Evaluation of older persons in the ambulatory setting

Interventions in Physician-Elderly Patient Interactions

Currently, most research in the area of physician-elderly patient interactions relates to either outcome, context, or interaction styles. There are limited data in the area of intervention studies. The authors recognize five specific areas of interventional research to consider: communication during encounters, characteristics of older patients, physical impairments, physician attributes, and the team approach to health care. Also highlighted are recognition and evaluation of the special needs of elderly patients through geriatric assessment. The authors recognize the need for more intervention studies that attempt to change patient or physician behaviors and the applicability of the classic randomized controlled model of research. Overall, the authors contend that the formation of strong, meaningful relationships between elderly patients and their physicians is best achieved through effective medical communication and care, and thus should be the function of appropriate interventions.

Patterns of care in the early stages of Alzheimer's disease: impediments to timely diagnosis

OBJECTIVE

Description of factors associated with delay in diagnosis of Alzheimer's disease (AD).

DESIGN

A self-administered mail questionnaire.

SETTING

Households including someone with AD identified through a nationwide marketing database.

PARTICIPANTS

A total of 1480 caregivers of patients diagnosed with AD.

MEASUREMENTS

There were two measures of delay examined through caregiver reports: (1) duration in years from first AD signs until determination of a definite problem, and (2) duration from problem recognition to first physician consultation. Also, caregivers were categorized by time since patient's diagnosis and relationship to patient. Within-group analyses examined the impact of these characteristics on delay measures.

RESULTS

Mean lag in years from observation of first symptoms to problem recognition for those diagnosed in the past 12 months, the past 13 to 48 months, and the past 49 months or more was, respectively, 1.20, 1.56, and 2.25 (P < .001). The timing of diagnosis also influenced lag from problem recognition to first physician consultation so that subgroups with recent, less recent, and distant diagnosis reported delays in years of .82, .84, and 1.31 (P < .001). Caregiver relationship was not significantly related to these lags. Correct diagnosis of AD was reported by caregivers in only 38% of cases at initial physician consultation.

CONCLUSIONS

These results suggest that both caregivers and physicians lack ready understanding of the difference between memory processes in aging and AD. Ongoing public and professional education is needed to convey the basics of the diagnosis of AD. In addition, routine screening for dementia should be considered to surmount attitudinal and logistical barriers.

A university-affiliated community hospital inpatient geriatrics program functioning in an administrative and educational capacity

OBJECTIVE

To demonstrate an unusual form of inpatient geriatric assessment with unique outcomes.

DESIGN

A prospective evaluation of patients admitted to a community hospital-based inpatient geriatrics unit utilizing traditional members of the assessment team along with educational assessment of nurses and satisfaction profiles of patients and/or families.

SETTING

A non-profit community hospital in Northeast Washington, DC.

PARTICIPANTS

All patients older than age 62 admitted to the 42-bed Geriatric Unit during a 4 1/2 year time period.

MEASUREMENTS

Number of total and category recommendations taken by attending physicians from the Inpatient Geriatric Assessment Team, periodic evaluation of unit nurses' geriatric knowledge base and certification, and patient satisfaction through periodic surveys.

RESULTS

More than 4500 patients have been evaluated during the past 4 1/2 years. The number of recommendations taken by attending physicians has averaged 31.3 to 50.7% during four consecutive chart reviews involving the first 25 consecutive patients for the month each performed every six months (n = 100). The average age of patients evaluated was 77.2 (minimum of 62 and maximum of 97); 67% were females and 33% males. The average number of recommendations communicated per patient was 4.1, and the average number adhered to 1.6/patient. The overall knowledge base and certification in geriatric nursing has increased significantly over a 2.5-year period. Composite monthly unit patient satisfaction survey scores increased as well.

CONCLUSIONS

The program is unique in its development, limitations, and outcomes. Other than the cost of limited geriatric nurse practitioner and faculty salary support, the program has been implemented using only current hospital department personnel. The role of the assessment team is to educate attending nurses and staff physicians. It has not yet been possible to measure objective outcomes. However, the current program also serves the purpose of introducing a new medical program to a community hospital in a nonthreatening way and offers opportunities for research. In addition, the program offers further opportunity for expansion and change.

Home-based assessment for family carers: a preventative strategy to identify and meet service needs

OBJECTIVE

To identify unmet need for services among family carers and their frail or disabled relatives and to facilitate links to services.

DESIGN

Intervention study with a subgroup of carer dyads from a random statewide survey of family carers, followed by telephone 2 months post intervention.

SETTING

Carer dyads in general community; urban and rural Victoria.

PARTICIPANTS

All 186 identified carers were approached. One-third of the dyads were ineligible; of the remainder, 67 (53%) participated, matching refusals on sociodemographic characteristics. Carers were typically married, middle-aged women looking after parents or spouses. Almost half of the care recipients were aged > or = 80; most had multiple disorders and impairments. Follow-up rate was 94%.

INTERVENTION

One off, multidisciplinary home-based assessment of dyad by research team and regional aged care assessment service (ACAT).

MAIN OUTCOME MEASURES

"Unmet need': % dyads recommended new services; number services per dyad via ACAT; increases in service range; extension of pre-existing services. Service linkage: % dyads linked to new services; perceived usefulness of linkages.

MAIN RESULTS

Dyads recommended a new service (93%); increased range (73%); extensions (41%). Average two services requiring ACAT implementation; commonly respite care, aids and paramedical services. Recommendations related to impairment severity and carer stress. ACAT implemented recommendations (90% relevant dyads); links rated useful (75% relevant dyads). Three-quarters of the carers rated intervention as helpful.

CONCLUSION

A preventative programme of needs assessment for carer dyads has considerable potential; (a) identifying needs and engaging new services; (b) providing emotional support.

Geriatric care approaches in health maintenance organizations

The objective of this project was to describe geriatric care provided under Medicare-risk contracts in HMOs with established Medicare programs. These findings provided the basis for an invitational workshop, sponsored by the National Institute on Aging and the Robert Wood Johnson Foundation, to formulate a research agenda for geriatric care in HMOs. The case study method involved site visits to seven HMOs by a physician with expertise in geriatrics, a managed care specialist, and a program development specialist. Representatives from the HMOs included senior executive officials, physicians recognized for providing and promoting geriatric care, research and program development staff, and various clinical staff including pharmacists, geriatric nurse practitioners, nurses, and social workers. The most frequently encountered geriatric care programs were categorized by the following six objectives: (1) identifying high risk patients, (2) assessing multi-problem patients, (3) treating multi-problem patients, (4) rehabilitating patients following acute events, (5) reducing medication problems, and (6) providing long-term care and home health care. Unique programs identified from these site visits included screening methods for new enrollees, approaches to comprehensive geriatric assessment, use of skilled nursing facilities for intensive rehabilitation and postacute care, and drug profiling and review. Utilization of geriatric nurse specialists and programs aimed at coordination with social services were pervasive in many of these HMOs. Workshop participants proposed several research and demonstration projects in all six areas. Overall consensus emerged that HMOs with Medicare-risk contracts provide a valuable setting for experimentation in geriatric care. Given the current health policy emphasis on managed care and capitated payment methodologies, geriatric care research in HMOs should be a high priority.

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.

Caregiver burden should be evaluated during geriatric assessment

This study examines the relationship between caregiver burden and use of long-term care services following geriatric assessment. One hundred nine older subjects underwent comprehensive assessment, which included a questionnaire completed by the primary caregiver to assess the sense of burden in providing care. Logistic regression was used to identify independent predictors of service use at 12 months. Among measures of the older person's cognitive and physical abilities, only activities of daily living predicted increased use of services. When the measure of caregiver burden was added, it also entered as an independent predictor, which significantly improved the prediction of service use (chi 2 = 5.9, P less than .02). In a separate analysis, caregiver burden predicted both the use of home services and nursing-home placement. During longitudinal follow-up, the measure of burden decreased over 12 months for the sample, with the greatest reduction in burden occurring for caregivers whose relative was placed in a nursing home. The fact that caregiver burden was the most important factor in determining who would use formal services suggests that burden should be evaluated as part of geriatric assessment.

Theory in action. The geriatric assessment team

The scientific principles of homeodynamics explain the older person in terms of unique wholeness; continuous interaction, and growth. Assessing the functional status of the older adult requires evaluation of both the person and the environment. Comparing the older adult to himself is often more accurate than comparing findings to so-called norms. The role of the clinical nurse specialist as a member of the geriatric assessment team is clarified when nursing actions are theory-based.

The yield of a home visit in the assessment of geriatric patients

Elderly patients often have problems not easily detected during an office visit. We investigated the yield of a home visit by a geriatric nurse specialist as part of an interdisciplinary assessment process. Compared with the findings of an office-based assessment by a general internist, the home visit resulted in up to four new problems (median = 2, mean = 1.7, 95% confidence interval = 1.5-1.8) and one to eight new recommendations (median = 4, mean = 3.6, 95% confidence interval = 3.4-3.9). Twenty-three percent of the problems could have resulted in death or significant morbidity. The most frequent problems related to psychobehavioral difficulties (23.1% of problems involving 38.3% of patients), safety (21.6% of problems involving 35.7% of patients), and caregiver related problems (20.4% of problems involving 33.8% of patients). The most common recommendations related to safety (30.7% of recommendations involving 81.8% of patients), caregiver well-being (19.8% of recommendations involving 52.6% of patients), and social issues (12.7% involving 33.8% of patients). Baseline clinical information did not predict the yield of the home visit in this sample. We conclude that an in-home assessment contributes unique and meaningful information to the geriatric assessment process.

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.