Comprehensive geriatric assessment

Identifying vulnerable older adults at risk for functional decline in cardiac care wards: time to shift the paradigm

OBJECTIVE

To determine whether routine screening with the Flemish version of the Triage Risk Screening Tool (fTRST) is a valid approach to determine which patients on cardiac care wards are at risk for inhospital functional decline and would benefit from geriatric expertise consultation.

METHODS

A secondary data-analysis of the G-COACH before-cohort, describing patient profiles and routine care processes, in 189 older adults on two cardiac care wards in the University Hospitals Leuven between September 2016 and June 2017. Inhospital functional decline was defined as an increase of at least one point on the Katz Index of Activities of Daily Living or death between hospital admission and discharge.

RESULTS

Nine in 10 patients had at least one geriatric syndrome and one-third developed functional decline. Based on the fTRST proposed cut-off of ≥2, 156 (82.5%) patients were at risk for functional decline (sensitivity of 95.2%, specificity of 23.8%, negative predictive value of 90.9% and Area Under the Curve of 0.60). Of the 156 'at risk' patients, 43 (27.6%) received a consultation by the geriatric consultation team after a median of four hospitalization days. A positive fTRST was not significantly related to geriatric consultations (x² = 0.57; p = 0.45).

CONCLUSION

The fTRST has a low discriminative value in identifying older cardiology patients at risk for functional decline. Given the high prevalence of geriatric syndromes, we propose a new paradigm were all older adults on cardiac care wards undergo a needs assessment upon hospital admission.

Complex mental health needs in older people living with frailty

Frailty describes a state of health whereby people develop multiple or cumulative deficits in physiological systems over the life course, leading to vulnerability and being less able to respond to acute and/or physiological stressors, which at times may be relatively minor. Mental health should be an important consideration in the assessment and management of frailty in older people. This article provides an overview and clinical perspective on the evidence relating to frailty and mental health assessment and management.

A comprehensive assessment for community-based, person-centered care for older adults

Background

Many health and social needs can be assessed and met in community settings, where lower-cost, person-centered, preventative and proactive services predominate. This study reports on the development and implementation of a person-centered care model integrating dental, social, and health services for low-income older adults at a community dental clinic co-located within a senior wellness center.

Methods

A digital comprehensive geriatric assessment (CGA) and referral system linking medical, dental, and psychosocial needs by real-time CGA-derived metrics for 996 older adults (age ≥ 60) was implemented in 2016–2018 as part of a continuous quality improvement project. This study aims to describe: 1) the development and content of a new CGA; 2) CGA implementation, workflows, triage, referrals; 3) correlations between CGA domains, and adjusted regression models, assessing associations with self-reported recent hospitalizations, emergency department (ED) visits, and clinically-assessed dental urgency.

Results

The multidisciplinary team from the senior wellness and dental centers planned and implemented a CGA that included standard medical history along with validated instruments for functional status, mental health and social determinants, and added oral health. Care navigators employed the CGA with 996 older adults, and made 1139 referrals (dental = 797, care coordination = 163, social work = 90, mental health = 32). CGA dimensions correlated between oral health, medical status, depressive symptoms, isolation, and reduced quality of life (QoL). Pain, medical symptoms, isolation and depressive symptoms were associated with poorer self-reported health, while general health was most strongly correlated with lower depressive symptoms, and higher functional status and QoL. Isolation was the strongest correlate of lower QoL.

Adjusted odds ratios identified social and medical factors associated with recent hospitalization and ED visits. General and oral health were associated with dental urgency. Dental urgency was most strongly associated with general health (AOR = 1.78,95%CI [1.31, 2.43]), dental symptoms (AOR = 2.39,95%CI [1.78, 3.20]), dental pain (AOR = 2.06,95%CI [1.55–2.74]), and difficulty chewing (AOR = 2.80, 95%CI [2.09–3.76]). Dental symptoms were associated with recent ED visits (AOR = 1.61, 95%CI [1.12–2.30]) or hospitalizations (AOR = 1.47, 95%CI [1.04–2.10]).

Conclusion

Community-based inter-professional care is feasible with CGAs that include medical, dental, and social factors. A person-centered care model requires coordination supported by new workflows. Real-time metrics-based triage process provided efficient means for client review and a robust process to surface needs in complex cases.

HIV and Aging: Reconsidering the Approach to Management of Comorbidities

Health care for older adults with human immunodeficiency virus can be highly complex, resource intensive, and carry a high administrative burden. Data from aging longitudinal cohorts and feedback from the human immunodeficiency virus community suggest that the current model is not meeting the needs of these older adults. We introduce the 6 Ms approach, which acknowledges the multicomplexity of older adults with human immunodeficiency virus, simplifies geriatric principles for non-geriatrics-trained providers, and minimizes extensive training and specialized screening tests or tools. Implementing novel approaches to care requires support at local/national levels.

Comprehensive geriatric assessment for older people admitted to a surgical service

BACKGROUND

Aging populations are at increased risk of postoperative complications. New methods to provide care for older people recovering from surgery may reduce surgery-related complications. Comprehensive geriatric assessment (CGA) has been shown to improve some outcomes for medical patients, such as enabling them to continue living at home, and has been proposed to have positive impacts for surgical patients. CGA is a coordinated, multidisciplinary collaboration that assesses the medical, psychosocial and functional capabilities and limitations of an older person, with the goal of establishing a treatment plan and long-term follow-up.

OBJECTIVES

To assess the effectiveness of CGA interventions compared to standard care on the postoperative outcomes of older people admitted to hospital for surgical care.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL and two clinical trials registers on 13 January 2017. We also searched grey literature for additional citations.

SELECTION CRITERIA

Randomized trials of people undergoing surgery aged 65 years and over comparing CGA with usual surgical care and reporting any of our primary (mortality and discharge to an increased level of care) or secondary (length of stay, re-admission, total cost and postoperative complication) outcomes. We excluded studies if the participants did not receive a complete CGA, did not undergo surgery, and if the study recruited participants aged less than 65 years or from a setting other than an acute care hospital.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened, assessed risk of bias, extracted data and assessed certainty of evidence from identified articles. We expressed dichotomous treatment effects as risk ratio (RR) with 95% confidence intervals and continuous outcomes as mean difference (MD).

MAIN RESULTS

We included eight randomised trials, seven recruited people recovering from a hip fracture (N = 1583) and one elective surgical oncology trial (N = 260), conducted in North America and Europe. For two trials CGA was done pre-operatively and postoperatively for the remaining. Six trials had adequate randomization, five had low risk of performance bias and four had low risk of detection bias. Blinding of participants was not possible. All eight trials had low attrition rates and seven reported all expected outcomes.CGA probably reduces mortality in older people with hip fracture (RR 0.85, 95% CI 0.68 to 1.05; 5 trials, 1316 participants, I² = 0%; moderate-certainty evidence). The intervention reduces discharge to an increased level of care (RR 0.71, 95% CI 0.55 to 0.92; 5 trials, 941 participants, I² = 0%; high-certainty evidence).Length of stay was highly heterogeneous, with mean difference between participants allocated to the intervention and the control groups ranging between -12.8 and 8.3 days. CGA probably leads to slightly reduced length of stay (4 trials, 841 participants, moderate-certainty evidence). The intervention probably makes little or no difference in re-admission rates (RR 1.00, 95% CI 0.76 to 1.32; 3 trials, 741 participants, I² = 37%; moderate-certainty evidence).CGA probably slightly reduces total cost (1 trial, 397 participants, moderate-certainty evidence). The intervention may make little or no difference for major postoperative complications (2 trials, 579 participants, low-certainty evidence) and delirium rates (RR 0.75, 95% CI 0.60 to 0.94, 3 trials, 705 participants, I² = 0%; low-certainty evidence).

AUTHORS' CONCLUSIONS

There is evidence that CGA can improve outcomes in people with hip fracture. There are not enough studies to determine when CGA is most effective in relation to surgical intervention or if CGA is effective in surgical patients presenting with conditions other than hip fracture.

Co-occurrence of disadvantage conditions in elderly subjects with depressive symptoms

The aim of this survey study is to describe the association of symptomatic depression with the co-occurrence of psycho-social, functional, and somatic disadvantage conditions in 390 over 70 subjects living at home. The most disadvantaged tertile of various conditions (age, social support, cognition, social interactions, self evaluation of health, disability, number of diseases, and somatic symptoms) was associated with greater risk of symptomatic depression. A subset of conditions that might be causally related to depression (age, social support, financial welfare, diseases, and disability) was used to divide subjects into five levels of increasing multiple disadvantage conditions (MDC). Increasing severity of MDC level was associated with greater risk of symptomatic depression even after adjustment for gender and all five conditions used to define MDC levels (odds ratios ranging from 2.7 to 11.3).