation of these findings in a larger sample is warranted.

Trial registration

The trial was registered in ClinicalTrials.gov on November 7, 2013 (NCT01991444).

Understanding What Is Most Important to Individuals with Multiple Chronic Conditions: A Qualitative Study of Patients' Perspectives

BACKGROUND

To improve care for individuals living with multiple chronic conditions, patients and providers must align care planning with what is most important to patients in their daily lives. We have a limited understanding of how to effectively encourage communication about patients' personal values during clinical care.

OBJECTIVE

To identify what patients with multiple chronic conditions describe as most important to their well-being and health.

DESIGN

We interviewed individuals with multiple chronic conditions in their homes and analyzed results qualitatively, guided by grounded theory.

PARTICIPANTS

A total of 31 patients (mean age 68.7 years) participated in the study, 19 of which included the participation of family members. Participants were from Kaiser Permanente Washington, an integrated health care system in Washington state.

APPROACH

Qualitative analysis of home visits, which consisted of semi-structured interviews aided by photo elicitation.

KEY RESULTS

Analysis revealed six domains of what patients described as most important for their well-being and health: principles, relationships, emotions, activities, abilities, and possessions. Personal values were interrelated and rarely expressed as individual values in isolation.

CONCLUSIONS

The domains describe the range and types of personal values multimorbid older adults deem important to well-being and health. Understanding patients' personal values across these domains may be useful for providers when developing, sharing, and following up on care plans.

Using comprehensive geriatric assessment for quality improvements in healthcare of older people in UK care homes: protocol for realist review within Proactive Healthcare of Older People in Care Homes (PEACH) study

INTRODUCTION

Care home residents are relatively high users of healthcare resources and may have complex needs. Comprehensive geriatric assessment (CGA) may benefit care home residents and improve efficiency of care delivery. This is an approach to care in which there is a thorough multidisciplinary assessment (physical and mental health, functioning and physical and social environments) and a care plan based on this assessment, usually delivered by a multidisciplinary team. The CGA process is known to improve outcomes for community-dwelling older people and those in receipt of hospital care, but less is known about its efficacy in care home residents.

METHODS AND ANALYSIS

Realist review was selected as the most appropriate method to explore the complex nature of the care home setting and multidisciplinary delivery of care. The aim of the realist review is to identify and characterise a programme theory that underpins the CGA intervention. The realist review will extract data from research articles which describe the causal mechanisms through which the practice of CGA generates outcomes. The focus of the intervention is care homes, and the outcomes of interest are health-related quality of life and satisfaction with services; for both residents and staff. Further outcomes may include appropriate use of National Health Service services and resources of older care home residents. The review will proceed through three stages: (1) identifying the candidate programme theories that underpin CGA through interviews with key stakeholders, systematic search of the peer-reviewed and non-peer-reviewed evidence, (2) identifying the evidence relevant to CGA in UK care homes and refining the programme theories through refining and iterating the systematic search, lateral searches and seeking further information from study authors and (3) analysis and synthesis of evidence, involving the testing of the programme theories.

ETHICS AND DISSEMINATION

The PEACH project was identified as service development following submission to the UK Health Research Authority and subsequent review by the University of Nottingham Research Ethics Committee. The study protocols have been reviewed as part of good governance by the Nottinghamshire Healthcare Foundation Trust. We aim to publish this realist review in a peer-reviewed journal with international readership. We will disseminate findings to public and stakeholders using knowledge mobilisation techniques. Stakeholders will include the Quality Improvement Collaboratives within PEACH study. National networks, such as British Society of Gerontology and National Care Association will be approached for wider dissemination.

TRIAL REGISTRATION NUMBER

The realist review has been registered on International Prospective Register of Systematic Reviews (PROSPERO 2017: CRD42017062601).

Understanding implementation of comprehensive geriatric care programs: a multiple perspective approach is preferred

BACKGROUND

The Prevention and Reactivation Care Program (PReCaP) provides a novel approach targeting hospital-related functional decline among elderly patients. Despite the high expectations, the PReCaP was not effective in preventing functional decline (ADL and iADL) among older patients. Although elderly PReCaP patients demonstrated slightly better cognitive functioning (Mini Mental State Examination; 0.4 [95% confidence interval (CI) 0.2-0.6]), lower depression (Geriatric Depression Scale 15; -0.9 [95% -1.1 to -0.6]), and higher perceived health (Short-form 20; 5.6 [95% CI 2.8-8.4]) 1 year after admission than control patients, the clinical relevance was limited. Therefore, this study aims to identify factors impacting on the effectiveness of the implementation of the PReCaPand geriatric care 'as usual'.

METHODS

We conducted semi-structured interviews with 34 professionals working with elderly patients in three hospitals, selected for their comparable patient case mix and different levels of geriatric care. Five non-participatory observations were undertaken during multidisciplinary meetings. Patient files (n = 42), hospital protocols, and care plans were screened for elements of geriatric care. Clinical process data were analysed for PReCaP components.

RESULTS

The establishment of a geriatric unit and employment of geriatricians demonstrates commitment to geriatric care in hospital A. Although admission processes are comparable, early identification of frail elderly patients only takes place in hosptial A. Furthermore, nursing care in the hospital A geriatric unit excels with regard to maximizing patient independency, an important predictor for hospital-related functional decline. Transfer nurses play a key role in arranging post-discharge geriatric follow-up care. Geriatric consultations are performed by geriatricians, geriatric nurses, and PReCaP case managers in hospital A. Yet hospital B consultative psychiatric nurses provide similar consultation services. The combination of standardized procedures, formalized communication channels, and advanced computerization contributes significantly to geriatric care in hospital B. Nevertheless, a small size hospital (hospital C) provides informal opportunities for information sharing and decision making, which are essential in geriatric care, given its multidisciplinary nature.

CONCLUSIONS

Geriatric care for patients with multimorbidity requires a multidisciplinary approach in a geriatric unit. Geriatric care, which integrates medical and reactivation treatment, by means of early screening of risk factors for functional decline, promotion of physical activity, and adequate discharge planning, potentially reduces the incidence of functional decline in elderly patients. Yet low treatment fidelity played a major role in the ineffective implementation of the PReCaP. Treatment fidelity issues are caused by various factors, including the complexity of projects, limited attention for implementation, and inadequate interdisciplinary communication. © 2016 The Authors The International Journal of Health Planning and Management Published by John Wiley & Sons Ltd.

The potential clinical benefits of medicines optimisation through comprehensive geriatric assessment, carried out by secondary care geriatricians, in a general practice care setting in North Staffordshire, UK: a feasibility study

OBJECTIVES

To evaluate the feasibility and potential clinical benefits of medicines optimisation through comprehensive geriatric assessment (CGA) of frail patients with multiple conditions, by secondary care geriatricians in a general practice care setting.

METHODS

Seven general practitioner (GP) practices in one region of Stoke-on-Trent volunteered to take part. GPs selected patients (n=186) who were local permanent residents, at least 65 years old and on eight or more medications per day. Patients were sent a written invitation outlining the assessment purpose/format. Prior to patient assessments, primary care staff prepared packs detailing patient medical history, recent consultations, current medications, recent laboratory tests and social circumstances. One hour was allocated for the CGA per patient, with one of three geriatricians, to enable sufficient time to explore all relevant aspects. Assessment comprised a full history, thorough clinical examination, assessment of balance and mobility, mental function and information on home environment and support arrangements. After consultation, geriatricians made recommendations regarding further assessments, investigations or medication changes. Geriatricians entered their main findings and recommendations onto a standard template.

RESULTS

In total, 687 recommendations for changes in patients' medication regimens were made for 169 (91%) patients. In 17 (9%) patients there was no recommendation to alter medications. This resulted in an average of four alterations in medication per patient. The predominant changes to medications were to stop medications (34%) or to reduce the dosage (24%). Starting a new medication represented 18% of all the medication changes. Adherence rates to geriatrician medication recommendations were 72% at 6 months and 65% at 12 months.

CONCLUSIONS

CGA of older patients with complex needs, by geriatricians in a general practice care setting, is feasible. Our study demonstrated constructive collaboration between GPs and geriatricians from secondary care, suggesting further studies and clinical trials are feasible and have scope to yield beneficial outcomes.

Comprehensive geriatric assessment for older adults admitted to hospital

BACKGROUND

Comprehensive geriatric assessment (CGA) is a multi-dimensional, multi-disciplinary diagnostic and therapeutic process conducted to determine the medical, mental, and functional problems of older people with frailty so that a co-ordinated and integrated plan for treatment and follow-up can be developed. This is an update of a previously published Cochrane review.

OBJECTIVES

We sought to critically appraise and summarise current evidence on the effectiveness and resource use of CGA for older adults admitted to hospital, and to use these data to estimate its cost-effectiveness.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, three other databases, and two trials registers on 5 October 2016; we also checked reference lists and contacted study authors.

SELECTION CRITERIA

We included randomised trials that compared inpatient CGA (delivered on geriatric wards or by mobile teams) versus usual care on a general medical ward or on a ward for older people, usually admitted to hospital for acute care or for inpatient rehabilitation after an acute admission.

DATA COLLECTION AND ANALYSIS

We followed standard methodological procedures expected by Cochrane and Effective Practice and Organisation of Care (EPOC). We used the GRADE approach to assess the certainty of evidence for the most important outcomes. For this update, we requested individual patient data (IPD) from trialists, and we conducted a survey of trialists to obtain details of delivery of CGA. We calculated risk ratios (RRs), mean differences (MDs), or standardised mean differences (SMDs), and combined data using fixed-effect meta-analysis. We estimated cost-effectiveness by comparing inpatient CGA versus hospital admission without CGA in terms of cost per quality-adjusted life year (QALY) gained, cost per life year (LY) gained, and cost per life year living at home (LYLAH) gained.

MAIN RESULTS

We included 29 trials recruiting 13,766 participants across nine, mostly high-income countries. CGA increases the likelihood that patients will be alive and in their own homes at 3 to 12 months' follow-up (risk ratio (RR) 1.06, 95% confidence interval (CI) 1.01 to 1.10; 16 trials, 6799 participants; high-certainty evidence), results in little or no difference in mortality at 3 to 12 months' follow-up (RR 1.00, 95% CI 0.93 to 1.07; 21 trials, 10,023 participants; high-certainty evidence), decreases the likelihood that patients will be admitted to a nursing home at 3 to 12 months follow-up (RR 0.80, 95% CI 0.72 to 0.89; 14 trials, 6285 participants; high-certainty evidence) and results in little or no difference in dependence (RR 0.97, 95% CI 0.89 to 1.04; 14 trials, 6551 participants; high-certainty evidence). CGA may make little or no difference to cognitive function (SMD ranged from -0.22 to 0.35 (5 trials, 3534 participants; low-certainty evidence)). Mean length of stay ranged from 1.63 days to 40.7 days in the intervention group, and ranged from 1.8 days to 42.8 days in the comparison group. Healthcare costs per participant in the CGA group were on average GBP 234 (95% CI GBP -144 to GBP 605) higher than in the usual care group (17 trials, 5303 participants; low-certainty evidence). CGA may lead to a slight increase in QALYs of 0.012 (95% CI -0.024 to 0.048) at GBP 19,802 per QALY gained (3 trials; low-certainty evidence), a slight increase in LYs of 0.037 (95% CI 0.001 to 0.073), at GBP 6305 per LY gained (4 trials; low-certainty evidence), and a slight increase in LYLAH of 0.019 (95% CI -0.019 to 0.155) at GBP 12,568 per LYLAH gained (2 trials; low-certainty evidence). The probability that CGA would be cost-effective at a GBP 20,000 ceiling ratio for QALY, LY, and LYLAH was 0.50, 0.89, and 0.47, respectively (17 trials, 5303 participants; low-certainty evidence).

AUTHORS' CONCLUSIONS

Older patients are more likely to be alive and in their own homes at follow-up if they received CGA on admission to hospital. We are uncertain whether data show a difference in effect between wards and teams, as this analysis was underpowered. CGA may lead to a small increase in costs, and evidence for cost-effectiveness is of low-certainty due to imprecision and inconsistency among studies. Further research that reports cost estimates that are setting-specific across different sectors of care are required.

Why geriatric medicine? A survey of UK specialist trainees in geriatric medicine

Background

there is concern that there are insufficient numbers of geriatricians to meet the needs of the ageing population. A 2005 survey described factors that influenced why UK geriatricians had chosen to specialise in the field-in the decade since, UK postgraduate training has undergone a fundamental restructure.

Objective

to explore whether the reasons for choosing a career in geriatric medicine in the UK had changed over time, with the goal of using this knowledge to inform recruitment and training initiatives.

Design

an online survey was sent to all UK higher medical trainees in geriatric medicine.

Methods

survey questions that produced categorical data were analysed with simple descriptive statistics. For the survey questions that produced free-text responses, an inductive, iterative approach to analysis, in keeping with the principles of framework analysis, was employed.

Results

two hundred and sixty-nine responses were received out of 641 eligible respondents. Compared with the previous survey, a substantially larger number of respondents regarded geriatric medicine to be their first-choice specialty and a smaller number regretted their career decision. A greater number chose geriatric medicine early in their medical careers. Commitments to the general medical rota and the burden of service provision were considered important downsides to the specialty.

Conclusions

there are reasons to be optimistic about recruitment to geriatric medicine. Future attempts to drive up recruitment might legitimately focus on the role of the medical registrar and perceptions that geriatricians shoulder a disproportionate burden of service commitments and obligations to the acute medical take.

Can we predict functional decline in hospitalized older people admitted through the emergency department? Reanalysis of a predictive tool ten years after its conception

Background

In the Emergency Department (ED), early and rapid identification of older people at risk of adverse outcomes, who could best benefit from complex geriatric intervention, would avoid wasting time, especially in terms of prevention of adverse outcomes, and ensure optimal orientation of vulnerable patients. We wanted to test the predictive ability of a screening tool assessing risk of functional decline (FD), named SHERPA, 10 years after its conception, and to assess the added value of other clinical or biological factors associated with FD.

Methods

A prospective cohort study of older patients (n = 305, ≥ 75 years) admitted through the emergency department, for at least 48 h in non-geriatric wards (mean age 82.5 ± 4.9, 55% women). SHERPA variables (i.e. age, pre-admission instrumental Activity of Daily Living (ADL) status, falls within a year, self-rated health and 21-point MMSE) were collected within 48 h of admission, along with socio-demographic, medical and biological data. Functional status was followed at 3 months by phone. FD was defined as a decrease at 3 months of at least one point in the pre-admission basic ADL score. Predictive ability of SHERPA was assessed using c-statistic, predictive values and likelihood ratios. Measures of discrimination improvement were Net Reclassification Improvement and Integrated Discrimination Improvement.

Results

One hundred and five patients (34%) developed 3-month FD. Predictive ability of SHERPA decreased dramatically over 10 years (c = 0.73 vs. 0.64). Only two of its constitutive variables, i.e. falls and instrumental ADL, were significant in logistic regression analysis for functional decline, while 21-point MMSE was kept in the model for clinical relevance. Demographic, comorbidity or laboratory data available upon admission did not improve the SHERPA predictive yield.

Conclusions

Prediction of FD with SHERPA is difficult, but predictive factors, i.e. falls, pre-existing functional limitation and cognitive impairment, stay consistent across time and with literature. As accuracy of SHERPA and others existing screening tools for FD is moderate, using these predictors as flags instead of using composite scales can be a way to screen for high-risk patients.

Electronic supplementary material

The online version of this article (doi:10.1186/s12877-017-0498-0) contains supplementary material, which is available to authorized users.

ANMCO Position Paper: hospital discharge planning: recommendations and standards

The hospital discharge is often poorly standardized and affected by discontinuity and fragmentation of care, putting patients at high risk of both post-discharge adverse events and early readmission. The present ANMCO document reviews the modifiable components of the hospital discharge process related to adverse events or re-hospitalizations and suggests the optimal methods for redesigning the whole discharge process. The key principles for proper hospital discharge or transfer of care acknowledge that the hospital discharge: • is not an isolated event, but a process that has to be planned as soon as possible after the admission, ensuring that the patient and the caregiver understand and contribute to the planned decisions, as equal partners; • is facilitated by a comprehensive systemic approach that begins with a multidimensional evaluation process; • must be organized by an operator who is responsible for the coordination of all phases of the hospital patient journey, involving afterward the general practitioner and transferring to them the information and responsibility at discharge; • is the result of an integrated multidisciplinary team approach; • appropriately uses the transitional and intermediate care services; • is carried out in an organized system of care and continuum of services; and • programs the passage of information to after-discharge services.

Cooperation between geriatricians and general practitioners for improved pharmacotherapy in home-dwelling elderly people receiving polypharmacy - the COOP Study: study protocol for a cluster randomised controlled trial

Background

Polypharmacy and inappropriate drug use is associated with negative health outcomes among older people. Various interventions for improving drug treatment have been evaluated, but the majority of studies are limited by the use of surrogate outcomes or suboptimal design. Thus, the potential for clinically significant improvements from different interventions is still unclear. The main objective of this study is therefore to evaluate the effect upon patient-relevant endpoints of a cooperation between geriatricians and general practitioners on complex drug regimens in home-dwelling elderly people.

Methods

This is a cluster randomised, single-blind, controlled trial where general practitioners are invited to participate with patients from their lists. The patients must be 70 years or older, use at least seven different medications and have their medications administered by the home nursing service. We plan to recruit 200 patients, with randomisation at physician level. The intervention consists of three main parts: (1) clinical geriatric assessment of the patient, combined with a thorough review of their medications; (2) a meeting between the geriatrician and general practitioner, where the two physicians combine their competence and knowledge and discuss the drug list systematically; (3) clinical follow-up, depending on the medication changes that have been done. The study period is 24 weeks, and the patients are assessed at baseline, 16 and 24 weeks. The primary outcome measure is health-related quality of life according to the 15D instrument. Secondary outcome measures include physical and cognitive functioning, medication appropriateness, falls, carer burden, use of health services (hospital or nursing home admissions, use of home nursing services) and mortality.

Discussion

Our choice of patient-relevant outcome measures will hopefully provide new knowledge on the potential for clinical improvements after performing comprehensive medication reviews in home-dwelling elderly people receiving polypharmacy.

Trial registration

ClinicalTrials.gov, NCT02379455. Registered on 27 February 2015.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-017-1900-0) contains supplementary material, which is available to authorized users.

Implementation of integrated geriatric care at a German hospital: a case study to understand when and why beneficial outcomes can be achieved

BACKGROUND

Many health systems have implemented integrated care as an alternative approach to health care delivery that is more appropriate for patients with complex, long-term needs. The objective of this article was to analyse the implementation of integrated care at a German geriatric hospital and explore whether the use of a "context-mechanisms-outcomes"-based model provides insights into when and why beneficial outcomes can be achieved.

METHODS

We conducted 15 semi-structured interviews with health professionals employed at the hospital. The data were qualitatively analysed using a "context-mechanisms-outcomes"-based model. Specifically, mechanisms were defined as the different components of the integrated care intervention and categorised according to Wagner's Chronic Care Model (CCM). Context was understood as the setting in which the mechanisms are brought into practice and described by the barriers and facilitators encountered in the implementation process. These were categorised according to the six levels of Grol and Wensing's Implementation Model (IM): innovation, individual professional, patient, social context, organisational context and economic and political context. Outcomes were defined as the effects triggered by mechanisms and context, and categorised according to the six dimensions of quality of care as defined by the World Health Organization, namely effectiveness, efficiency, accessibility, patient-centeredness, equity and safety.

RESULTS

The integrated care intervention consisted of three main components: a specific reimbursement system ("early complex geriatric rehabilitation"), multidisciplinary cooperation, and comprehensive geriatric assessments. The inflexibility of the reimbursement system regarding the obligatory number of treatment sessions contributed to over-, under- and misuse of services. Multidisciplinary cooperation was impeded by a high workload, which contributed to waste in workflows. The comprehensive geriatric assessments were complemented with information provided by family members, which contributed to decreased likelihood of adverse events.

CONCLUSIONS

We recommend an increased focus on trying to understand how intervention components interact with context factors and, combined, lead to positive and/or negative outcomes.

Integrated Care Program for Older Adults: Analysis and Improvement

OBJECTIVE

We aimed to in-depth analyse the Integrated Care Programme for older in- and out-patients implemented for more than 25 years at the Hospital Universitario de Getafe, in Madrid, Spain. We identify the strengths and barriers hindering the full operation, and we proposed a technological solution that overcame these constraints and facilitated integration.

DESIGN

First, we carried out a comprehensive analysis of the integrated care program at the HUG following Case Study Research; the primary unit of analysis was the Geriatrics service and its clinical units. Secondary sources of analyses were professionals' insights (obtained thought direct observation and interviews) and statistics on the service. After the identification of the barriers preventing complete success; we designed a Health Information System and developed a mock-up that was validated with the professionals. Finally, we passed the specifications to the Information System Unit at the Hospital to develop and integrate the system into the hospital one.

SETTING

The Geriatrics Service of the University Hospital of Getafe, pertaining to the public Healthcare System of the Region of Madrid (Spain).

PARTICIPANTS

No patient participated in the study. All staff from the Geriatrics Service and the ICT manager of the hospital contributed to the design of the Health Information System; and 3 geriatricians from the Service and 1 primary care physician validated it.

MEASUREMENTS

First, we qualitative analysed the Integrated Care Program taking as dimensions eight facilitators towards integrated care. In response, we proposed an integrated information system solution. Later, we interviewed the staff geriatricians to analyse the Integrated Care Programme. Finally, we validated our proposed system in terms of usability and user experience using the System Usability Score-SUS and the User Experience Questionnaire-UEQ, respectively.

RESULTS

The Integrated Care Program has demonstrated a high impact since its launch; however, the lack of integration in terms of information system was hindering the full deployment. We have designed an integrated information system which has been validated by physicians and nurses from the Geriatrics Service in terms of usability. We obtained a SUS score of 81 (68 is considered to be the cut-off point for usable systems). Besides, the perception of these professionals on our system was 'Excellent' in 5 out of the 6 items covered by UEQ (Attractiveness, Perspicuity, Dependability, Stimulation and Novelty) and 'Good' in terms of the 1 remaining (Efficiency), where there is still room for improvement.

CONCLUSIONS

Our dedicated Health Information System is a robust solution to bridge information gaps and facilitate the complete integration of our Integrated Care Programme for older in- and outpatients.

Impact of joint consultation by a clinical pharmacist and a clinical geriatrician to improve inappropriate prescribing for elderly patients

Objective

Appropriate prescribing is a key quality element in medication safety. It is unclear if therapeutic interventions resulting from medication review lead to clinically relevant improvements. The effect of medication review on prescribing appropriateness was evaluated in the setting of an outpatient consultation team, consisting of a clinical pharmacist and a clinical geriatrician, in a large non-academic teaching hospital in the Netherlands.

Method

A group of 49 elderly patients with polypharmacy was included after referral by their general practitioner for drug related problems. After a regular assessment by a clinical geriatrician and medication record review by a clinical pharmacist, a treatment plan was implemented based on the recommended interventions. The main outcome measure was the change in the Medication Appropriateness Index (MAI) before and 3 months after primary consultation.

Results

Overall 82% of the recommended interventions of the pharmacist were implemented by the geriatrician of which 63% persisted up to the last visit. Per patient an average of 6.6 interventions were carried out. The interventions showed a reduction of the MAI per patient of 50%. The number of drugs per patient was reduced from 12.1 to 11.0. The number of medications listed on the Beers list decreased from 2.3 to 1.5 and the number of drugs listed on the Hospital Admissions Related to Medication (HARM) Trigger list decreased from 2.1 to 1.5.

Conclusions

Interventions from a multidisciplinary outpatient consultation team were effective in improving appropriate prescribing in elderly outpatients with polypharmacy.

New horizons: urgent care for older people with frailty

Urgent care for older people is a major public health issue and attracts much policy attention. Despite many efforts to curb demand, many older people with frailty and urgent care needs to access acute hospital services. The predominant model of care delivered in acute hospitals tends to be medically focussed, yet the evidence-based approaches that appear to be effective invoke a holistic model of care, delivered by interdisciplinary teams embedding geriatric competencies into their service. This article reviews the role for holistic care-termed Comprehensive Geriatric Assessment in the research literature-and how it can be used as an organising framework to guide future iterations of acute services to be better able to meet the multifaceted needs of older people.

Frailty and cognitive impairment: Unique challenges in the older emergency surgical patient

INTRODUCTION

Older patients (>65 years of age) admitted as general surgical emergencies increasingly require improved recognition of their specific needs relative to younger patients. Two such needs are frailty and cognitive impairment. These are evolving research areas that the emergency surgeon increasingly requires knowledge of to improve short- and long-term patient outcomes.

METHODS

This paper reviews the evidence for frailty and cognitive impairment in the acute surgical setting by defining frailty and cognitive impairment, introducing methods of diagnosis, discussing the influence on prognosis and proposing strategies to improve older patient outcomes.

RESULTS

Frailty is present in 25% of the older surgical population. Using frailty-scoring tools, frailty was associated with a significantly longer hospital stay and higher mortality at 30 and 90 days after admission to an acute surgical unit. Cognitive impairment is present in a high number of older acute surgical patients (approximately 70%), whilst acute onset cognitive impairment, termed delirium, is documented in 18%. However, patients with delirium had significantly longer hospital stays and higher in-hospital mortality than those with cognitive impairment.

CONCLUSIONS

Improved knowledge of frailty and delirium by the emergency surgeon allows the specialised needs of older surgical patients to be taken into account. Early recognition, and consideration of minimally invasive surgery or radiological intervention alongside potentially transferable successful elective interventions such as comprehensive geriatric assessment, may help to improve short- and long-term patient outcomes in this vulnerable population.

New horizons in the implementation and research of comprehensive geriatric assessment: knowing, doing and the 'know-do' gap

In this paper, we outline the relationship between the need to put existing applied health research knowledge into practice (the 'know-do gap') and the need to improve the evidence base (the 'know gap') with respect to the healthcare process used for older people with frailty known as comprehensive geriatric assessment (CGA). We explore the reasons for the know-do gap and the principles of how these barriers to implementation might be overcome. We explore how these principles should affect the conduct of applied health research to close the know gap. We propose that impaired flow of knowledge is an important contributory factor in the failure to implement evidence-based practice in CGA; this could be addressed through specific knowledge mobilisation techniques. We describe that implementation failures are also produced by an inadequate evidence base that requires the co-production of research, addressing not only effectiveness but also the feasibility and acceptability of new services, the educational needs of practitioners, the organisational requirements of services, and the contribution made by policy. Only by tackling these issues in concert and appropriate proportion, will the know and know-do gaps for CGA be closed.

The Association of Medication-Use and Frailty-Related Factors with Gait Performance in Older Patients

The increased fall risk associated with the use of psychotropic drugs might be caused by underlying problems in postural control that are induced by sedative side-effects of these drugs. The current literature on the effects of psychotropics on postural control only examined acute single-drug effects, and included relatively healthy young elderly. Consequently, it is unclear what the impact of the long-term use of these drugs is on gait in frail older persons with polypharmacy. Therefore, it was aimed in the present study to explore the association between the use of psychotropics, multiple other medications, frailty-related parameters and gait performance in older patients. Eighty older persons (79±5.6 years) were recruited. Comorbid diseases, frailty-related parameters, and medication-use were registered. Trunk accelerations during a 3-minute-walking-task were recorded, whereof walking speed, mean stride times, coefficient of variation (CV) of stride times, and step consistency were determined. Multivariate Partial Least Squares (PLS) regression analysis was used to examine the association between population characteristics and medication-use, versus gait parameters. A PLS-model existing of four latent variables was built, explaining 45% of the variance in four gait parameters. Frailty-related factors, being female, and laxative-use were most strongly associated with lower walking speed, higher mean stride times, higher CV of stride times, and less consistent steps. In conclusion, frailty-related parameters were stronger associated with impaired gait performance than the use of psychotropic drugs. Possibly, at a certain frailty-level, the effect of the deterioration in physical functioning in frailty is so large, that the instability-provoking side-effects of psychotropic drugs have less impact on gait.

Brazilian recommendations of mechanical ventilation 2013. Part 2

Perspectives on invasive and noninvasive ventilatory support for critically ill patients are evolving, as much evidence indicates that ventilation may have positive effects on patient survival and the quality of the care provided in intensive care units in Brazil. For those reasons, the Brazilian Association of Intensive Care Medicine (Associação de Medicina Intensiva Brasileira - AMIB) and the Brazilian Thoracic Society (Sociedade Brasileira de Pneumologia e Tisiologia - SBPT), represented by the Mechanical Ventilation Committee and the Commission of Intensive Therapy, respectively, decided to review the literature and draft recommendations for mechanical ventilation with the goal of creating a document for bedside guidance as to the best practices on mechanical ventilation available to their members. The document was based on the available evidence regarding 29 subtopics selected as the most relevant for the subject of interest. The project was developed in several stages, during which the selected topics were distributed among experts recommended by both societies with recent publications on the subject of interest and/or significant teaching and research activity in the field of mechanical ventilation in Brazil. The experts were divided into pairs that were charged with performing a thorough review of the international literature on each topic. All the experts met at the Forum on Mechanical Ventilation, which was held at the headquarters of AMIB in São Paulo on August 3 and 4, 2013, to collaboratively draft the final text corresponding to each sub-topic, which was presented to, appraised, discussed and approved in a plenary session that included all 58 participants and aimed to create the final document.

Treating older adults with cancer: geriatric perspectives

The proportion of older adults (age 65 and older) in oncology practices continues to increase. Older adults present with unique issues that complicate management decisions and evidence from randomized clinical trials to inform management of these patients is lacking. Despite this, principles of geriatric medicine need to be incorporated into oncology practice to provide optimal individualized care to patients. There is increasing evidence from observational studies that geriatric assessment (GA) strategies can be applied in oncology, can help predict treatment outcomes, and can inform supportive care management for older adults. In this review, we discuss the principles of GA and their use in older adults with cancer. In addition, considerations on when to refer to a geriatrician and issues related to management of vulnerable older adults will be addressed.

Embedding comprehensive geriatric assessment in the emergency assessment unit: the impact of the COPE zone

We introduced a geographically embedded frailty unit, the comprehensive older person's evaluation 'COPE' zone within our emergency assessment unit (EAU). We collated data for all medical patients over 75 years admitted non-electively for one month before and after this service change. Significantly more patients were seen by a geriatrician on the EAU earlier in their admission in 2014 (33.4 vs 19.3%, p<0.001; 11 vs 20 h, p<0.001). More patients had documented comprehensive geriatric assessment and discussion in a geriatrician multidisciplinary team meeting (relative risk (RR) 3.3, 95% confidence interval (CI) 2.35-4.73, p<0.001; RR 3.6, 95% CI 2.26-5.57, p<0.001, respectively). More patients with markers of frailty were discharged directly from EAU (42.2 vs 29.0%, p = 0.006) without increasing readmissions. Mean length of stay was reduced (9.5 vs 6.8 days, p = 0.02). The introduction of the COPE zone has improved service delivery at the point of access for older people admitted to hospital.

Long-Term Evaluation of the Ambulatory Geriatric Assessment: A Frailty Intervention Trial (AGe-FIT): Clinical Outcomes and Total Costs After 36 Months

OBJECTIVE

To compare the effects of care based on comprehensive geriatric assessment (CGA) as a complement to usual care in an outpatient setting with those of usual care alone. The assessment was performed 36 months after study inclusion.

DESIGN

Randomized, controlled, assessor-blinded, single-center trial.

SETTING

A geriatric ambulatory unit in a municipality in the southeast of Sweden.

PARTICIPANTS

Community-dwelling individuals aged ≥ 75 years who had received inpatient hospital care 3 or more times in the past 12 months and had 3 or more concomitant medical diagnoses were eligible for study inclusion. Participants were randomized to the intervention group (IG) or control group (CG).

INTERVENTION

Participants in the IG received CGA-based care for 24 to 31 months at the geriatric ambulatory unit in addition to usual care.

OUTCOME MEASURES

Mortality, transfer to nursing home, days in hospital, and total costs of health and social care after 36 months.

RESULTS

Mean age (SD) of participants was 82.5 (4.9) years. Participants in the IG (n = 208) lived 69 days longer than did those in the CG (n = 174); 27.9% (n = 58) of participants in the IG and 38.5% (n = 67) in the CG died (hazard ratio 1.49, 95% confidence interval 1.05-2.12, P = .026). The mean number of inpatient days was lower in the IG (15.1 [SD 18.4]) than in the CG (21.0 [SD 25.0], P = .01). Mean overall costs during the 36-month period did not differ between the IG and CG (USD 71,905 [SD 85,560] and USD 65,626 [SD 66,338], P = .43).

CONCLUSIONS

CGA-based care resulted in longer survival and fewer days in hospital, without significantly higher cost, at 3 years after baseline. These findings add to the evidence of CGA's superiority over usual care in outpatient settings. As CGA-based care leads to important positive outcomes, this method should be used more extensively in the treatment of older people to meet their needs.

Geriatric oncology: problems with under-treatment within this population

We are currently faced with an aging population, which is rapidly growing worldwide. Two thirds of cancer occurs in the over 65-year age group. Societal conceptions from the past have created ageist stereotypes; old age is associated with frailty and the elderly are perceived to be destined for deterioration and loss of independence. Cancer within the elderly is also subject to these stereotypes, with elderly cancer patients considered by some not as likely to recover as younger patients with cancer. We summarise and review the current concerns regarding elderly management and treatments utilised for the management of oncological disease in the elderly, and discuss the impact of under-treatment within this population.

A telegeriatric service in a small rural hospital: A case study and cost analysis

Introduction

Small hospitals in rural areas usually have an insufficient caseload of frail old people to justify the regular presence of a geriatrician. This study examined the costs of providing a telegeriatric service by videoconference in a rural hospital, compared to the costs of a visiting geriatrician that travels to undertake in-person consultations.

Methods

A cost analysis was undertaken to compare the costs of the telegeriatric service model with the costs of a visiting geriatrician service model. A recently established telegeriatric service at Warwick Hospital was used as a case study.

Results

In the base case model (assuming four patients per round and a round-trip travel distance of 312 kilometres), an estimated AUD$131 per patient consultation can be saved in favour of the telegeriatric service model. Key drivers of costs are the number of patients per round and the travel distance and time in the visiting geriatrician model. At a workload of four patients per round, it is less expensive to conduct a telegeriatric service than a visiting geriatrician service when the round-trip travel time exceeds 76 minutes.

Discussion

Even under quite conservative assumptions, a telegeriatric service offers an economically feasible approach to the delivery of specialist geriatric assessment in rural and remote settings.

Initiatives on early detection and intervention to proactively identify health and social problems in older people: experiences from the Netherlands

Background

Over the last years, several initiatives on early detection and intervention have been put in place to proactively identify health and social problems in (frail) older people. An overview of the initiatives currently available in the Netherlands is lacking, and it is unknown whether they meet the preferences and needs of older people. Therefore, the objectives of this study were threefold: 1. To identify initiatives on early detection and intervention for older people in the Netherlands and compare their characteristics; 2. To explore the experiences of professionals with these initiatives; and 3. To explore to what extent existing initiatives meet the preferences and needs of older people.

Methods

We performed a qualitative descriptive study in which we conducted semi-structured interviews with seventeen experts in preventive elderly care and three group interviews with volunteer elderly advisors. Data were analysed using the framework analysis method.

Results

We identified eight categories of initiatives based on the setting (e.g. general practitioner practice, hospital, municipality) in which they were offered. Initiatives differed in their aims and target groups. The utilization of peers to identify problems and risks, as was done by some initiatives, was seen as a strength. Difficulties were experienced with identifying the target group that would benefit from proactive delivery of care and support most, and with addressing prevalent issues among older people (e.g. psychosocial issues, self-reliance issues).

Conclusion

Although there is a broad array of initiatives available, there is a discrepancy between supply and demand. Current initiatives insufficiently address needs of (frail) older people. More insight is needed in “what should be done by whom, for which target group and at what moment”, in order to improve current practice in preventive elderly care.

Initiatives on early detection and intervention to proactively identify health and social problems in older people: experiences from the Netherlands

BACKGROUND

Over the last years, several initiatives on early detection and intervention have been put in place to proactively identify health and social problems in (frail) older people. An overview of the initiatives currently available in the Netherlands is lacking, and it is unknown whether they meet the preferences and needs of older people. Therefore, the objectives of this study were threefold: 1. To identify initiatives on early detection and intervention for older people in the Netherlands and compare their characteristics; 2. To explore the experiences of professionals with these initiatives; and 3. To explore to what extent existing initiatives meet the preferences and needs of older people.

METHODS

We performed a qualitative descriptive study in which we conducted semi-structured interviews with seventeen experts in preventive elderly care and three group interviews with volunteer elderly advisors. Data were analysed using the framework analysis method.

RESULTS

We identified eight categories of initiatives based on the setting (e.g. general practitioner practice, hospital, municipality) in which they were offered. Initiatives differed in their aims and target groups. The utilization of peers to identify problems and risks, as was done by some initiatives, was seen as a strength. Difficulties were experienced with identifying the target group that would benefit from proactive delivery of care and support most, and with addressing prevalent issues among older people (e.g. psychosocial issues, self-reliance issues).

CONCLUSION

Although there is a broad array of initiatives available, there is a discrepancy between supply and demand. Current initiatives insufficiently address needs of (frail) older people. More insight is needed in "what should be done by whom, for which target group and at what moment", in order to improve current practice in preventive elderly care.

[INTEGRATED APPROACH TO PREVENT FUNCTIONAL DECLINE IN HOSPITALIZED ELDERLY]

BACKGROUND

Hospital related functional decline in older patients is an underestimated problem. Thirty-five procent of 70-year old patients experience functional decline during hospital admission in comparison with pre-illness baseline. This percentage increases considerably with age.

METHODS/DESIGN

To address this issue, the Vlietland Ziekenhuis in The Netherlands has implemented the Prevention and Reactivation Care Programme (PReCaP), an innovative program aimed at reducing hospital related functional decline among elderly patients by offering interventions that are multidisciplinary, integrated and goal-oriented at the physical, social, and psychological domains of functional decline.

DISCUSSION

This paper presents a detailed description of the intervention, which incorporates five distinctive elements: (1) Early identification of elderly patients with a high risk of functional decline, and if necessary followed by the start of the reactivation treatment within 48 h after hospital admission; (2) Intensive follow-up treatment for a selected patient group at the prevention and Reactivation Centre; (3) Availability of multidisciplinary geriatric expertise; (4) Provision of support and consultation of relevant professionals to informal caregivers; (5) Intensive follow-up throughout the entire chain of care by a casemanager with geriatric expertise. Outcome and process evaluations are ongoing and results will be published in a series of forthcoming papers. This article is an edited translation of the previously published article 'Integrated approach to prevent functional decline in hospitalized elderly: the Prevention and Reactivation Care Program (PReCaP), BMC Geriatrics 2012;12:7, AJBM de Vos, KJE Asmus-Szepesi, TJEM Bakker, PL de Vreede, JDH van Wijngaarden, EW Steyerberg, JP Mackenbach, AP Nieboer.

[Patients' need for consultation after a geriatric assessment in family practice : Survey]

BACKGROUND

During a doctor-patient consultation patients usually seek information by disclosing their reasons for requesting the encounter. Geriatric assessment allows a proactive examination of patients' overall health and function and provides an opportunity to broach issues beyond the initial purposes of the consultation.

OBJECTIVES

The study aimed at investigating older patients' information seeking behavior following a geriatric assessment and the kind of topics they wished to discuss, taking a variety of patient and health-related factors into account.

MATERIAL AND METHODS

A total of 317 patients (≥ 70 years) underwent a geriatric assessment in 40 general practices. Subsequently they obtained a list of the problems uncovered and rated the relevance and information needs for each problem. Analyses consisted of determining the prevalence of information need for each health topic and identifying predictors in a mixed model (multilevel regression analysis).

RESULTS

The 317 patients presented with a median of 11 health problems (interquartile range, IQR 8-14) and 80 % of the patients had information needs concerning only a few of the problems. High information needs were present for physical complaints and for vaccination issues. Little information seeking behavior was evident for unhealthy lifestyles, falls, limitations in daily activities and psychosocial problems. In the mixed model the personal relevance and the type of health problem both had a significant and independent effect on information seeking behavior.

CONCLUSION

A geriatric assessment generates a moderate need for information. It provides physicians with an opportunity to focus on those health problems that are important to older patients but not usually addressed in normal consultations. This particularly applies to limitations in daily activities and psychosocial problems.

Implementation of geriatric assessment-based recommendations in older patients with cancer: A multicentre prospective study

PURPOSE

The main objective of this study was to describe geriatric recommendations based on a geriatric assessment (GA) and to evaluate the implementation of these recommendations.

PATIENTS AND METHODS

A two-step approach of screening followed by a GA was implemented in nine hospitals in Belgium. Patients ≥ 70 years were included at diagnosis or at disease progression/relapse. Concrete geriatric recommendations were systematically documented and reported to the treating physicians and consisted of referrals to professional health care workers. Patient charts were reviewed after one month to verify which geriatric recommendations have been performed.

RESULTS

From August 2011 to July 2012, 1550 patients were included for analysis. The median age was 77 (range: 70-97) and 57.0% were female. A solid tumour was diagnosed in 91.4% and a haematological malignancy in 8.6%. Geriatric screening with the G8 identified 63.6% of the patients for GA (n=986). A median of two geriatric recommendations (range: 1-6) were given for 76.2% (95%CI: 73.4-78.8) of the evaluable patients (n=710). A median of one geriatric recommendation (range: 1-5) was performed in 52.1% (95%CI: 48.4-55.8) of the evaluable patients (n=689). In general, 460 or 35.3% (95%CI: 32.8-38.0) of all the geriatric recommendations were performed. Geriatric recommendations most frequently consisted of referrals to the dietician (60.4%), social worker (40.3%), and psychologist (28.9%).

CONCLUSION

This implementation study provides insight into GA-based recommendations/interventions in daily oncology practice. Geriatric recommendations were given in about three-fourths of patients. About one-third of all geriatric recommendations were performed in approximately half of these patients.

Medical Crises in Older People: cohort study of older people attending acute medical units, developmental work and randomised controlled trial of a specialist geriatric medical intervention for high-risk older people; cohort study of older people with mental health problems admitted to hospital, developmental work and randomised controlled trial of a specialist medical and mental health unit for general hospital patients with delirium and dementia; and cohort study of residents of care homes and interview study of health-care provision to residents of care homes

Background

This programme of research addressed shortcomings in the care of three groups of older patients: patients discharged from acute medical units (AMUs), patients with dementia and delirium admitted to general hospitals, and care home residents.

Methods

In the AMU workstream we undertook literature reviews, performed a cohort study of older people discharged from AMU (Acute Medical Unit Outcome Study; AMOS), developed an intervention (interface geriatricians) and evaluated the intervention in a randomised controlled trial (Acute Medical Unit Comprehensive Geriatric Assessment Intervention Study; AMIGOS). In the second workstream we undertook a cohort study of older people with mental health problems in a general hospital, developed a specialist unit to care for them and tested the unit in a randomised controlled trial (Trial of an Elderly Acute care Medical and mental health unit; TEAM). In the third workstream we undertook a literature review, a cohort study of a representative sample of care home residents and a qualitative study of the delivery of health care to care home residents.

Results

Although 222 of the 433 (51%) patients recruited to the AMIGOS study were vulnerable enough to be readmitted within 3 months, the trial showed no clinical benefit of interface geriatricians over usual care and they were not cost-effective. The TEAM study recruited 600 patients and there were no significant benefits of the specialist unit over usual care in terms of mortality, institutionalisation, mental or functional outcomes, or length of hospital stay, but there were significant benefits in terms of patient experience and carer satisfaction with care. The medical and mental health unit was cost-effective. The care home workstream found that the organisation of health care for residents in the UK was variable, leaving many residents, whose health needs are complex and unpredictable, at risk of poor health care. The variability of health care was explained by the variability in the types and sizes of homes, the training of care home staff, the relationships between care home staff and the primary care doctors and the organisation of care and training among primary care doctors.

Discussion

The interface geriatrician intervention was not sufficient to alter clinical outcomes and this might be because it was not multidisciplinary and well integrated across the secondary care–primary care interface. The development and evaluation of multidisciplinary and better-integrated models of care is justified. The specialist unit improved the quality of experience of patients with delirium and dementia in general hospitals. Despite the need for investment to develop such a unit, the unit was cost-effective. Such units provide a model of care for patients with dementia and delirium in general hospitals that requires replication. The health status of, and delivery of health care to, care home residents is now well understood. Models of care that follow the principles of comprehensive geriatric assessment would seem to be required, but in the UK these must be sufficient to take account of the current provision of primary health care and must recognise the importance of the care home staff in the identification of health-care needs and the delivery of much of that care.

Trial registration

Current Controlled Trials ISRCTN21800480 (AMIGOS); ClinicalTrials.gov NCT01136148 (TEAM).

Funding

This project was funded by the NIHR Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 3, No. 4. See the NIHR Journals Library website for further project information.

Incomplete assessments: towards a better understanding of causes and solutions. The case of the interRAI home care instrument in Belgium

The chronic diseases, comorbidities and rapidly changing needs of frail older persons increase the complexity of caregiving. A comprehensive, systematic and structured collection of data on the status of the frail older person is presumed to be essential in facilitating decision-making and thus improving the quality of care provided. However, the way in which an assessment is completed has a substantial impact on the quality and value of the results. This study examines the online completion of interRAI Home Care assessments, the possible causes for incomplete assessments and the consequences of these factors with respect to the quality of care received. Our findings indicate high nurse engagement and poor physician participation. We also observed the poor completion of items in predominantly medically- oriented sections characterized by, first, the fact that the assessors felt incapable of answering certain questions, second, the absence of required data or of a competent person to fill out the data, and third, the lack of tools necessary for essential measurements. The incompleteness of assessments has a clear negative influence on outcome generation. Moreover, without the added value of support outcomes, the improvement of care quality can be impeded and information technology can easily be seen as burdensome by the assessors. We have observed that multidisciplinary cooperation is an important prerequisite to establishing high-quality assessments aimed at improving the quality of care.

From research to reality: minimizing the effects of hospitalization on older adults

This review examines ways to decrease preventable effects of hospitalization on older adults in acute care medical (non-geriatric) units, with a focus on the Israeli experience at the Rambam Health Care Campus, a large tertiary care hospital in northern Israel. Hospitalization of older adults is often followed by an irreversible decline in functional status affecting their quality of life and well-being after discharge. Functional decline is often related to avoidable effects of in-hospital procedures not caused by the patient's acute disease. In this article we review the literature relating to the recognized effects of hospitalization on older adults, pre-hospitalization risk factors, and intervention models for hospitalized older adults. In addition, this article describes an Israeli comprehensive research study, the Hospitalization Process Effects on Functional Outcomes and Recovery (HoPE-FOR), and outlines the design of a combined intervention model being implemented at the Rambam Health Care Campus. The majority of the reviewed studies identified preadmission personal risk factors and psychosocial risk factors. In-hospital restricted mobility, under-nutrition care, over-use of continence devices, polypharmacy, and environmental factors were also identified as avoidable processes. Israeli research supported the findings that preadmission risk factors together with in-hospital processes account for functional decline. Different models of care have been developed to maintain functional status. Much can be achieved by interdisciplinary teams oriented to the needs of hospitalized elderly in making an impact on hospital processes and continuity of care. It is the responsibility of health care policy-makers, managers, clinicians, and researchers to pursue effective interventions to reduce preventable hospitalization-associated disability.

Associations between vertebral fractures, increased thoracic kyphosis, a flexed posture and falls in older adults: a prospective cohort study

BACKGROUND

Vertebral fractures, an increased thoracic kyphosis and a flexed posture are associated with falls. However, this was not confirmed in prospective studies. We performed a prospective cohort study to investigate the association between vertebral fractures, increased thoracic kyphosis and/or flexed posture with future fall incidents in older adults within the next year.

METHODS

Patients were recruited at a geriatric outpatient clinic. Vertebral fractures were evaluated on lateral radiographs of the spine with the semi-quantitative method of Genant; the degree of thoracic kyphosis was assessed with the Cobb angle. The occiput-to-wall distance was used to determine a flexed posture. Self-reported falls were prospectively registered by monthly phone contact for the duration of 12 months.

RESULTS

Fifty-one older adults were included; mean age was 79 years (SD = 4.8). An increased thoracic kyphosis was independently associated with future falls (OR 2.13; 95% CI 1.10-4.51). Prevalent vertebral fractures had a trend towards significancy (OR 3.67; 95% CI 0.85-15.9). A flexed posture was not significantly associated with future falls.

CONCLUSION

Older adults with an increased thoracic kyphosis are more likely to fall within the next year. We suggest clinical attention for underlying causes. Because patients with increased thoracic curvature of the spine might have underlying osteoporotic vertebral fractures, clinicians should be aware of the risk of a new fracture.

Urinary incontinence and poor functional status in fragility fracture patients: an underrecognized and underappreciated association

PURPOSE/INTRODUCTION

Urinary incontinence (UI) affects some 20 % of community-dwelling older people and 30-60 % of people in institutional care. UI is known as an independent predictor of falls, and likely impacts fracture rates. The aim of the study was to measure the prevalence of UI in a typical fragility fracture population, to evaluate the relationship of UI with functional disability in the post-acute setting.

METHODS

Our study is a retrospective cross-sectional study of patients admitted to rehabilitation setting after inpatient hospital management for a fragility fracture. We included all consecutively admitted fragility fracture patients aged over 65. All patients underwent standard clinical examination and Geriatric Assessment. We assessed UI using a two-stage process with a six-item UI screening questionnaire followed by an interview.

RESULTS

1,857 (80.7 % female) patients were available for analysis, mean age was 81.7 years. UI was identified in 59.2 % of all fragility fracture patients, and was more prevalent in females. Patients suffering from UI differed significantly in almost all measured functional and cognitive tests, with increased dependency/lower ADL scores, increased rates of immobility, and higher rates of cognitive dysfunction and depression.

CONCLUSION

This study confirms the high prevalence of UI in older fragility fracture patients, and the association between UI and functional impairments. The diagnostic work-up and treatment of patients should be focused on the special needs of these older patients. More efforts are needed to increase awareness about prevalence and consequences of UI among older fragility fracture patients.

International Society of Geriatric Oncology consensus on geriatric assessment in older patients with cancer

PURPOSE

To update the International Society of Geriatric Oncology (SIOG) 2005 recommendations on geriatric assessment (GA) in older patients with cancer.

METHODS

SIOG composed a panel with expertise in geriatric oncology to develop consensus statements after literature review of key evidence on the following topics: rationale for performing GA; findings from a GA performed in geriatric oncology patients; ability of GA to predict oncology treatment–related complications; association between GA findings and overall survival (OS); impact of GA findings on oncology treatment decisions; composition of a GA, including domains and tools; and methods for implementing GA in clinical care.

RESULTS

GA can be valuable in oncology practice for following reasons: detection of impairment not identified in routine history or physical examination, ability to predict severe treatment-related toxicity, ability to predict OS in a variety of tumors and treatment settings, and ability to influence treatment choice and intensity. The panel recommended that the following domains be evaluated in a GA: functional status, comorbidity, cognition, mental health status, fatigue, social status and support, nutrition, and presence of geriatric syndromes. Although several combinations of tools and various models are available for implementation of GA in oncology practice, the expert panel could not endorse one over another.

CONCLUSION

There is mounting data regarding the utility of GA in oncology practice; however, additional research is needed to continue to strengthen the evidence base.

Intermediate care in nursing home after hospital admission: a randomized controlled trial with one year follow-up

BACKGROUND

Intermediate care is intended to reduce hospital admissions and facilitate early discharge. In Norway, a model was developed with transfer to intermediate care shortly after hospital admission. Efficacy and safety of this model have not been studied previously.In a parallel-group randomized controlled trial, patients over 70 years living at home before admission were eligible if clinically stable, without need for surgical treatment and deemed suited for intermediate care by attending physician. Intervention group patients were transferred to a nursing home unit with increased staff and multidisciplinary assessment, for a maximum stay of three weeks. Patients in the control group received usual care in hospital. Blinding to group assignment was not possible.The primary outcome was number of days living at home in a follow-up period of 365 days. Secondary outcomes were mortality, hospital admissions, need for residential care and home care services. Data were obtained from patient records and registers.

RESULTS

376 patients were included, 74% female and mean age 84 years. There was no significant differences between intervention (n=190) and control group (n=186) for number of days living at home (253.7 vs 256.5, p=0.80) or days in hospital (10.4 vs 10.5, p=0.748). Intervention group patients spent less time in nursing home (40.6 days vs. 55.0, p=0.046), and more patients lived independently without home health care services (31.6% vs 19.9%, p=0.007). For orthopaedic patients (n=128), mortality was higher in the intervention group; 15 intervention patients and 7 controls died (25.1% vs 10.3%, p=0.049). There was no significant difference in one-year mortality for medical patients (n=150) or the total study population.

CONCLUSIONS

This model of rapid transfer to intermediate care did not significantly influence number of days living at home during one year follow-up, but reduced demand for nursing home care and need for home health care services. In post-hoc analysis mortality was increased for orthopedic patients.

TRIAL REGISTRATION

The trial was registered 26. July 2013 at Current Controlled Trials and assigned with registration number ISRCTN21608185.

Do elderly patients with non-small cell lung cancer get the best out of recent advances in first-line treatment? A comparative study in two tertiary cancer centers in Greece

BACKGROUND

Elderly patients with advanced non-small cell lung cancer (NSCLC) are thought to receive suboptimal treatment mainly due to concerns for poor compliance and/or excessive toxicity.

PATIENTS AND METHODS

Using the age of 70 years as the pre-defined cut-off, we compared elderly patients with advanced NSCLC suitable for first line chemotherapy with their younger counterparts in terms of: i) diagnosis and disease characteristics ii) adherence to treatment schedule, including dose intensity (DI), and relative dose intensity (RDI), iii) toxicity, tolerance, and efficacy outcomes.

RESULTS

Among 292 eligible patients, data were available for 245, of whom 107 (43.7%) belonged to the elderly group. This group was more likely to present with co-morbidities, non-smoking current status and diagnosis based on cytology alone. As compared to the non-elderly, elderly patients were more likely to receive single-agent therapy (8.0% vs. 29.2% respectively, p < 0.001) and less likely to receive platinum-based chemotherapy (80.3% vs. 57.9%, p < 0.001). Elderly patients also received docetaxel (24.3% vs. 40.4%), and bevacizumab (7.5% vs. 21.3%) significantly less often and received oral vinorelbine (24.3% vs. 11.8%) more frequently. Non-elderly patients were more likely to receive any of the cytotoxic drugs with RDI > 0.8 (49.6% vs. 33.0%, p = 0.012) and RDI > 0.9 (29.6% vs. 16%, p = 0.015). Substantial toxicity, as well as median overall survival did not differ significantly between the two groups.

CONCLUSIONS

Only one third of the elderly patients received at least 80% of the scheduled treatment intensity. Nearly half received diagnosis based on cytology alone, which may deprive them from new, histology-driven, therapeutic approaches.

Quality of care for people with dementia in general hospitals: national cross-sectional audit of patient assessment

There have been recent reports of poor quality care in the National Health Service in the UK, and older people with dementia are particularly vulnerable. This study aims to examine the quality of assessment of people with dementia admitted to hospital. Cross-sectional case-note audit of key physical and psychosocial assessments was carried out in 7,934 people with dementia who were discharged from 206 general hospitals. Most people had no record of a standardised assessment of their cognitive state (56.8%, 95% confidence interval [CI] = 55.8-58.0) or functioning (74.2%, 95% CI = 73.2-75.1). Information from carers was documented in 39.0% of cases (95% CI = 37.9-40.1). There was considerable variation across hospital sites. Key assessments were less likely when people were admitted to surgical wards. Assessments fall well below recommended standards especially with regard to social and cognitive functioning. Problems are particularly marked on surgical wards.

Short-term outcomes of seniors aged 80 years and older with acute illness: hospitalist care by geriatricians and other internists compared

BACKGROUND

Although acute geriatric units have improved the outcomes of hospitalized seniors, it is uncertain as to whether hospitalist care by geriatricians outside of these units confers similar benefit.

OBJECTIVE

To determine whether hospitalist care by geriatricians reduces short-term mortality and readmission, and length of stay (LOS) for seniors aged 80 years and older with acute medical illnesses compared with care by other internists.

DESIGN

Retrospective cohort study using administrative and chart review data on demographic, admission-related, and clinical information of hospital episodes.

SETTING

General internal medicine department of an acute-care hospital in Singapore from 2005 to 2008.

PATIENTS

Seniors aged 80 years and older with specific focus on 2 subgroups with premorbid functional impairment and acute geriatric syndromes.

INTERVENTION

Hospitalist care by geriatricians compared with care by other internists.

MEASURES

Hospital mortality, 30-day mortality or readmission, and LOS.

RESULTS

For 1944 hospital episodes (intervention: 968, control: 976), there was a nonsignificant trend toward lower hospital mortality (15.5% vs 16.9%) but not 30-day mortality or readmission, or LOS for care by geriatricians compared with care by other internists. A marginally stronger trend toward lower hospital mortality for care by geriatricians among those with acute geriatric syndromes (20.2% vs 23.1%) was observed. Similar treatment effects were found after adjustment for demographic, admission-related, and clinical factors.

CONCLUSIONS

For seniors aged 80 years and over with acute medical illness, hospitalist care by geriatricians did not significantly reduce short-term mortality, readmission, or LOS, compared with care by other internists.

Brazilian recommendations of mechanical ventilation 2013. Part 2

Perspectives on invasive and noninvasive ventilatory support for critically ill patients are evolving, as much evidence indicates that ventilation may have positive effects on patient survival and the quality of the care provided in intensive care units in Brazil. For those reasons, the Brazilian Association of Intensive Care Medicine (Associação de Medicina Intensiva Brasileira - AMIB) and the Brazilian Thoracic Society (Sociedade Brasileira de Pneumologia e Tisiologia - SBPT), represented by the Mechanical Ventilation Committee and the Commission of Intensive Therapy, respectively, decided to review the literature and draft recommendations for mechanical ventilation with the goal of creating a document for bedside guidance as to the best practices on mechanical ventilation available to their members. The document was based on the available evidence regarding 29 subtopics selected as the most relevant for the subject of interest. The project was developed in several stages, during which the selected topics were distributed among experts recommended by both societies with recent publications on the subject of interest and/or significant teaching and research activity in the field of mechanical ventilation in Brazil. The experts were divided into pairs that were charged with performing a thorough review of the international literature on each topic. All the experts met at the Forum on Mechanical Ventilation, which was held at the headquarters of AMIB in São Paulo on August 3 and 4, 2013, to collaboratively draft the final text corresponding to each sub-topic, which was presented to, appraised, discussed and approved in a plenary session that included all 58 participants and aimed to create the final document.