What sort of "health checks" for older people?

A randomised controlled trial of the outcome of health assessment of people aged 75 years and over

OBJECTIVES

To measure the outcomes of a health assessment, conducted by a nurse, of people aged 75 years and older (75+HA) living independently in their own homes.

DESIGN

Randomised controlled trial (RCT).

SETTING

A convenience sample of six general practices within the Adelaide Western Division of General Practice (AWDGP). A random sample of 100 participants was drawn from practice age-sex registers. Data were collected in initial visits between 1 August 1998 and February 1999, then in follow-up visits one year later.

PARTICIPANTS

Participants were aged 75 years and over on 1 August 1998 and living independently in the community. 145 eligible patients were invited to join the study, and 100 of these consented to enrol (69%).

INTERVENTION

A 75+HA conducted in the participant's home by a nurse and reported to their usual general practitioner.

MAIN OUTCOME MEASURES

Primary: number of problems in each group; number of participants with problems; and mortality. Secondary: physical function; psychological (including cognitive) function; falls; and admission to institution.

RESULTS

There were no significant differences between the control and intervention groups at follow-up in the number of problems, the number of participants with problems, or mortality. In the intervention group, there was significant improvement in self-rated health, geriatric depression score (GDS 15), and number of falls.

CONCLUSIONS

This RCT has not demonstrated improvement in health status of the intervention group which received a 75+HA compared with a control group left to usual care.

Prevention in primary care: the annual assessment of elderly people

The recent reforms of the NHS have clearly emphasised the potential role of prevention in reducing mortality and morbidity. The specific focus of this paper is the preventive aspects of the new GP contract, and in particular the contractual obligation on GPs to offer an annual assessment to all patients within their practice aged 75 years and over. In reviewing the literature for evidence pertaining to the assessment of elderly people, it is argued that there are a number of unresolved issues which raise certain question marks over the Government's decision to include such assessments in the GP contract. The most fundamental of these issues is whether the costs of such screening are justified by the associated benefits. Other issues relate to the organisation of the assessments. In an attempt to cast some light on these unresolved issues, the results from a recent national survey of GPs in Scotland are presented. The results do not allow a categorical statement to be made on whether or not the assessments are worthwhile per se. However, they do help to clarify the current state of screening elderly people in general practice. In the light of this, directions for future research into the screening of elderly people are suggested.

Randomised trial of case finding and surveillance of elderly people at home

Health screening for old people who live at home has been the subject of debate for 30 years or so. It has come to the fore again in the UK with the new emphasis on annual assessments by general practitioners (GPs) of those aged 75 or more. Screening in the elderly has implications for manpower. How can it best be done? We describe here a randomised, controlled study of case finding and surveillance in patients aged 65 and over in a general practice in South Wales. Problem identification was by a postal questionnaire, focusing on function, that was sent at random to 369 eligible patients with subsequent verification and intervention by a specially appointed nurse. The 356 controls had no questionnaires and no contact with that nurse. The study lasted 3 years, and end-points included mortality, self-ratings of quality of life, and health status, and use of all services (GP contacts, hospital admission, home help, and so on). Mortality was significantly lower in the intervention group (18%) than in the controls (24%) (difference 6.0% [95% CI 0.1-11.9%], p less than 0.05). Total number of hospital admissions did not differ between intervention and control groups, but duration of hospital stay of patients aged 65 to 74 years was significantly shorter in the intervention group (difference 4.6 days [95% CI 1.6-7.6], p less than 0.01). An increase in visits to a GP was largely offset by a lower number of home visits by a GP. Quality-of-life measures revealed no between-group differences, but self-rated health status was superior in the intervention group. We conclude that the use of a postal screening questionnaire with selective follow-up and intervention can favourably influence outcome and use of health care resources by elderly people living at home.

Screening in the elderly

It has been known for some years that elderly people have unreported health problems and screening as a means of earlier detection and treatment has been advocated in the past. More recently there has been a renewed interest in this type of preventive health care for elderly people. Conventional screening for early asymptomatic disease is often termed secondary prevention, but in the case of elderly people, screening more closely resembles tertiary prevention. Regular call and recall or consultation-based opportunistic screening are alternative ways of organising screening of elderly people in primary care. Each approach has particular problems but the increased workload for staff resulting from screening is common to both. Selective screening has been tried to resolve this issue. It has taken two forms; the 'at-risk' group approach and the use of postal questionnaires. Neither of these approaches is entirely satisfactory. The published randomised controlled screening trials are too small to show any significant effect on measures of disability levels, social functioning or psychological well-being in old people, although one study demonstrated decreased mortality in the intervention group. Larger evaluative studies are needed before any form of screening for elderly people can be recommended.

Contact with general practitioners and differences in health status among people aged over 85 years

A survey of the health and social service needs of all people aged 85 years and over was commissioned in 1986 by members of City and Hackney health authority and Hackney social services department. In 1987, 662 people who lived at home were traced from family practitioner committee records and interviewed. Eighty six per cent of respondents had consulted their general practitioner in the 12 months before the interview. Analyses showed that those who had not consulted within the 12 month period reported fewer physical and psychological symptoms, consumed less prescribed medication and reported better emotional well-being than those who had consulted more recently. However, the survey detected a considerable amount of unreported morbidity among both recent consulters and non-recent consulters. This finding questions the suggestion that the problem of under-consultation among elderly people is exaggerated but recommends that in studies of case finding attention should be focused on unreported morbidity rather than infrequent consultation.