Comprehensive geriatric assessment for older adults admitted to hospital

Discharge planning from hospital to home

BACKGROUND

Discharge planning is a routine feature of health systems in many countries. The aim of discharge planning is to reduce hospital length of stay and unplanned readmission to hospital, and improve the co-ordination of services following discharge from hospital.

OBJECTIVES

To determine the effectiveness of planning the discharge of individual patients moving from hospital.

SEARCH METHODS

We updated the review using the Cochrane EPOC Group Trials Register, MEDLINE, EMBASE and the Social Science Citation Index (last searched in March 2012).

SELECTION CRITERIA

Randomised controlled trials (RCTs) that compared an individualised discharge plan with routine discharge care that was not tailored to the individual patient. Participants were hospital inpatients.

DATA COLLECTION AND ANALYSIS

Two authors independently undertook data analysis and quality assessment using a pre designed data extraction sheet. Studies are grouped according to patient group (elderly medical patients, patients recovering from surgery and those with a mix of conditions) and by outcome. Our statistical analysis was done on an intention to treat basis, we calculated risk ratios for dichotomous outcomes and mean differences for continuous data using fixed-effect meta-analysis. When combining outcome data was not possible, because of differences in the reporting of outcomes, we have presented the data in narrative summary tables.

MAIN RESULTS

We included twenty-four RCTs (8098 patients); three RCTS were identified in this update. Sixteen studies recruited older patients with a medical condition, four recruited patients with a mix of medical and surgical conditions, one recruited patients from a psychiatric hospital, one from both a psychiatric hospital and from a general hospital, and two trials patients admitted to hospital following a fall (110 patients). Hospital length of stay and readmissions to hospital were statistically significantly reduced for patients admitted to hospital with a medical diagnosis and who were allocated to discharge planning (mean difference length of stay -0.91, 95% CI -1.55 to -0.27, 10 trials; readmission rates RR 0.82, 95% CI 0.73 to 0.92, 12 trials). For elderly patients with a medical condition there was no statistically significant difference between groups for mortality (RR 0.99, 95% CI 0.78 to 1.25, five trials) or being discharged from hospital to home (RR 1.03, 95% CI 0.93 to 1.14, two trials). This was also the case for trials recruiting patients recovering from surgery and a mix of medical and surgical conditions. In three trials, patients allocated to discharge planning reported increased satisfaction. There was little evidence on overall healthcare costs.

AUTHORS' CONCLUSIONS

The evidence suggests that a discharge plan tailored to the individual patient probably brings about reductions in hospital length of stay and readmission rates for older people admitted to hospital with a medical condition. The impact of discharge planning on mortality, health outcomes and cost remains uncertain.

The science and art of pain management in older persons: case study and discussion

INTRODUCTION

Evidence-based medicine has been adopted as a means of achieving optimal medical care and to reduce variations in clinical practice. Randomised controlled trials are considered the highest level of scientific evidence. Older individuals are either excluded or underrepresented in these studies, and those who are included are often atypical of patients seen in clinical practice.

OBJECTIVE

To examine the approach to clinical decision making in frail older persons when there is little or no scientific evidence to guide management.

METHODS

A case study is presented of refractory post herpetic neuralgia in a frail older person. Management plans were developed combining the scientific evidence from the pain literature with the practice known as Comprehensive Geriatric Assessment. The rationale and evidence for clinical decision making is explored.

RESULTS

Standard therapies for post herpetic neuralgia had been ineffective or limited by side effects in this patient. By a process of trial and error a combination of treatments was found that improved pain and mood but adversely affected cognition. Adjustment in treatments over time resulted in improved pain, mood, and cognition.

CONCLUSIONS

The art of medicine is not the antithesis of the scientific approach. The art of medicine involves balancing the scientific evidence with the circumstances and the preferences of the patient. Combining the practices of Pain Medicine and Comprehensive Geriatric Assessment may result in a better outcome. When treating older people, clinicians not only need to take into consideration the severity of pain, but also the impact of pain and its treatment on cognition, mood and functional status.

Adverse drug reactions in older people: detection and prevention

Adverse drug reactions (ADRs) in older adults are an important healthcare problem since they are frequently a cause of hospitalization, occur commonly during admission, and are an important cause of morbidity and mortality. Older adults are particularly susceptible to ADRs because they are usually on multiple drug regimens and because age is associated with changes in pharmacokinetics and pharmacodynamics. The presentation of an ADR in older adults is often atypical, which further complicates its recognition. One potential strategy for improving recognition of ADRs is to identify those patients who are at risk of an ADR. The recently developed GerontoNet ADR Risk Score is a practical tool for identification of older patients who are at increased risk for an ADR and who may represent a target for interventions aimed at reducing ADRs. Provision of adequate education in the domain of clinical geriatric pharmacology can improve recognition of ADRs. Besides formal surveillance systems, built-in computer programs with electronic prescribing databases and clinical pharmacist involvement in patient care within multidisciplinary geriatric teams might help to minimize the occurrence of ADRs. In addition, a number of actions can be taken in hospitals to stimulate appropriate prescribing and to assure adequate communication between primary and hospital care. In older adults with complex medical problems and needs, a global evaluation obtained through a comprehensive geriatric assessment may be helpful in simplifying drug prescription and prioritizing pharmacological and healthcare needs, resulting in an improvement in quality of prescribing.

Frailty screening methods for predicting outcome of a comprehensive geriatric assessment in elderly patients with cancer: a systematic review

Comprehensive geriatric assessment (CGA) is done to detect vulnerability in elderly patients with cancer so that treatment can be adjusted accordingly; however, this process is time-consuming and pre-screening is often used to identify fit patients who are able to receive standard treatment versus those in whom a full CGA should be done. We aimed to assess which of the frailty screening methods available show the best sensitivity and specificity for predicting the presence of impairments on CGA in elderly patients with cancer. We did a systematic search of Medline and Embase, and a hand-search of conference abstracts, for studies on the association between frailty screening outcome and results of CGA in elderly patients with cancer. Our search identified 4440 reports, of which 22 publications from 14 studies, were included in this Review. Seven different frailty screening methods were assessed. The median sensitivity and specificity of each screening method for predicting frailty on CGA were as follows: Vulnerable Elders Survey-13 (VES-13), 68% and 78%; Geriatric 8 (G8), 87% and 61%; Triage Risk Screening Tool (TRST 1+; patient considered frail if one or more impairments present), 92% and 47%, Groningen Frailty Index (GFI) 57% and 86%, Fried frailty criteria 31% and 91%, Barber 59% and 79%, and abbreviated CGA (aCGA) 51% and 97%. However, even in case of the highest sensitivity, the negative predictive value was only roughly 60%. G8 and TRST 1+ had the highest sensitivity for frailty, but both had poor specificity and negative predictive value. These findings suggest that, for now, it might be beneficial for all elderly patients with cancer to receive a complete geriatric assessment, since available frailty screening methods have insufficient discriminative power to select patients for further assessment.

Co-managed care: the gold standard for geriatric fracture care

With a worldwide aging population, the incidence and consequences of geriatric fractures are assuming an increasing importance to health care providers and institutions. Studies have shown that optimal efficient management ensures the best outcome for the patient, at the least cost to the institution. A review of the recent literature was performed to establish the current best evidence ie, gold standard, for geriatric fracture care. Given the complexities of the subject, randomized controlled trials are difficult and confounded by the multiple medical issues of the population being studied. RCT's are best suited to study individual questions, rather than systems of care. Hence, the importance of peer-reviewed models of care, as well as prospective population registries is established in defining what the gold standard of care should be for this vulnerable population.

[Consensus for the identification of geriatric patients in the emergency care setting in Germany]

For the treatment of geriatric inpatients, the efficacy of a multimodal geriatric intervention based on findings of a comprehensive geriatric assessment has well been established. Therefore, the focus of elderly inpatient care switched to the identification of geriatric patients who have unintended or unscheduled contact to an accident and emergency department. In Germany, a uniform standard on how to correctly identify geriatric patients in such settings has yet to be established.Three medical societies, the Federal Association of Geriatrics ("Bundesverband Geriatrie", BVG), the German Society for Gerontology and Geriatrics ("Deutsche Gesellschaft für Gerontologie und Geriatrie", DGGG) and the German Geriatrics Society ("Deutsche Gesellschaft für Geriatrie", DGG) have reached a consensus on tools and instruments for the identification of geriatric patients in the emergency care setting. Basis of the consensus were the existing scientific evidence and further considerations, especially the applicability of international findings in Germany and feasibility.Three recommendations are made: (1) The use of prognostic indices is not recommended, as prognostic indices appear to be inappropriate to disclose the complex needs of geriatric patients. (2) Comprehensive geriatric assessment is established and effective, but too complex for use in the emergency setting. It is recommended for cases in which information from screening instruments or other sources does not allow a clear decision. (3) Among screening instruments, the Identification of Seniors At Risk (ISAR) screening tool seems to be well established and suitable for screening purposes in Germany. A German adaption is recommended as well as the implementation in settings where no other tools or geriatric expertise are available.

Identifying modifiable factors to improve quality for older adults in hospital: a scoping review

BACKGROUND

Traditional ways of viewing hospitalisation do not always recognise how elements within the hospital environment contribute to disability. Four theoretical dimensions of older adult-hospital environment fit have been proposed in previous research on elder-friendly hospitals: social climate, physical design, care systems and processes, policies and procedures; however, modifiable factors for each dimension are not yet identified.

DESIGN

Exploratory iterative design guided by Arksey and O'Malley (2005, International Journal of Social Research Methodology 8, 19) scoping review methodology.

METHOD

We undertook a scoping review of primary research related to hospitalised community-dwelling older adults. Keys search terms and criteria were used to identify relevant articles with modifiable factors extracted from articles meeting study criteria.

RESULTS

A total of 66 studies were included and evaluated for modifiable factor mapping. We were able to map all 66 studies to the four dimensions. The majority of included studies described care systems and processes, with little relating to social climate, physical design and policies and procedures. Thirty-nine potentially modifiable factors were identified and mapped to the theoretical dimensions according to four overarching themes: models of care; assessment of potential geriatric issues; targeting care to a specific clinical issue and supporting transitions home themes.

CONCLUSION

The dimensions of older adult-hospital fit help us to organise key features of an elder-friendly hospital and identify potentially modifiable factors. Although it makes intuitive sense to cluster and organise according to the dimensions to help with understanding, this tells us little about the synergy of interactions and hierarchical relationships. Our results highlight the importance of competent gerontological nursing in care for hospitalised older adults and the need for further understanding of the older adult and family as a unit of care.

IMPLICATIONS FOR PRACTICE

Registered nurses have a leadership role to ensure safe quality care for older people in hospital. This leadership role can be framed in interventions that focus on fixing the fit between what older people need and what the hospital environment provides. Modifiable factors for improvement are within the scope and competency of the registered nurse.

The value of geriatric assessments in predicting treatment tolerance and all-cause mortality in older patients with cancer

BACKGROUND

Awareness of the use of geriatric assessments for older patients with cancer is increasing. The aim of this review is to summarize all available evidence on the association between geriatric assessments and relevant oncologic outcomes.

METHOD

A systematic search was conducted in Medline and Embase of studies on geriatric assessment in oncology, focusing on the association between baseline assessment and outcome.

RESULTS

The literature search identified 2008 reports; 51 publications from 37 studies were selected for inclusion in the review. The quality of studies was heterogeneous and generally poor. A median of five geriatric conditions were assessed per study (interquartile range: 4-8). Little consistency was found in the results of the studies. Furthermore, different tools appear to be predictive depending on the outcome measure: frailty, nutritional status, and comorbidity assessed by the Cumulative Illness Rating Scale for Geriatrics were predictive for all-cause mortality; frailty was predictive for toxicity of chemotherapy; cognitive impairment and activities of daily living impairment were predictive for chemotherapy completion; and instrumental activities of daily living impairment was predictive for perioperative complications.

CONCLUSION

Although various geriatric conditions appear to be of some value in predicting outcome in elderly patients with cancer, the results are too inconsistent to guide treatment decisions. Further research is needed to elucidate the role of geriatric assessments in the oncologic decision-making process for these patients.

Use of geriatric assessment for older adults in the oncology setting: a systematic review

BACKGROUND

Geriatric assessment is a multidisciplinary diagnostic process that evaluates the older adult's medical, psychological, social, and functional capacity. No systematic review of the use of geriatric assessment in oncology has been conducted. The goals of this systematic review were: 1) to provide an overview of all geriatric assessment instruments used in the oncology setting; 2) to examine the feasibility and psychometric properties of those instruments; and 3) to systematically evaluate the effectiveness of geriatric assessment in predicting or modifying outcomes (including the impact on treatment decision making, toxicity of treatment, and mortality).

METHODS

We searched Medline, Embase, Psychinfo, Cinahl, and the Cochrane Library for articles published in English, French, Dutch, or German between January 1, 1996, and November 16, 2010, reporting on cross-sectional, longitudinal, interventional, or observational studies that assessed the feasibility or effectiveness of geriatric assessment instruments. The quality of articles was evaluated using relevant quality assessment frameworks.

RESULTS

We identified 83 articles that reported on 73 studies. The quality of most studies was poor to moderate. Eleven studies examined psychometric properties or diagnostic accuracy of the geriatric assessment instruments used. The assessment generally took 10-45 min. Geriatric assessment was most often completed to describe a patient's health and functional status. Specific domains of geriatric assessment were associated with treatment toxicity in 6 of 9 studies and with mortality in 8 of 16 studies. Of the four studies that examined the impact of geriatric assessment on the cancer treatment decision, two found that geriatric assessment impacted 40%-50% of treatment decisions.

CONCLUSION

Geriatric assessment in the oncology setting is feasible, and some domains are associated with adverse outcomes. However, there is limited evidence that geriatric assessment impacted treatment decision making. Further research examining the effectiveness of geriatric assessment on treatment decisions and outcomes is needed.

Inpatient care: should the general physician now take charge?

In an ageing population, patients are living longer with one or more chronic disease, and with acute illnesses increasingly extending outside the boundaries of a single medical specialty. Therefore, is it time for the general physician to take charge?

Development and delivery of patient treatment in the Trondheim Hip Fracture Trial. A new geriatric in-hospital pathway for elderly patients with hip fracture

BACKGROUND

Hip fractures are common among frail elderly persons and often have serious consequences on function, mobility and mortality. Traditional treatment of these patients is performed in orthopedic departments without additional geriatric assessment. However, studies have shown that interdisciplinary geriatric treatment may be beneficial compared to traditional treatment. The aim of the present study is to investigate whether treatment of these patients in a Department of Geriatrics (DG) during the entire hospital stay gives additional benefits as compared to conventional treatment in a Department of Orthopaedic Surgery (DOS).

FINDINGS

A new clinical pathway for in-hospital treatment of hip fracture patients was developed. In this pathway patients were treated pre-and postoperatively in DG. Comprehensive geriatric assessment was performed as an interdisciplinary, multidimensional, systematic assessment of all patients focusing on each patient's capabilities and limitations as recommended in guidelines and systematic reviews. Identification and treatment of co-morbidities, pain relief, hydration, oxygenation, nutrition, elimination, prevention and management of delirium, assessment of falls and osteoporosis were emphasized. Discharge planning started as early as possible. Initiation of rehabilitation with focus on early mobilisation and development of individual plans was initiated in hospital and continued after discharge from hospital. Fracture specific treatment was based upon standard treatment for the hospital, expert opinions and a review of the literature.

CONCLUSION

A new treatment program for old hip fracture patients was developed, introduced and run in the DG, the potential benefits of which being compared with traditional care of hip fracture patients in the DOS in a randomised clinical trial.

Too complex and time-consuming to fit in! Physicians' experiences of elderly patients and their participation in medical decision making: a grounded theory study

OBJECTIVE

To explore physicians' thoughts and considerations of participation in medical decision making by hospitalised elderly patients.

DESIGN

A qualitative study using focus group interviews with physicians interpreted with grounded theory and completed with a questionnaire.

SETTING AND PARTICIPANTS

The setting was three different hospitals in two counties in Sweden. Five focus groups were conducted with physicians (n=30) in medical departments, with experience of care of elderly patients.

RESULTS

Physicians expressed frustration at not being able to give good care to elderly patients with multimorbidity, including letting them participate in medical decision making. Two main categories were found: 'being challenged' by this patient group and 'being a small part of the healthcare production machine'. Both categories were explained by the core category 'lacking in time'. The reasons for the feeling of 'being challenged' were explained by the subcategories 'having a feeling of incompetence', 'having to take relatives into consideration' and 'having to take cognitive decline into account'. The reasons for the feeling of 'being a small part of the healthcare production machine' were explained by the subcategories 'at the mercy of routines' and 'inadequate remuneration system', both of which do not favour elderly patients with multimorbidity.

CONCLUSIONS

Physicians find that elderly patients with multimorbidity lead to frustration by giving them a feeling of professional inadequacy, as they are unable to prioritise this common and rapidly growing patient group and enable them to participate in medical decision making. The reason for this feeling is explained by lack of time, competence, holistic view, appropriate routines and proper remuneration systems for treating these patients.

Comparing the prognostic accuracy for all-cause mortality of frailty instruments: a multicentre 1-year follow-up in hospitalized older patients

Background

Frailty is a dynamic age-related condition of increased vulnerability characterized by declines across multiple physiologic systems and associated with an increased risk of death. We compared the predictive accuracy for one-month and one-year all-cause mortality of four frailty instruments in a large population of hospitalized older patients in a prospective multicentre cohort study.

Methods and Findings

On 2033 hospitalized patients aged ≥65 years from twenty Italian geriatric units, we calculated the frailty indexes derived from the Study of Osteoporotic Fractures (FI-SOF), based on the cumulative deficits model (FI-CD), based on a comprehensive geriatric assessment (FI-CGA), and the Multidimensional Prognostic Index (MPI). The overall mortality rates were 8.6% after one-month and 24.9% after one-year follow-up. All frailty instruments were significantly associated with one-month and one-year all-cause mortality. The areas under the receiver operating characteristic (ROC) curves estimated from age- and sex-adjusted logistic regression models, accounting for clustering due to centre effect, showed that the MPI had a significant higher discriminatory accuracy than FI-SOF, FI-CD, and FI-CGA after one month (areas under the ROC curves: FI-SOF = 0.685 vs. FI-CD = 0.738 vs. FI-CGA = 0.724 vs. MPI = 0.765, p<0.0001) and one year of follow-up (areas under the ROC curves: FI-SOF = 0.694 vs. FI-CD = 0.729 vs. FI-CGA = 0.727 vs. MPI = 0.750, p<0.0001). The MPI showed a significant higher discriminatory power for predicting one-year mortality also in hospitalized older patients without functional limitations, without cognitive impairment, malnourished, with increased comorbidity, and with a high number of drugs.

Conclusions

All frailty instruments were significantly associated with short- and long-term all-cause mortality, but MPI demonstrated a significant higher predictive power than other frailty instruments in hospitalized older patients.

Comprehensive geriatric assessment for older adults admitted to hospital: meta-analysis of randomised controlled trials

OBJECTIVE

To evaluate the effectiveness of comprehensive geriatric assessment in hospital for older adults admitted as an emergency.

SEARCH STRATEGY

We searched the EPOC Register, Cochrane's Controlled Trials Register, the Database of Abstracts of Reviews of Effects (DARE), Medline, Embase, CINAHL, AARP Ageline, and handsearched high yield journals.

SELECTION CRITERIA

Randomised controlled trials of comprehensive geriatric assessment (whether by mobile teams or in designated wards) compared with usual care. Comprehensive geriatric assessment is a multidimensional interdisciplinary diagnostic process used to determine the medical, psychological, and functional capabilities of a frail elderly person to develop a coordinated and integrated plan for treatment and long term follow-up.

DATA COLLECTION AND ANALYSIS

Three independent reviewers assessed eligibility and trial quality and extracted published data. Two additional reviewers moderated.

RESULTS

Twenty two trials evaluating 10,315 participants in six countries were identified. For the primary outcome "living at home," patients who underwent comprehensive geriatric assessment were more likely to be alive and in their own homes at the end of scheduled follow-up (odds ratio 1.16 (95% confidence interval 1.05 to 1.28; P = 0.003; number needed to treat 33) at a median follow-up of 12 months versus 1.25 (1.11 to 1.42; P < 0.001; number needed to treat 17) at a median follow-up of six months) compared with patients who received general medical care. In addition, patients were less likely to be living in residential care (0.78, 0.69 to 0.88; P < 0.001). Subgroup interaction suggested differences between the subgroups "wards" and "teams" in favour of wards. Patients were also less likely to die or experience deterioration (0.76, 0.64 to 0.90; P = 0.001) and were more likely to experience improved cognition (standardised mean difference 0.08, 0.01 to 0.15; P = 0.02) in the comprehensive geriatric assessment group.

CONCLUSIONS

Comprehensive geriatric assessment increases patients' likelihood of being alive and in their own homes after an emergency admission to hospital. This seems to be especially true for trials of wards designated for comprehensive geriatric assessment and is associated with a potential cost reduction compared with general medical care.