Comprehensive geriatric assessment in a day hospital

Out of sight, out of mind? Does terminating the physical presence of a geriatric consultant in the community clinic reduce the implementation rate for geriatric recommendations

AIM

To assess the effect of moving the geriatric consultation from the primary care clinic to another setting, on the rate of implementation of geriatric recommendations by family physicians.

METHODS

A retrospective review of the computerized medical records of elderly patients in four primary care clinics. The rate of implementation of geriatric recommendations was compared between clinics in which a geriatric consultant was physically present (control clinics) and a clinic where the consultation took place elsewhere (study clinic). In addition, the results of the present study were compared to a previous study in which the geriatric consultation was carried out in the study clinic and the family doctor was an active participant.

RESULTS

127 computerized files were reviewed in the study clinic and 133 in the control clinics. The mean age of the patients was 81.1±6.3 years and 63.1% were women. The overall implementation of geriatric recommendations by family doctors in the study clinic was 55.9%, a statistically significant decrease compared to the previous study where the rate was 73.9% (p<0.0001). In contrast, there was no change in the implementation rate in the control clinics at 65.0% in the present study and 59.9% in the previous one (p=0.205).

CONCLUSIONS

Direct, person-to-person contact between the geriatric consultant and the family doctor has a beneficial effect on the implementation of geriatric recommendations. This should be considered by healthcare policy makers when planning geriatric services in the community.

Medical day hospital care for older people versus alternative forms of care

BACKGROUND

The proportion of the world's population aged over 60 years is increasing. Therefore, there is a need to examine different methods of healthcare provision for this population. Medical day hospitals provide multidisciplinary health services to older people in one location.

OBJECTIVES

To examine the effectiveness of medical day hospitals for older people in preventing death, disability, institutionalisation and improving subjective health status.

SEARCH METHODS

Our search included the Cochrane Effective Practice and Organisation of Care (EPOC) Group Register of Studies, CENTRAL (2013, Issue 7), MEDLINE via Ovid (1950-2013 ), EMBASE via Ovid (1947-2013) and CINAHL via EbscoHost (1980-2013). We also conducted cited reference searches, searched conference proceedings and trial registries, hand searched select journals, and contacted relevant authors and researchers to inquire about additional data.

SELECTION CRITERIA

Randomised and quasi-randomised trials comparing medical day hospitals with alternative care for older people (mean/median > 60 years of age).

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial eligibility and risk of bias and extracted data from included trials. We used standard methodological procedures expected by the Cochrane Collaboration. Trials were sub-categorised as comprehensive care, domiciliary care or no comprehensive care.

MAIN RESULTS

Sixteen trials (3689 participants) compared day hospitals with comprehensive care (five trials), domiciliary care (seven trials) or no comprehensive care (four trials). Overall there was low quality evidence from these trials for the following results.For the outcome of death, there was no strong evidence for or against day hospitals compared to other treatments overall (odds ratio (OR) 1.05; 95% CI 0.85 to 1.28; P = 0.66), or to comprehensive care (OR 1.26; 95% CI 0.87 to 1.82; P = 0.22), domiciliary care (OR 0.97; 95% CI 0.61 to 1.55; P = 0.89), or no comprehensive care (OR 0.88; 95% CI 0.63 to 1.22; P = 0.43).For the outcome of death or deterioration in activities of daily living (ADL), there was no strong evidence for day hospital attendance compared to other treatments (OR 1.07; 95% CI 0.76 to 1.49; P = 0.70), or to comprehensive care (OR 1.18; 95% CI 0.63 to 2.18; P = 0.61), domiciliary care (OR 1.41; 95% CI 0.82 to 2.42; P = 0.21) or no comprehensive care (OR 0.76; 95% CI 0.56 to 1.05; P = 0.09).For the outcome of death or poor outcome (institutional care, dependency, deterioration in physical function), there was no strong evidence for day hospitals compared to other treatments (OR 0.92; 95% CI 0.74 to 1.15; P = 0.49), or compared to comprehensive care (OR 1.05; 95% CI 0.79 to 1.40; P = 0.74) or domiciliary care (OR 1.08; 95% CI 0.67 to 1.74; P = 0.75). However, compared with no comprehensive care there was a difference in favour of day hospitals (OR 0.72; 95% CI 0.53 to 0.99; P = 0.04).For the outcome of death or institutional care, there was no strong evidence for day hospitals compared to other treatments overall (OR 0.85; 95% CI 0.63 to 1.14; P = 0.28), or to comprehensive care (OR 1.00; 95% CI 0.69 to 1.44; P = 0.99), domiciliary care (OR 1.05; 95% CI 0.57 to1.92; P = 0. 88) or no comprehensive care (OR 0.63; 95% CI 0.40 to 1.00; P = 0.05).For the outcome of deterioration in ADL, there was no strong evidence that day hospital attendance had a different effect than other treatments overall (OR 1.11; 95% CI 0.68 to 1.80; P = 0.67) or compared with comprehensive care (OR 1.21; 0.58 to 2.52; P = 0.61), or domiciliary care (OR 1.59; 95% CI 0.87 to 2.90; P = 0.13). However, day hospital patients showed a reduced odds of deterioration compared with those receiving no comprehensive care (OR 0.61; 95% CI 0.38 to 0.97; P = 0.04) and significant subgroup differences (P = 0.04).For the outcome of requiring institutional care, there was no strong evidence for day hospitals compared to other treatments (OR 0.84; 95% CI 0.58 to 1.21; P = 0.35), or to comprehensive care (OR 0.91; 95% CI 0.70 to 1.19; P = 0.49), domiciliary care (OR 1.49; 95% CI 0.53 to 4.25; P = 0.45), or no comprehensive care (OR 0.58; 95% CI 0.28 to 1.20; P = 0.14).

AUTHORS' CONCLUSIONS

There is low quality evidence that medical day hospitals appear effective compared to no comprehensive care for the combined outcome of death or poor outcome, and for deterioration in ADL. There is no clear evidence for other outcomes, or an advantage over other medical care provision.

Hospitalization replacement technologies in the Russian Federation

The article presents data on different forms of hospitalization replacement technologies in foreign countries and in the Russian Federation. The author describes an experience of administering medical aid according to individual profiles under the conditions of hospitalization replacement technologies.

Rehabilitation outcomes of older Chinese patients with different cognitive function in a geriatric day hospital

The relationship between cognitive function and geriatric day hospital (GDH) rehabilitation has not been explored. This study investigated this association in 547 older Chinese patients attended GDH. Cognitive status was assessed by Cantonese version of mini-mental state examination (C-MMSE). Functional independence measure (FIM) upon GDH admission and discharge were measured, with FIM gain = FIM discharge-FIM admission while FIM efficiency = FIM gain/by number of GDH visits. FIM discharge ≥ 90 was defined as satisfactory outcome of rehabilitation. Positive correlation was observed between C-MMSE admission and FIM discharge (p < 0.001). There were significant differences in the FIM admission and FIM discharge among the three C-MMSE groups, with lower discharge scores in low C-MMSE groups (p < 0.001). The FIM gain and FIM efficiency during GDH rehabilitation were not different among different C-MMSE groups. C-MMSE admission (p = 0.03) and FIM admission (p < 0.001) were both positive independent predictors for a satisfactory rehabilitation outcomes (FIM discharge ≥90). Cognitive function was not associated with FIM gain and efficiency. This suggested that selected patients with impaired cognition could still benefit from GDH rehabilitation.

Medical day hospital care for the elderly versus alternative forms of care

BACKGROUND

The proportion of the world's population aged 60 or over is increasing. This review sets out to examine the effectiveness and resource implications of geriatric medical day hospital attendance for elderly people. This is an update of a Cochrane review first published in 1999.

OBJECTIVES

To examine the effectiveness of attendance at a medical day hospital for elderly people in preventing death, disability, and institutionalisation and improving subjective health status.

SEARCH STRATEGY

We searched the EPOC group specialist register (March 2008), Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 1, 2008), MEDLINE (1996 to January 2008), EMBASE (1996 to 2008 week 5), and other databases.

SELECTION CRITERIA

Randomised and quasi-randomised studies comparing attendance at a geriatric medical day hospital with alternative forms of care for elderly medical patients (usually > 60 years).

DATA COLLECTION AND ANALYSIS

Three review authors independently assessed research reports to determine eligibility, categorise trial type and extract data.

MAIN RESULTS

Thirteen trials involving 3007 participants were included. These compared day hospital with a) comprehensive elderly care (five trials), b) domiciliary care (five trials), or c) no comprehensive elderly care (three trials).There were no significant differences between day hospital attendance and the sub-categories of comparison treatments for the outcomes of death, death or requiring institutional care, death or deterioration in ADL. When death or a 'poor' outcome at follow up was examined there was a significant difference in favour of day hospital attendance when compared to no comprehensive elderly care (odds ratio (OR) 0.73; 95% confidence interval (CI) 0.53 to 1.00; P < 0.05).Dependency was measured in 12 trials using a variety of ADL measures; two described short-term improvement for the day hospital group, one reported improved outcome for the comparison group, while in the remaining trials there was no statistically significant difference. Using the outcome of deterioration in ADL among survivors, day hospital patients showed a reduced odds of deterioration when compared with those receiving no comprehensive elderly care (OR 0.60; 95% CI 0.38 to 0.97; P < 0.05).When resource use was examined the day hospital group showed trends towards reductions in hospital bed use and placement of survivors in institutional care.

AUTHORS' CONCLUSIONS

Medical day hospital care for the elderly appears to be more effective than no intervention but may have no clear advantage over other forms of comprehensive elderly medical services.

A pilot study of the vulnerable elders survey-13 compared with the comprehensive geriatric assessment for identifying disability in older patients with prostate cancer who receive androgen ablation

BACKGROUND

Impairments in geriatric domains adversely affect health outcomes of the elderly. The Comprehensive Geriatric Assessment (CGA) is a key component of the treatment approach for older cancer patients, but it is time consuming. In this pilot study, the authors evaluated the validity of a brief, functionally based screening tool, the Vulnerable Elders Survey-13 (VES-13), for identifying older patients with prostate cancer (PCa) with impairment in the oncology clinic setting.

METHODS

Patients with PCa aged >or=70 years who actively were receiving androgen ablation treatment and who were followed within the clinics at the University of Chicago were eligible. Patients self-completed the VES-13 and CGA instruments and repeated the VES-13 1 month later. Physical performance and cognitive assessments were administered by a research assistant.

RESULTS

Of 50 participating patients, 50% were identified as impaired by the VES-13 (score >or=3). Sixty percent of patients scored as impaired on >or=2 tests within the CGA, exhibiting deficits in multiple domains. The reliability of the VES-13 (Pearson correlation coefficient) was 0.92. The cut-off score of 3 on the VES-13 had 72.7% sensitivity and 85.7% specificity for CGA deficits and was highly predictive for identifying impairment (area under the receiver operating characteristic curve, 0.90). Patients who had mean VES-13 scores >or=3 performed significantly worse on evaluations of activities of daily living (P = .001), physical performance (P = .002), comorbidity (P = .004), and cognitive impairment (P = .003).

CONCLUSIONS

Functional and cognitive impairments are highly prevalent among older patients with PCa who receive androgen ablation in oncology clinics. The current results indicated that the brief VES-13 performed nearly as well as a conventional CGA in detecting geriatric impairment in this population.

Needs of family caregivers caring for stroke patients: based on the rehabilitation treatment phase and the treatment setting

The objective of the study was to identify the needs of family members across rehabilitation treatment phases and treatment settings. Participants were 123 family caregivers in rehabilitation settings in South Korea that replied to the survey. The needs were measured by the Family Needs Questionnaire (FNQ) and the t-test and one-way ANOVA were used to analyze collected data. In the comparison of two rehabilitation phases, the family caregivers caring for their patients in the acute rehabilitation phase perceived the need for health information as more important than those in the postacute phase. In addition, the family caregivers caring for patients in the acute rehabilitation phase were less satisfied with community network support and family support than those in the postacute phase. In the comparison of treatment settings, family caregivers caring for their patients in outpatient clinic services showed the lowest satisfaction of their needs in four areas (health information, emotional support, instrumental support, and professional support) compared with those in inpatient facilities or day hospitals. Findings are discussed within the context of the empirical and theoretical literature and implications for social work practice are considered.

Delivery of rehabilitation services to people aging with a disability

The disabled elderly population continues to grow. Systems of care for the disabled elderly are vast, ranging from inpatient facilities to outpatient programs and home programs. Recent advances in technology allow us to reach patients in their homes through telemedicine. Support services within the community are growing, and case managers are becoming more necessary as it becomes more difficult to navigate the health care system. As providers of rehabilitative services, we must help our patients find the most appropriate setting to receive care. As the focus continues to shift from inpatient to outpatient care and to home services, we must approach health care in a dynamic fashion and with flexibility. We must be advocates for our patients and their caretakers. Significant research questions remain, and health care policy requires development. As the population ages and the disabled elderly population become a focus of fiscal experts, we must look to provide the most cost-effective yet functionally productive health care. We may shift from focusing on functional performance in a therapy gym or inpatient rehabilitation unit to functional performance at home. We must focus on IADL and QOL indicators and must strive to find ways to provide efficient, cost-effective care. Medicaid, Medicare, and third-party insurers offer various options. The VHA offers additional benefit to those who are eligible. Advocacy groups such as the American Association of Retired Persons struggle to meet its members' needs and concerns while generating income to provide education and other resources. We must work to promote the strengths of the elderly population by addressing preventive strategies while maintaining functional independence.

Too Old to Care?

Shortly before his death in 1995, Kenneth B. Schwartz, a cancer patient at Massachusetts General Hospital (MGH), founded The Kenneth B. Schwartz Center at MGH (http://www.theschwarzcenter.org/rounds.asp). The Schwartz Center is a nonprofit organization dedicated to supporting and advancing compassionate health care delivery, which provides hope to the patient and support to caregivers, and encourages the healing process. The center sponsors the Schwartz Center Rounds, a monthly multidisciplinary forum where caregivers reflect on important psychosocial issues faced by patients, their families, and their caregivers, and gain insight and support from fellow staff members. Ageism is a pervasive problem throughout society. It is rooted in language, attitudes, beliefs, behaviors, and policies. Aging profoundly influences physiology, challenging the medical community to accommodate but not discriminate. The elderly are at an increased risk of disease and disability. Sixty percent of cancer occurs in people aged 65 and older, and the population is aging. The treatment of cancer in the elderly is complicated by comorbidities and other physiological factors, particularly renal, bone marrow, and metabolic reserve. Caregivers have to treat patients in a manner that optimizes treatment and avoids anticipated harm. However, the caregiver is often faced with situations where they must balance their personal beliefs, professional values, and knowledge of medicine with their patients' preferences and needs. Discussion in the Rounds focused on age bias, drug toxicity, life prolongation, and symptom relief, with the role of the caregiver, and the relationship to the patient, being pivotal.

Geriatric oncology: a clinical approach to the older patient with cancer

Due to the ageing of the population and the sharp increase in life expectancy, cancer in the older person has become an increasingly common problem in the Western world. Although several authors have stressed that elderly cancer patients deserve special attention as a target group for research efforts, older aged patients are still less likely to be offered participation in clinical trials. The cellular and molecular mechanisms regulating the physiological process of ageing and senescence are far from understood, although inflammation is likely to play an important role, at least in some cancers. In addition, the relationship between ageing and cancer risk is also far from understood. One of the most intriguing aspects of ageing is how different the ageing process is from person to person; the basis for this variation is largely unknown. Population-based studies and longitudinal surveys have shown that comorbidity and physical and mental functioning are important risk factors; thus, a meaningful assessment of comorbidity and disability should be implemented in clinical practice. Modern geriatrics is targeted towards patients with multiple problems. Such patients are not simply old, but are geriatric patients because of interacting psychosocial and physical problems. As a consequence, the health status of old persons cannot be evaluated by merely describing the single disease, and/or by measuring the response, or survival after treatment. Conversely, it is necessary to conduct a more comprehensive investigation of the 'functional status' of the aged person. A geriatric consultation provides a variety of relevant information and enables the healthcare team to manage the complexity of health care in the elderly; this process is referred to as the Comprehensive Geriatric Assessment (CGA). The use of CGA is now being introduced into oncological practice. The definition of frailty is still controversial and represents a major issue of debate in clinical geriatrics. As the frail population increases, clinical trials in frail persons are needed. The usefulness of these trials requires a consensus as to the definition of frailty. Clearly, the management of older persons with cancer requires the acquisition of special skills in the evaluation of the older person and in the recognition and management of emergencies as well as experience in geriatric case management.

Comprehensive geriatric assessment adds information to Eastern Cooperative Oncology Group performance status in elderly cancer patients: an Italian Group for Geriatric Oncology Study

PURPOSE

To appraise the performance of Comprehensive Geriatric Assessment (CGA) in elderly cancer patients (> or = 65 years) and to evaluate whether it could add further information with respect to the Eastern Cooperative Oncology Group performance status (PS).

PATIENTS AND METHODS

We studied 363 elderly cancer patients (195 males, 168 females; median age, 72 years) with solid (n = 271) or hematologic (n = 92) tumors. In addition to PS, their physical function was assessed by means of the activity of daily living (ADL) and instrumental activities of daily living (IADL) scales. Comorbidities were categorized according to Satariano's index. The association between PS, comorbidity, and the items of the CGA was assessed by means of logistic regression analysis.

RESULTS

These 363 elderly cancer patients had a good functional and mental status: 74% had a good PS (ie, lower than 2), 86% were ADL-independent, and 52% were IADL-independent. Forty-one percent of patients had one or more comorbid conditions. Of the patients with a good PS, 13.0% had two or more comorbidities; 9.3% and 37.7% had ADL or IADL limitations, respectively. By multivariate analysis, elderly cancer patients who were ADL-dependent or IADL-dependent had a nearly two-fold higher probability of having an elevated Satariano's index than independent patients. A strong association emerged between PS and CGA, with a nearly five-fold increased probability of having a poor PS (ie, > or = 2) recorded in patients dependent for ADL or IADL.

CONCLUSION

The CGA adds substantial information on the functional assessment of elderly cancer patients, including patients with a good PS. The role of PS as unique marker of functional status needs to be reappraised among elderly cancer patients.

Hematopoietic growth factors in the older cancer patient

Aging is associated with a progressive decline in the functional reserve of multiple organ systems, which may lead to enhanced susceptibility to stress such as that caused by cancer chemotherapy. Myelodepression is the most common and the most commonly fatal complication of antineoplastic drug therapy and may represent a serious hindrance to the management of cancer in older individuals. This is already a common and pervasive problem and promises to become more so. Currently 60% of all neoplasms occur in persons aged 65 years and older, and this percentage is expected to increase as the population ages. This well-known phenomenon, sometimes referred to as squaring or the age pyramid, is caused by the combination of an increasing life expectancy and a decreasing birth rate. This article explores the use of hematopoietic growth factors in the older cancer patient after reviewing the influence of age on hemopoiesis and chemotherapy-related complications. The issue is examined in terms of effectiveness and cost. An outline of the assessment of the older cancer patient is provided at the end of the chapter as a frame of reference for clinical decisions.

Cancer and age in the USA

Cancer in the older person has become an increasingly common problem with the aging of the population. The goal of this paper is to review the influence of age on cancer biology and cancer management. Specific interactions of cancer and aging include: Increased incidence of cancer with the age: This association may be reported to three factors: duration of carcinogenesis; increased susceptibility of older tissues to late stage carcinogens, and systemic effects of aging, including immune-senescence and enhanced cytokine production. Biological behavior of cancer: With aging, the prognosis of certain neoplasms, including acute myelogenous leukemia and large-cell non-Hodgkin's lymphoma worsens, whereas the behavior of other tumors becomes more indolent. In these biologic variations one may recognize both a 'seed" effect (different tumor cells) and a "soil" effect (different ways in which the older tumor host handles tumor growth. Goals of prevention and treatment: Given the limited life-expectancy of older individuals and reduced tolerance of clinical intervention, the main goal is compression of morbidity, rather than prolongation of survival. Cancer prevention in the older person: In virtue of increased susceptibility to environmental carcinogens, the older person appears an ideal candidate for primary prevention of cancer, including chemoprevention; though randomized controlled studies have not been performed, the older person may benefit from secondary prevention (screening), when the average life-expectancy is 3 years or longer. Cancer treatment: The risk of surgical complications increases only slightly with age for elective surgery, but increases dramatically for emergency surgery. Radiation therapy appears a valuable method of cancer treatment in patients of all ages. Chemotherapy can be made safer by the following provisions: use of hemopoietic growth factors for patients aged 70 and older receiving moderately toxic chemotherapy (CHOP and CHOP-like); maintenance of hemoglobin levels at 12 g/dl with erythropoietin; adjustment of the dose of renally excreted agents to the glomerular filtration rate; selection of the best candidates for chemotherapy based on comprehensive geriatric assessment.

Life expectancy, comorbidity and quality of life: the treatment equation in the older cancer patients

With ageing, function preservation and maintenance of quality of life represent a major goal in an increasing proportion of patients. Life expectancy is a function of age, comorbidity, disability and cancer type and stage. Decision-making involves a delicate balance among all these factors, evaluation of treatment related complications of the overall effects of cancer and cancer treatment on the patients' quality of life. Despite several instruments for the assessment of quality of life being validated, none have been calibrated to the special requirements of the older patients. The structured interview administered by a trained clinician represents a standard approach for geriatric research and even for clinical practice because of the frailty of the older population. The combination of this approach with the self-administered questionnaire appears the most effective way to minimise missing data in collecting information for patients unable to complete the form.

The application of the principles of geriatrics to the management of the older person with cancer

Is the patient going to die of cancer or with cancer? Is the patient going to suffer pain and disability due to cancer? Is the patient able to tolerate aggressive life-prolonging treatment? This paper tries to reply to the fundamentals of these questions by introducing the multidimensional assessment that evaluates areas where age-related changes are more likely. Chronologic age cannot be used to predict the degree of comorbidity and of functional deterioration of the single individual up to age 85 at least. Assessment of aging includes health, functional status, nutrition, cognition, socio-economic and emotion evaluations. This multidisciplinary assessment is referred to as comprehensive geriatric assessment (CGA). The risk of comorbid conditions increases with age and may result in underdiagnosis: in older patients, new symptoms may not be clearly recognized by the patient and may be dismissed by practitioners as manifestations of preexisting conditions. A meaningful assessment of comorbidity may be obtained with a comorbidity index. The Charlson scale and the Chronic Illness Rating Scale - Geriatric (CIRS-G), have enjoyed the widest acceptance. The Instrumental Activities of Daily Living (IADL) and the Activities of Daily Living (ADL) are the most sensitive assessment of function in older individuals. IADLs include shopping, managing finances, housekeeping, laundry, meal preparation, ability to use transportation and telephone and ability to take medications: in simple words, the IADLs are those skills a person needs to live independently. ADLs include feeding, grooming, transferring, toileting and are the skills necessary for basic living. Though a correlation exists among comorbidity, performance status, ADL and IADL, this correlation is not strong enough to be reflected in a single parameter. The Folstein Mini Mental Status (MMS), is the instrument of most frequent use to screen older individuals for dementia. The main problem with the MMS is lack of sensitivity to early stages of dementia. The Geriatric Depression Scale (GDS), a simple tool that can be completed by most patients at home, doubles the rate of detection of depression. The Mini Nutritional assessment is very sensitive to screen older persons for malnutrition. The risk of polypharmacy increases with age and partly results from the fact that older patients visit different practitioners. A CGA should also include evaluation of the so called Geriatric Syndromes like delirium, incontinence, osteoporosis, all of which represent a hallmark of frailty. The CGA may help the management of older individuals with cancer in at least three areas: detection of frailty, treatment of unsuspected conditions, removal of social barrier to treatment.

Management of cancer in the older person: a practical approach

The management of cancer in the older aged person is an increasingly common problem. The questions arising from this problem are: Is the patient going to die with cancer or of cancer? Is the patient able to tolerate the stress of antineoplastic therapy? Is the treatment producing more benefits than harm? This article explores a practical, albeit evolving, approach to these questions including a multidimensional assessment of the older person and simple pharmacologic interventions that may ameliorate the toxicity of antineoplastic agents. Age may be construed as a progressive loss of stress tolerance, due to decline in functional reserve of multiple organ systems, high prevalence of comorbid conditions, limited socioeconomic support, reduced cognition, and higher prevalence of depression. Aging is highly individualized: chronologic age may not reflect the functional reserve and life expectancy of an individual. A comprehensive geriatric assessment (CGA) best accounts for the diversities in the geriatric population. The advantages of the CGA include:Recognition of potentially treatable conditions such as depression or malnutrition, that may lessen the tolerance of cancer treatment and be reversed with proper intervention; Assessment of individual functional reserve; Gross estimate of individual life expectancy; and Adoption of a common language to classify older cancer patients. The CGA allows the practitioner to recognize at least three stages of aging:People who are functionally independent and without comorbidity, who are candidates for any form of standard cancer treatment, with the possible exception of bone marrow transplant. People who are frail (dependence in one or more activities of daily living, three or more comorbid conditions, one or more geriatric syndromes), who are a candidate only for palliative treatment; and People in between, who may benefit from some special pharmacological approach, such as reduction in the initial dose of chemotherapy with subsequent does escalations. The pharmacological changes of age include decreased renal excretion of drugs and increased susceptibility to myelosuppression, mucositis, cardiotoxicity and neurotoxicity. Based on these findings, the proposal was made that all persons aged 70 and older, treated with cytotoxic chemotherapy of dose intensity comparable to CHOP, receive prophylactic growth factor treatment, and that the hemoglobin of these patients be maintained >/=12 gm/dl.

The modern geriatric day hospital

Geriatric day hospitals have played a major role in the rehabilitation of older people, although the evidence base has proved thin. As the provision of geriatric medicine changes, they need to develop new roles such as responding to subacute crises, providing specialist services and ensuring comprehensive geriatric assessment before long-term care.

Medical day hospital care for the elderly versus alternative forms of care

BACKGROUND

Geriatric day hospitals provide multi-disciplinary rehabilitation in an outpatient setting. Concern has been expressed that evidence for effectiveness is equivocal and that day hospital care is expensive.

OBJECTIVES

To assess the effects of medical day hospitals for elderly people.

SEARCH STRATEGY

We searched The Cochrane Library, MEDLINE, Sigle, Bids, and Cinahl up to January 1997, and reference lists of articles. We also searched Index Medicus and International Dissertation Abstracts up to January 1997. We contacted authors of previous studies of day hospital care.

SELECTION CRITERIA

Randomised trials comparing geriatric medical day hospitals with alternative forms of care. The participants were elderly medical patients. The outcomes were death, place of residence, dependency, global 'poor' outcome (death, institutionalisation or dependency), activities of daily (ADL) score, subjective health status, patient satisfaction, and resource use.

DATA COLLECTION AND ANALYSIS

Three reviewers independently extracted data and assessed study quality.

MAIN RESULTS

Twelve studies were included involving 22 day hospitals and 2867 patients. Five studies compared day hospital with comprehensive elderly care, four compared day hospital with domiciliary care and three compared day hospital with no comprehensive elderly care. There were no significant differences between day hospital attendance and comparison treatments for the outcomes of death, death or requiring institutional care, death or deterioration in ADL. When death or a 'poor' outcome at follow up was examined there was a significant difference in favour of day hospital attendance when compared to no comprehensive elderly care (odds ratio 0.73; 95% confidence interval 0.53-1.00; P < 0.05). Dependency was measured in 11 studies using a variety of ADL measures; two described short-term improvement for the day hospital group, one reported improved outcome for the comparison group, while in the remainder there was no statistically significant difference. Using the outcome of deterioration in ADL among survivors, day hospital patients showed reduced odds of deterioration compared with those receiving no comprehensive elderly care (0.60; 0.38-0.97; P <0.05). When resource use was examined the day hospital group showed trends towards reductions in hospital bed use and placement of survivors in institutional care. Nine studies comparing treatment costs indicated that day hospital attendance was a more expensive option, although only two analyses took into account long-term care costs.

REVIEWER'S CONCLUSIONS

Medical day hospital care for the elderly appears to be more effective than no intervention but may have no clear advantage over other forms of comprehensive elderly medical services.

Systematic review of day hospital care for elderly people. The Day Hospital Group

OBJECTIVE

To examine the effectiveness of day hospital attendance in prolonging independent living for elderly people.

DESIGN

Systematic review of 12 controlled clinical trials (available by January 1997) comparing day hospital care with comprehensive care (five trials), domiciliary care (four trials), or no comprehensive care (three trials).

SUBJECTS

2867 elderly people.

MAIN OUTCOME MEASURES

Death, institutionalisation, disability, global "poor outcome," and use of resources.

RESULTS

Overall, there was no significant difference between day hospitals and alternative services for death, disability, or use of resources. However, compared with subjects receiving no comprehensive care, patients attending day hospitals had a lower odds of death or "poor" outcome (0.72, 95% confidence interval 0.53 to 0.99; P<0.05) and functional deterioration (0.61, 0.38 to 0.97; P<0.05). The day hospital group showed trends towards reductions in hospital bed use and placement in institutional care. Eight trials reported treatment costs, six of which reported that day hospital attendance was more expensive than other care, although only two analyses took into account cost of long term care.

CONCLUSIONS

Day hospital care seems to be an effective service for elderly people who need rehabilitation but may have no clear advantage over other comprehensive care. Methodological problems limit these conclusions, and further randomised trials are justifiable.

Outcomes of elderly stroke patients. Day hospital versus conventional medical management

BACKGROUND AND PURPOSE

Much controversy exists over the value of geriatric day hospitals in the rehabilitation of elderly patients, and cerebrovascular accident is a particularly common diagnosis among patients referred to these day hospitals. We carried out a prospective, randomized study to compare the outcomes of elderly stroke patients managed by a geriatric team using a day hospital facility versus conventional medical management.

METHODS

One hundred twenty elderly patients with acute stroke were randomized to inpatient care on a stroke ward under the care of either a neurologist or a geriatric team. Those under the care of neurologists were hospitalized until the attending physician felt that the patients had reached full rehabilitation potential. Patients under the care of the geriatric team were discharged home as soon as the team felt they were able to cope and given follow-up rehabilitation at the day hospital. Family or community support was arranged when necessary for both treatment groups. On recruitment, patient demographics, medical history, clinical features related to stroke, and functional ability as measured by the Barthel Index were noted. Subjects were reviewed at 3 and 6 months to assess functional level, hospital and outpatient services received, general well-being, mood, and level of satisfaction. Costs of treatment of the two groups were also compared.

RESULTS

Functional improvement (Barthel Index score) was greater in the group managed by the geriatricians with a day hospital facility compared with the conventional group at 3 months (P = .03). There were also fewer outpatient visits among the day hospital patients at 6 months (P = .03). No significant difference was found in costs between the two treatment groups.

CONCLUSIONS

Compared with conventional medical management, care in the geriatric day hospital hastened functional recovery and reduced outpatient visits in elderly stroke patients without additional cost.