A geriatric rehabilitation and assessment unit in a community hospital

Process and outcome of care: comparison of two inpatient geriatric rehabilitation settings

The objective of this study was to compare the process of care and outcome of rehabilitation in geriatric hospitals and in geriatric wards of general hospitals. It was longitudinal in design. Patients were interviewed on admission and on discharge. Data were retrieved from medical records and a questionnaire on the process of care was administered to staff members. Geriatric wards in four general hospitals and four independent geriatric hospitals in Israel provided the setting and approximately 50 consecutive admissions of patients with hip fracture or stroke, a total of 410 patients, were recruited from each setting. Four process indices and three outcome indices were used to measure quality of care. %

The main outcome showed that the functional status of the study population was higher on discharge than on admission and most patients were discharged to their former residence. When controlling for other variables, geriatric hospitals contributed more to higher functional status on discharge than did geriatric wards in general hospitals. Yet satisfaction with treatment was higher in geriatric wards in general hospitals than in geriatric hospitals. The main factors affecting patient satisfaction were functional status on discharge and the amount of rehabilitative treatment given.

Predictors of Community Discharge from a Geriatric Assessment and Rehabilitation Unit

This study explored admission factors which predicted the successful return to the community of patients entering a Geriatric Assessment and Rehabilitation Program (GARP). A stepwise logistic regression technique was used to determine predictive factors from a consecutive sample of 100 medical or surgical geriatric patients admitted for a four to six week rehabilitation program. The significant independent predictors of discharge which could be determined at the time of admission were ability to safely medicate, admission from the community, GDS score and the number of supports. The ability to safely medicate may be an important but under-utilized predictor.

Prospects and Pitfalls: Use of the RAI-HC Assessment by the Department of Veterans Affairs for Home Care Clients

PURPOSE

The U.S. Department of Veterans Affairs has adopted two functional assessment systems that guide care planning: one for nursing home residents (the Resident Assessment Instrument [RAI]) and a compatible one for home care clients (RAI-HC). The purpose of this article is to describe the RAI-HC (often referred to as the Minimum Data Set-Home Care or MDS-HC) and its uses and offer lessons learned from implementation experiences in other settings.

DESIGN AND METHODS

We reviewed implementation challenges associated both with the RAI and the RAI-HC in the United States, Canada, and other adopter countries, and drew on these to suggest lessons for the Department of Veterans Affairs as well as other entities implementing the RAI-HC.

RESULTS

Beyond its clinical utility, there are a number of evidence-based uses for the assessment system. The resident-level data can be aggregated and analyzed, and scales identify clinical conditions and risk for various types of negative outcomes. In addition, the data can be used for other programmatic and research purposes, such as determining eligibility, setting payment rates for contract care, and evaluating clinical interventions. At the same time, there are a number of implementation challenges the Department of Veterans Affairs and other organizations may face.

IMPLICATIONS

Policy makers and program managers in any setting, including state long-term-care programs, who wish to implement an assessment system must anticipate and address a variety of implementation problems with a clear and consistent message from key leadership, adequate training and clinical support for assessors, and appropriate planning and resources for data systems.

Le maniement des médicaments anticancéreux chez les malades âgés

The management of elderly patients with cancer is not established. The use of antineoplastic agents (particularly of chemotherapy) raises a lot of questions. Efficiency and toxicity. Data come from subgroups of clinical trials and from selected populations. Chronological age itself does not contra-indicate chemotherapy. Pharmacokinetics. Physiologic and functional changes occur with aging but there is great inter-patient variability. Oral chemotherapy. Oral treatments underline the problem of compliance. Under-treatment. Elderly patients are under-represented in clinical trials. Relevant issues have to be defined individually and cancer's real place in patient's general situation has to be specified. Geriatric assessment. This tool has proved its usefulness in many domains for global management of elderly patients. A multidisciplinary team is necessary, under geriatrician coordination. The aim is to elaborate an individualized medico-social intervention program. Geriatric assessment in oncology. Its interest for cancer patients is shown by emerging reports but its routine use by oncologists is impossible. Treatment strategies. They are not validated.

FUTURE

New clinical and pharmacokinetic studies are necessary in order to specify the place of the various tools and to enhance the handling of such molecules.

Outcomes of Inpatient Geropsychiatric Treatment: The Value of Assessment Protocols

The purpose of this evaluative study was to determine if elderly patients' mental health assessment scores improved after receiving specialized inpatient treatment. A random sample of 106 cases was drawn from existing medical records of patients treated during a 2-year time period in a comprehensive geropsychiatric inpatient clinical outcome assessment program. The clinical assessments included measures of cognitive, affective, and functional levels and used scores from the Mini-Mental State Exam, the Geriatric Depression Scale, the Allen Cognitive and Level of Care Assessment, and the Global Assessment of Function on admission and at discharge. Comparisons of these scores revealed a statistical significance between admission and discharge scores, and the mean assessment scores did improve during the average 12-day hospital stay. Although specific treatment efficacy cannot be inferred from these results, at least the overall efficacy of such treatment was supported by this study's findings.

Development of a conceptual framework for the assessment of geriatric rehabilitation outcomes

The objective of the study was to develop a conceptual framework of key assessment areas for the evaluation of rehabilitation outcomes in older persons. The study was designed in four stages. First, a review of the literature generated a list of 84 potential outcome variables. Second, semi-structured interviews were conducted with older adults informants (n = 19) to record their thoughts about important rehabilitation outcomes. From the analyses of the transcripts, 20 recurrent themes became apparent. Third, relevant assessment areas were determined based on the merged data from the literature and the interviews. Fourth, a focus group was held with a panel of eight interdisciplinary experts with strong involvement in geriatric rehabilitation to evaluate, improve, and validate the preliminary work. As a result of the study, the conceptual framework for the assessment of geriatric rehabilitation outcomes (FAGRO) is composed of four primary outcome domains related to important activities for community-living older persons: mobility activities, basic activities of daily living, activities of independent living, and leisure activities. The models also allows for four brief evaluations of underlying functioning components, including: physical functioning, psychological functioning, social functioning, and factors related to the caregiver status and available resources. The model has the potential to become a valuable additional tool for outcome assessment, researched and developed specifically for geriatric rehabilitation.

A randomized controlled trial of rehabilitation after hospitalization in frail older women: effects on strength, balance and mobility

When frail older people become acutely ill, they are at increased risk of further functional deterioration and rehabilitation is needed to restore functioning. The effects of an out-patient multicomponent training program including strength training after hospitalization were studied in a randomized controlled trial. Sixty-eight women (mean age 83.0 +/- 3.9 years) who were hospitalized due to an acute illness and were mobility impaired at admission were randomized into training (N = 34) and home exercise (N = 34) groups. Maximal voluntary isometric strength of knee extension and hip abduction, dynamic balance, and maximal walking speed were measured before and after the 10-week training period, and 3 and 9 months after the end of the intervention. After the intervention, significant improvements were observed in the training group compared to the home exercise group in the maximal voluntary isometric knee extension strength (20.8% vs. 5.1%, P= 0.009), balance scale (+ 4.4 points vs. -1.3 points, P= 0.001) and walking speed (+ 0.12 m s-1 vs. -0.05 m s-1, P= 0.022). Effects on knee extension and hip abduction strength, balance and walking speed were observed 3 months later, and some effects on hip abduction strength (9.0% vs. -11.8%, P= 0.004) and mobility were still apparent even 9 months after the intervention.

Functional decline in hospitalized elders: preventive nursing measures

Functional status in older adults admitted to hospitals is a major predictor of outcomes. Functional decline, which is complex and multifactorial in cause, is a common complication of hospital stays. Many factors contributing to functional decline are preventable and treatable by proper nursing. Advanced practice nurses have an important, multifaceted role to play in resolving this geriatric problem.

Predictors of functional ability in geriatric rehabilitation patients

This study explored the impact that motivation, cognitive status, depression, age, and physical status have on the functional ability of older adults in a rehabilitation program. The study was based on a hypothesized model and was conducted with 200 patients on a geriatric rehabilitation unit. Structural equation modeling was done to test the hypothesized model. The average age of participants was 78 years, and the majority were female, Caucasian, unmarried, and had been admitted for rehabilitation after an orthopedic event. The data fit the hypothesized model; however, only five paths were significant. Mental status was a significant predictor of function on admission and a direct and indirect predictor of function at discharge, and diagnosis and age directly predicted function at discharge.

The OBRA-87 nursing home regulations and implementation of the Resident Assessment Instrument: effects on process quality

OBJECTIVE

To characterize changes in key aspects of process quality received by nursing home residents before and after the implementation of the national nursing home Resident Assessment Instrument (RAI) and other aspects of the Omnibus Budget Reconciliation Act (OBRA) nursing home reforms.

DESIGN

A quasi-experimental study using a complex, multistage probability-based sample design, with data collected before (1990) and after (1993) implementation of the RAI and other OBRA provisions.

SETTING AND PARTICIPANTS

Two independent cohorts (n > 2000) of residents in a random sample of 254 nursing facilities located in metropolitan statistical areas in 10 states.

INTERVENTION

OBRA-87 enhanced the regulation of nursing homes and included new requirements on quality of care, resident assessment, care planning, and the use of neuroleptic drugs and physical restraints. One of the key provisions, used to help implement the OBRA requirements in daily nursing home practice, was the mandatory use of a standardized, comprehensive system, known as the RAI, to assist in assessment and care planning. OBRA provisions went into effect in federal law on October 1, 1990, although delays issuing the regulations led to actual implementation of the RAI during the Spring of 1991. MEASUREMENTS AND ANALYSES: Research nurses spent an average of 4 days per facility in each data collection round, assessing a sample of residents, collecting data through interviews with and observations of residents, interviews with multiple shifts of direct staff caregivers for the sampled residents, and review of medical records, including physician's orders, treatment and care plans, nursing progress notes, and medication records. The RNs collected data on the characteristics of the sampled residents, on the care they received, and on facility practices. The effect of being a member of the 1990 pre-OBRA or the 1993 post-OBRA cohort was assessed on the accuracy of information in the residents' medical records, the comprehensiveness of care plans, and on other key aspects of process quality while controlling for any changes in resident case-mix. The data were analyzed using contingency tables and logistic regression and a special statistical software (SUDAAN) to assure proper variance estimation.

RESULTS

Overall, the process of care in nursing homes improved in several important areas. The accuracy of information in residents' medical records increased substantially, as did the comprehensiveness of care plans. In addition, several problematic care practices declined during this period, including use of physical restraints (37.4 to 28.1% (P < .001)) and indwelling urinary catheters (9.8 to 7% (P < .001)). There were also increases in good care practices, such as the presence of advanced directives, participation in activities, and use of toileting programs for residents with bowel incontinence. These results were sustained after controlling for differences in the resident characteristics between 1990 and 1993. Other practices, such as use of antipsychotic drugs, behavior management programs, preventive skin care, and provision of therapies were unaffected, or the differences were not statistically significant, after adjusting for changes in resident case-mix.

CONCLUSION

The OBRA reforms and introduction of the RAI constituted an unprecedented implementation of comprehensive geriatric assessment in Medicare- and Medicaid-certified nursing homes. The evaluation of the effects of these interventions demonstrates significant improvements in the quality of care provided to residents. At the same time, these findings suggest that more needs to be done to improve process quality. The results suggest the RAI is one tool that facility staff, therapists, pharmacy consultants, and physicians can use to support their continuing efforts to provide high quality of care and life to the nation's 1.7 million nursing home residents.

Looking inside the black box of comprehensive geriatric assessment: a classification system for problems, recommendations, and implementation strategies

OBJECTIVE

To develop and test the inter-rater reliability of a coding system for geriatric problems identified through Comprehensive Geriatric Assessment (CGA) of hospitalized older persons, recommendations generated by the assessment, and implementation strategies for these recommendations.

DESIGN

Validation study.

SETTING

A health maintenance organization and a geriatrics academic program.

PARTICIPANTS

A total of 49 hospitalized older persons, who met at least 1 of 13 inclusionary "targeting" criteria, two geriatricians, and one social worker who coded forms.

MEASUREMENTS

Standardized coding of CGA consultation sheets into (1) geriatric problems identified, (2) recommendations, and (3) implementation strategies; inter-rater reliability testing of coding system using two physicians and a social worker.

RESULTS

On average, each assessed patient had 4.8 recommendations. The largest percentages of recommendations were for non-physician referrals (18.2%), advance directives (13.4%), medication adjustments (11.5%), diagnostic evaluation/monitoring (11.5%), and community services (10.9%). The proportions of agreement between raters in coding problems ranged from 0.77 to 0.90, in coding recommendations from 0.69 to 0.86, and in coding implementation strategies from 0.68 to 0.83.

CONCLUSION

A classification system for measuring some components of the process of care of CGA has satisfactory inter-rater reliability, can be adapted for other settings, and may provide valuable insight into determining which components of CGA confer health benefits.

Inpatient community-based geriatric assessment reduces subsequent mortality

OBJECTIVE

To evaluate the effect of an Inpatient Geriatric Consultation Team on patient outcome.

DESIGN

Randomized controlled clinical trial.

SETTING

A non-academic-affiliated 503-bed community hospital.

PATIENTS

All inpatients over the age of 70 years. Sixty-two patients received multidimensional geriatric assessment, and 58 patients received no intervention.

INTERVENTION

Team assessment, leading to formal recommendations to the attending physician.

MEASUREMENTS

Data were collected on hospital length of stay, referrals to community service, discharge destination, hospital readmissions in 6 months, number of post-discharge physician visits, and change in functional status. Mortality at 6 months and at 1 year was determined for each patient.

MAIN RESULTS

At 6 months, 12/58 patients (21%) had died in the control group versus 3/62 (6%) patients in the experimental group (P = 0.01). During hospitalization, the length-of-stay was 10.1 days for the control group versus 9.0 days for the experimental group (P = 0.20). The control group had significantly more readmissions (0.6 per patient vs 0.3 per patient, P = 0.02). A higher number of experimental patients, 22% (13/59), showed improvement in ADL scores compared with 7% (4/46) of control patients, P = 0.07. At one year for all randomized patients, 7/68 (10%) of experimental patients and 13/64 (20%) of control patients had died.

CONCLUSIONS

Short-term mortality can be reduced in community inpatient acute hospital settings by comprehensive geriatric consultation teams. Important differences in mortality remain at 1 year of followup. Trends towards improved functional status and fewer hospital readmissions favor the intervention group.

Research considerations. Geropsychiatry unit evaluation

The specialized psychiatric units for geriatric patients are believed to be effective, yet no studies could be found documenting this. A method of evaluating the effectiveness of a geropsychiatric program is to measure changes in the cognitive and functional status of its patients. This study supports the hypothesis that there would be an improvement in the geropsychiatric patients' cognitive and functional assessment scores by discharge and after hospitalization.

Patients in acute care settings. Which health-care services are provided?

Studies have shown that early discharge planning, multidisciplinary care, and a focus on functional abilities for older adults do reduce acute care hospital readmissions. Of the 101 records reviewed of acute care admissions 75 years of age and older, 36 had no multidisciplinary service documented and 75 had no discharge planning documented within 48 hours of admission. Eleven functional activities were assessed and documented in one record with a range of 4 to 11 activities assessed in the remaining 100 documents. Identifying and filling gaps in care provided to this age group might provide substantial cost savings, improve care, and decrease complications. Advocacy, coordination of care, and greater knowledge may be keys to narrowing these service gaps.

Impact of a geriatric assessment unit on subsequent health care charges

BACKGROUND

In a recent randomized controlled trial assessing the efficacy of an inpatient geriatric assessment unit (GAU), we demonstrated that patients assigned to the unit were less likely than those in the usual care group to be admitted to a nursing home and more likely to remain living in the community. Despite evidence of benefits of GAU care, questions remain about its cost. We examine the impact of GAU treatment on subsequent health care charges.

METHODS

Sequential referrals of elderly disabled patients considered at risk for institutionalization or likely to improve with rehabilitation were randomized to the GAU or to usual care. Charge data were collected on utilization of a wide variety of health care services starting at the point of randomization.

RESULTS

The group randomized to the GAU experienced significantly higher rehabilitation charges per participant ($10,583 vs $2066, P = .0001), but lower mean nursing home charges ($1798 vs $3426, P = .004). Total health care charges per participant over the 1 year follow-up were greater for the GAU group ($28,406 vs $16,444, P = .004). When charges were adjusted per year of life survived, the GAU group still showed a substantial (but nonsignificant, P = .10) increase in total charges. However, when charges were adjusted per day subsequently spent residing in the community, adjusted total charges were similar between the two groups.

CONCLUSIONS

Our results indicated that improved outcomes from GAU care require an investment in rehabilitation that is not totally offset by decreased institutional charges in the following year.

Impacts of geriatric evaluation and management programs on defined outcomes: overview of the evidence

Comprehensive geriatric assessment is a technique for multidimensional diagnosis of frail elderly people with the purpose of planning and/or delivering medical, psychosocial, and rehabilitative care. When comprehensive geriatric assessment is coupled with some therapy, then the term geriatric evaluation and management (GEM) will be used. Following a brief history of comprehensive geriatric assessment, we describe the varied patterns of GEM program organization and review the literature of studies examining GEM effectiveness. Program diversity complicates drawing firm conclusions about GEM effects; however, the vast majority of studies report positive, if not uniformly significant, results. Our analysis suggests that much of the variability in findings is due to sample size limitations. In order to reach conclusions of program effects across studies and to avoid problems of small sample sizes, we undertook a formal meta-analysis. In this initial meta-analysis, we sought to evaluate the effect of GEM programs on a single outcome: mortality. We pooled all published GEM controlled trials into four major groups: inpatient consultation services, inpatient GEM units, home assessment services, and outpatient GEM programs. Meta-analysis of 6-month mortality demonstrates a 39% reduction of mortality for inpatient consultation services (odds ratio 0.61, 95% confidence interval 0.46-0.81, P = 0.0008) and a 37% reduction of mortality for inpatient GEM units (odds ratio 0.63, 95% CI 0.42-0.93, P = 0.02). Home assessment services reduced mortality by 29% (odds ratio 0.71, 95% CI 0.55-0.90, P = 0.005). On the other hand, no significant survival effect was found for outpatient GEM programs (odds ratio 0.96, 95% confidence interval 0.61-1.49).(ABSTRACT TRUNCATED AT 250 WORDS)

Comparison of subjective ratings of function with observed functional ability of frail older persons

BACKGROUND

Important clinical decisions often hinge on patients' functional status. Previous studies have shown disagreement among sources of ratings of patients' functional status. This study compared patient self-ratings, family member ratings, and physician ratings of patient function to performance-based functional testing criteria.

METHODS

Five activities of daily living of 73 older patients were studied at admission to a rehabilitation unit following discharge from an acute care community hospital. Data were collected from patients, family members, and physicians and were compared with performance-based function testing.

RESULTS

Patient ratings were significantly more accurate than physician ratings for walking, transferring, and telephoning. Patients were significantly more accurate than family members for rating walking and telephoning, but patients were not significantly more accurate than family members or physicians for rating eating or dressing.

CONCLUSIONS

We conclude that decisions about patients' functional level should be based on performance testing. If performance testing is unavailable, patients' own ratings are most accurate, followed by family ratings. Physicians' ratings are least accurate.

Geriatric evaluation and management: current status and future research directions

In the last decade the concept of geriatric evaluation and management (GEM) has been widely discussed in the literature. Studies of GEM have occurred primarily in three settings: inpatient units, outpatient clinics, and specialized types of home care. We have reviewed the literature, focusing on randomized trials, to determine the strength of the evidence for the efficacy of these interventions. Two single-site randomized controlled trials of inpatient GEM units have been conducted and indicate that such units that provide care to targeted disabled older patients probably have a favorable impact on subsequent physical function, rates of institutionalization, and mortality. Two randomized trials of inpatient GEM consultation teams have been conducted. The trial that did not target high-risk individuals showed no benefit while the trial that did target an at-risk group showed that those receiving the service had improvements in mental status and short-term mortality. The results of randomized trials of outpatient GEM clinics to date have been unimpressive. Two trials of in-home GEM by a trained observer tended to show that the service resulted in a reduction in mortality. To date randomized trials of GEM have been very heterogeneous in terms of the type of assessment and subsequent care, the site in which services are delivered, and the manner in which patients are selected for the studies. This limits the ability to compare and extrapolate across studies. In the future there is a need to better clarify the selection of study participants, the exact structure of the assessment intervention provided, and the elements of successful interventions that may be most critical to insuring a good outcome.

Functional and mental status outcomes of clients discharged from acute gerontological versus medical/surgical units

The goal of a specialized geriatric unit in an acute care hospital setting is to minimize losses and have the patient maintain or achieve an optimal level of functioning and cognition. This study showed that more acute clients on a geriatric unit maintained or improved functioning capacity at a significant level in fewer days and at a lowered cost. Nursing implications include inservice training specific to caring for geriatric clients and providing early assessment and identification of strengths. Interventions such as reality orientation and early proactive measures can be used to maintain or achieve optimal cognitive functional capacity.

Outpatient geriatric assessment: associations between referral sources and assessment findings

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

The natural history of functional morbidity in hospitalized older patients

This study provides data on changes in the functional status of older patients that are associated with acute hospitalization. Seventy-one patients over the age of 74 admitted to the medical service of Stanford University Hospital between February and May 1987 received functional assessments covering seven domains: mobility, transfer, toileting, incontinence, feeding, grooming, and mental status. Assessments were obtained by report from the patient's caregiver (or the patient when he or she lived alone) for 2 weeks before admission; from the patient's nurse on day 2 of hospitalization and on the day before discharge; and again from the caregiver (or patient) 1 week after discharge. The sample had a mean age of 84, covered 37 Diagnostic Related Groups, and had a median length of stay of 8 days. Between baseline and day 2, statistically significant deteriorations occurred for the overall functional score and for the individual scores for mobility, transfer, toileting, feeding, and grooming. None of these scores improved significantly by discharge. In the case of mobility, 65% of the patients experienced a decline in score between baseline and day 2. Between day 2 and discharge, 67% showed no improvement, and another 10% deteriorated further. These data suggest that older patients may experience a burden of new and worsened functional impairment during hospitalization that improves at a much slower rate than the acute illness. An awareness of delayed functional recovery should influence discharge planning for older patients. Greater efforts to prevent functional decline in the hospitalized older patient may be warranted.

A randomized, controlled trial of a geriatric assessment unit in a community rehabilitation hospital

We conducted a randomized trial in a community rehabilitation hospital to determine the effect of treatment in a geriatric assessment unit on the physical function, institutionalization rate, and mortality of elderly patients. Functionally impaired elderly patients (mean age, 78.8 years) who were recovering from acute medical or surgical illnesses and were considered at risk for nursing home placement were randomly assigned either to the geriatric assessment unit (n = 78) or to a control group that received usual care (n = 77). The two groups were similar at entry and were stratified according to the perceived risk of an immediate nursing home placement. After six months, the patients treated in the geriatric assessment unit had significantly more functional improvement in three of eight basic self-care activities (P less than 0.05). Those in the lower-risk stratum had significantly more improvement in seven of eight self-care activities. Both six weeks and six months after randomization, significantly more patients treated in the geriatric assessment unit than controls (79 vs. 61 percent after six months) were residing in the community. During the year of follow-up, the control patients had more nursing home stays of six months or longer (10 vs. 3; P less than 0.05). However, there was no difference between the groups in the mean number of days spent in health care facilities (acute care hospital, nursing home, or rehabilitation hospital). Survival analysis showed a trend toward fewer deaths among the patients treated in the geriatric assessment unit, and mortality was significantly reduced in the patients considered to be at lower risk of immediate nursing home placement (P less than 0.05). We conclude that the treatment of selected elderly patients in a specialized geriatric rehabilitation unit improves function, decreases the risk of nursing home placement, and may reduce mortality. The beneficial effects on mortality and function appear greatest for patients at a moderate rather than high risk of nursing home placement.

Comprehensive geriatric assessment: toward understanding its efficacy

Comprehensive geriatric assessment (CGA) offers health care professionals a technique for multidimensional diagnosis of frail elderly people to plan medical, psychosocial, and rehabilitative care. In the present paper, we provide a brief history of geriatric assessment, a description of the varied organization of geriatric assessment programs (GAPs), and a review of published effectiveness studies of programs worldwide performing comprehensive geriatric assessment. Program diversity has complicated drawing conclusions about the efficacy of CGA from a literature reporting generally positive, but not uniformly significant, results. We suggest that sample size limitations explain much of the variability in findings. Using the techniques of meta-analysis, we evaluate the effect of GAPs on mortality when all controlled trials are considered cumulatively. Meta-analysis of six-month mortality demonstrates a statistically significant 36% reduction of mortality for inpatient CGA programs (odds ratio = 0.64; 95% confidence interval = 0.50 to 0.83), and a 32% mortality reduction for all CGA programs (odds ratio = 0.68; 95% confidence interval = 0.57 to 0.80). Further use of meta-analytic techniques can be employed to clarify the effect of GAPs on other important outcomes (e.g., reduced hospital and nursing home use, improved functional status), and to identify program characteristics best promoting these benefits.

Outcomes of a geriatric rehabilitation program in a long-term care facility

This study investigated outcomes of geriatric rehabilitation and predictors of success among 81 consecutive admissions to a 40-bed rehabilitation unit in a long-term care facility. Predictors measured at admission included sociodemographic variables, functional status (both current and prior to illness), social contact, and self-motivation. In all, 62 patients (77%) successfully completed the rehabilitation program; 76% of the successes were discharged home. Failure to discharge successfully rehabilitated subjects was mainly due to placement problems and patient and family preference. Both of the success groups showed significant improvement in functional status (Barthel Index), while failures had poorer initial functional status, and showed no improvement on average. At six-month follow-up, functional status (measured by the Sickness Impact Profile) was similar in the two success groups. No predictors other than functional status were associated with rehabilitation success. Among the successes, better functional status at six months was predicted by aspects of self-motivation.

Do nursing diagnoses affect functional status?

1. Nurses in this study often made diagnoses pertaining to physiological or physical problems rather than psychosocial problems. One diagnostic category, "impaired home maintenance management," was consistently used incorrectly, suggesting a need for careful clinical training of nursing staff in diagnostic reasoning. 2. Patients who had a greater number of nursing diagnoses had greater improvements in function during the hospital stay. One explanation is that more nursing diagnoses may lead to more independent nursing actions, resulting in improvements in functional abilities. 3. Functional status on admission measured by the Katz ADL was the most powerful predictor of functional status at discharge. The scale can readily be used by nurses to document basic functioning and to quickly identify patients needing or coordinated discharge planning. 4. Institutionalized had a higher mean number of nursing diagnoses than those who were discharged to their own homes. The most powerful predictor of institutionalization was the Katz ADL score.

How does the team approach to outpatient geriatric evaluation compare with traditional care: a report of a randomized controlled trial

Although team-oriented geriatric assessment clinics are growing throughout the country, little documentation exists regarding their clinical efficacy, cost-effectiveness, or impact on patient functioning and well-being. This report describes a randomized controlled clinical trial to evaluate the effectiveness of a team-oriented geriatric assessment approach compared to traditional care. One hundred-seventeen subjects 65 years of age and over, meeting eligibility criteria to target frail older persons with changing medical and social needs, were randomly assigned to receive a comprehensive geriatric assessment by a multidisciplinary team (treatment) or by one of a panel of community internists who were reimbursed according to their usual and customary fee (controls). Extensive analysis of baseline information failed to identify any significant differences between groups. Over the 1-year follow-up period, treatment participants experienced 26 hospital admissions and used 670 hospital days compared with 23 admissions and 1113 days for controls (a 39.8% difference). Annual hospital costs averaged $4297 for treatment subjects and $7018 for controls. Overall institutional costs including hospital and nursing home care revealed an average saving of $2189 per person for treatment subjects compared with controls, a 25% reduction. A small proportion of subjects accounted for this difference. No significant differences were noted in patient or caregiver satisfaction with the evaluation process, functional ability, or health status. These findings suggest that team-oriented outpatient geriatric assessment provides a promising way to deliver high-quality, satisfying care to older persons without increasing (and possibly decreasing) health care costs.

Identifying the older person likely to require long-term care services

The purpose of this study is to determine the accuracy of predictions in identifying older persons who subsequently require long-term care such as home services or institutionalization. Eighty-six individuals undergoing geriatric evaluation between May 1983 and April 1984 were evaluated using a series of commonplace tasks such as opening doors, stacking checkers, and copying a simple sentence. Predictions of an individual's use of long-term care services were made during the initial evaluation and were based on whether the person could complete all the manual tasks and on the amount of time required to do so. Outcomes were determined by telephone interviews by a trained social worker in Dec 1984. A statistically significant association (P less than 0.005) was observed between the predictions and actual outcomes. Analysis of variance confirmed that the mean times for each outcome were different (F = 2.6, P less than 0.05). The results suggest that timing manual performance offers a useful way to prospectively identify older persons at risk of requiring additional long-term care services.

Trial of a geriatric consultation team in an acute care hospital

A controlled trial was conducted to examine the effects of superimposing an interdisciplinary geriatric consultation team upon the conventional patterns of care in medical wards of an acute care hospital. Two hundred and twenty-two patients, aged 69 years of age or older, admitted from the emergency room to two trial wards and 182 similar patients admitted to two control wards where the team did not work, were followed. Evaluations at admission, two and four weeks, and three and six months postadmission by independent evaluators allowed comparisons between the care groups with reference to survival, length of stay, disposition, physical, mental, and social functional levels, and use of services after discharge. Data from charts and treatment logs allowed the care processes to be compared. Findings determined that patients in the two groups were alike on socio-demographic and clinical characteristics at entry. Results demonstrated that patients in the trial and control groups fared similarly on the outcome measures at each evaluation point, although a trend toward better survival among team patients was noted. It was concluded that the addition of a consultative geriatric team to the medical wards failed to show a significant impact on patient outcomes.

Use of assessment instruments in clinical settings

In recent years, increased emphasis has been placed in the field of geriatric medicine on the need for multidimensional assessment of elderly patients. There is an increasing tendency to use standardized structured assessment instruments or questionnaires in this process. Frequently, the exact question or set of questions to be answered by the instrument has not been carefully analyzed. Although comprehensive structured multidimensional instruments allow the collection of large amounts of data in multiple domains (physical, social, psychologic, economic), these instruments may require excess data collection and may not be reliable in clinical settings. Clinicians considering using a variety of assessment instruments should carefully consider their goals for data collection and carefully review the validity, reliability, and population sampled for any assessment instruments under consideration. Also, the clinical setting in which the instrument is to be used can have a negative impact on either instrument validity or reliability.

Evaluation research in long-term care. Scope and methodology

Several policy issues pertaining to long-term care (LTC) were assessed, and they include (1) What are the cost-effective alternatives in long-term care? (2) What are the major societal and individual factors that are amenable to program interventions for reducing unnecessary and inappropriate institutionalization of the chronically ill? (3) What are the critical elements of a successful evaluation research design in long-term care? (4) How can LTC research findings be transmitted into policy relevant guides for program planning and development? The strengths and weaknesses of a variety of evaluation designs in long-term care research were discussed.

Evaluation of older persons in the ambulatory setting

This report provides a comprehensive description of an established outpatient geriatric consultation service. The basic objectives of the service are to promote health and to prevent or minimize disability. The consultation service uses a multidisciplinary team with core participants from medicine, nursing, and social work and is based in a setting where a wide range of specialty consultants and ancillary services are available. A detailed description of 131 individuals who received geriatric consultations during a one-year period is provided. Despite a substantial burden of disability, most older persons after the consultation process were able to continue living in their own preferred setting. The degree to which the geriatric consultation service contributed to these favorable outcomes is currently being evaluated through a randomized clinical trial.

New areas of theory development and practice in patient education

Patient education, which is central to nursing practice, is evolving as a body of theory and in its application to groups of clients. This paper outlines a new body of theory known as self-efficacy theory, which has considerable potential to improve patient outcomes from teaching. This theory posits that patient belief that he can perform a necessary behaviour (self-efficacy) can be affected by four principal sources of information: performance attainments, vicarious experience, verbal persuasion, and perceived physiological states. This paper also describes new applications of patient education for psychiatric patients and notes the potential for the expanded educational services for geriatric patients. These programmes have the potential to save hospital costs and to improve quality of life but appear to be in early stages of programme development. Active development and management of a field's theory base and practice applications is fragmented in the patient education field but important to the field's continued relevance and vigour.

Medical paternalism and patient self-determination

In response to the common belief that paternalism directed toward a competent patient necessarily transgresses the patient's right of self-determination and is therefore morally suspect, the authors argue that such a general view fails to appreciate the complexity of the patient/physician relationship as it is manifested in various clinical settings. It is the authors' contention that some strongly paternalistic acts may fail to violate the patient's right of autonomy, that other such acts may actually be a function of respect for patient autonomy, and that others may only suspend or momentarily infringe upon patient autonomy. They conclude that if these instances of paternalism differ from the classical examples of strong paternalism, then so also should the moral appraisal.