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[Geriatric assessment in family practice--results of concerted action by 7 European countries].

General practitioners are faced with the complex medical care of an increasing number of older people. Traditional demand led care is not able to provide optimal management for this age group, since it has been shown that many important health problems remain unknown or not optimally treated. Preventive geriatric assessment offers primary health care providers new opportunities to focus their management on the particular health problems of older people. A European concerted action involving seven countries formed to develop a "standard assessment for elderly people in primary care (STEP)". The aim was threefold: 1) to identify important and preventable health problems in old age, 2) to supply health care planners and providers with scientific evidence of the corresponding preventive procedures, and 3) to initiate a practical assessment framework for use in European primary care practices. Using a strict methodological protocol, 33 health problems were identified that potentially improve health outcomes in preventive programs for older people. A summary of the evidence is given for each of the included health areas. Taking the best available evidence, patients' preferences, and practice conditions into account, a preventive assessment program was developed containing validated and accepted instruments. The approach is algorithmic with a simple problem identification level and a further diagnostic stage. All recommended procedures are harmonized for common European use. An evidence-based preventive assessment program is expected not only to prevent disease and minimize disability and handicap, but it also offers health care planners a European data set of older peoples' needs for optimized resource allocation.

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Geriatric assessment, coordinated case management, and information systems: an integrated model for delivery of services to nursing home residents.

Several interventions have been developed to minimize the effects of a fragmented health care system and improve services to older adults in long-term care settings. In the context of scarce specialized resources and expertise, this article describes Comprehensive Geriatric Assessment, Minimum Data Set, and Resident Assessment Protocols, the integration of which offers promise for effective evaluation and case management. The model's significance and potential benefits for targeting services to residents at risk for adverse outcomes are explored as components of an integrated information system for enhancing the care of nursing home residents.

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Non-Hodgkin's lymphoma in the elderly. A review with emphasis on elderly patients, geriatric assessment, and future perspectives.

With rising age the incidence of non-Hodgkin's lymphoma (NHL), together with the fact that the proportion of people older than 65 years in Western populations will double during the next 40 years, poses the challenge to adequately meet the needs of elderly patients. After a general introduction on cancer in the elderly, a review is given concerning aspects of epidemiology and prognostic factors of NHL. Therapeutic strategies, including the use of hematopoietic growth factors, for the elderly with aggressive NHL are discussed. The future role for so-called comprehensive geriatric assessment (CGA) to appropriately determine treatment possibilities is emphasized. Much scientific work has to be performed before the true value of CGA instruments can be acknowledged. Screening instruments are discussed and the role for specially trained oncology nurses in the assessment process is stipulated.

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Comprehensive geriatric assessment in the elderly cancer patient.

The proportion of older cancer patients is increasing due to demographic and disease-specific reasons. However, this group of patients is severely underrepresented in research and clinical therapy. Limitation in physical and functional capacity with considerable interindividual heterogeneity remains one of the important problems in the treatment decision process. One approach to this problem is the use of a Comprehensive Geriatric Assessment (CGA) to describe and classify these deficits with high validity and reliability. The different domains of CGA are described with special respect to the instruments applied, as CGA has also a key role in the decision process.

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The comprehensive geriatric assessment: when, where, how.

Cancer is increasingly a disease of the aged, a segment of the population that is the fastest growing. Often, cancer adds on to the progressive deterioration of normal aging and to the impairment associated with the presence of multiple concomitant medical problems. Thus, the likelihood that cancer leads to disability is much greater among older patients than younger ones. In consideration of the dimension of the problem, and of the peculiarities of the elderly patient, it has recently been proposed that a new approach termed 'comprehensive geriatric assessment' (CGA) might allow a better management and more efficient care of elderly patients with cancer. The systematic introduction of CGA in clinical research and in daily practice can contribute to: identify cancer patients for whom we could expect the greatest benefit from treatment; assess their physiologic, functional and health-related quality of life; formulate appropriate treatment and management strategies; monitor clinical and functional outcomes; provide a more accurate evaluation of prognostic indicators.

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Attitudes and anxieties of elderly patients on admission to a geriatric assessment unit.

A semi-structured interview schedule has been used to investigate the attitudes and anxieties of 100 lucid elderly patients on admission to a geriatric assessment unit. Results show that most patients are unconcerned by admission to a geriatric unit and expect a favourable outcome. A minority, mainly higher social class patients, or those who do not live with a close relative, are disturbed by the geriatric nature of the ward and in particularly by the presence of confused patients. More than half the group reacted unfavourably to the idea of admission to local authority residential accommodation.

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[Comprehensive geriatric assessment for management of the elderly with diabetes mellitus].

In medical care for the elderly patients with diabetes mellitus, there are many cases that are not indicated for active treatment, because of their impairment of activity of daily living (ADL), instrumental ADL and cognitive function, and also the presence of some complications, such as cerebrovascular disorder. On the other hand, poor glycemic control is easy to induce dehydration, bacterial infection, and cognitive disorders in the elderly. Thus, it is necessary to maintain good glycemic control to preserve better ADL. However, compulsion of strict glycemic control might rather decrease QOL of the patient. To solve such a medical dilemma, the comprehensive geriatric assessment (CGA) is useful for the individual diabetic patient.

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Computer-assisted comprehensive geriatric assessment in a family physician's office.

Family physicians and other medical care providers are beginning to realize the importance of a comprehensive assessment examination for elderly patients. The components of such an examination are well documented, and include not only the standard history and physical examination, but also evaluation of mental health, functional status, and socioeconomic status of the person. A major impediment to a family physician doing such an extensive evaluation is that most offices lack the team approach commonly used in tertiary care medical facilities. In this paper I report the implementation of a computer-assisted program that was developed for use in a private physician's office. The first 22 patients examined using this protocol are discussed. A new diagnosis was uncovered in all but three of the subjects. This finding suggests that performing comprehensive geriatric assessments in a family practice setting might create an immediate benefit in terms of patient management.

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Outpatient geriatric assessment in a Health Maintenance Organization. Its structure, practice, and clinical implications.

The authors review their experience with the implementation of a geriatric assessment unit (GAU) within the Rhode Island Group Health Association, a Health Maintenance Organization (HMO). Included is a historical background of the involvement of HMOs with care of Medicare patients, a description of the structure of an outpatient GAU, and the authors' experience to date with this population of patients. This article concludes with a discussion of the future role of GAUs and HMOs in the care of older patients.

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New paradigms for treating elderly patients with cancer: the comprehensive geriatric assessment and guidelines for supportive care.

Strategies for treating cancer are evolving to address the growing number of elderly patients with cancer. Older patients have highly variable physiologic ages, and their treatment should be individualized for optimal outcomes. Treatment paradigms should also take into account the diversity of patients' life expectancy, functional reserve, social support, and personal preference. A Comprehensive Geriatric Assessment (CGA) is a useful tool for estimating life expectancy and tolerance of treatment and for identifying reversible factors that may interfere with cancer treatment, including depression, malnutrition, anemia, neutropenia, and lack of caregiver support. Adopting a common language to describe older patients may facilitate the design and analysis of studies to determine effective drugs and care strategies for them. Information from a CGA can guide the prescription of potentially curative therapy, determine the best use of supportive care agents, and help identify frail patients for whom palliative care is the best option. There is evidence in a number of settings that the routine use of a CGA has a positive effect on health outcomes by reducing hospitalizations, preserving functional independence, and preventing geriatric syndromes. Guidelines for supportive care are also important in treating elderly patients with cancer. Pain, caused by cancer or its treatment, is prevalent, and guidelines for its assessment and treatment should be implemented to improve quality of life. Toxicities such as neutropenia and mucositis should be managed aggressively. Growth factors reduce the incidence and severity of neutropenia and its complications in older patients, particularly when they are administered in the early cycles of chemotherapy. The development of effective strategies for the management of toxicity caused by anticancer drugs may help the elderly, as much as younger patients, expect and look forward to a positive outcome with their treatment.

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Benefit from admission to a geriatric assessment and rehabilitation unit. Discrepancy between health professional and client perception of improvement.

To determine differences in perception of benefit from a patient's admission to a geriatric Assessment and Rehabilitation Unit, we asked both medical and nursing staff (health team) and the patient and carer (clients) for their evaluation after discharge. The areas studied were functional ability, relief of the principal symptom, education about the principal problem, and development of coping skills. Of 94 patients studied, 58 patients were discharged to the community (52 to carers, 6 to live alone) and 36 to institutions. In the former group, the health team had a consistently higher perception of benefit than the clients (P less than .001). Factors positively predicting health team perception of benefit were a higher carer happiness, improvement in patient independence, and internalization of the patient's locus of control. A negative predictor was an increase in patients' responsibilities. Client perception of benefit was positively predicted by fewer problems with companionship and communication with others. The health team's perception rated the adequacy of patient education and development of coping skills more highly than did the clients. In the patients discharged to the community, their perception of benefit at 1 week was a good predictor of survival in the community to 6 weeks. The possible reasons for these differences in perception of benefit and their implications are discussed.

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What is the value of a Geriatric Assessment Unit in a teaching hospital? A comparative study of the management of elderly inpatients.

This study at the Flinders Medical Centre, compared the management of 50 elderly patients, admitted acutely ill to the Geriatric Assessment Unit, with the management of 50 elderly patients admitted, under similar circumstances, to other medical units in the Centre. Patients under the care of the Geriatric Unit had a comparable mean length of stay, were on less medication at discharge, and were more likely to return home to their pre-admission accommodation, compared with patients admitted to other medical units. The multidisciplinary approach adopted in such units, coupled with increased utilization of community based services, appears to significantly limit rates of referral to institutional care.

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Elderly confidants in geriatric assessment.

This study focuses on patterns of consensus between linked samples (focal person and confidant; total n = 124) for the purpose of explaining divergent reports and of assessing this design's utility in geriatric case assessment. Correlations, difference scores and group contrasts suggest that elderly informants who are also confidants can describe most internal states of their partners as these states are self-reported. Partners differed however, on ratings of self-esteem; confidant scores were significantly higher than self-ratings. Under certain conditions self-other discrepancy also occurs on spouse ratings of functional health: in early stages of decline and in marriages judged by clinicians to be of poor quality. This pattern is absent in pairs with women friends. The findings suggest that losses and age-related limitations have the potential to erode the self-esteem of older people and that linked samples would strengthen the process of functional assessment by bringing special information to the clinician.

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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.

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Geriatrics assessment is not just for geriatricians.

Because of the demographic imperative all healthcare professionals who interact with elderly patients must possess the basic understanding of the elders' unique needs. Knowledge of individual patients can be improved by performing geriatric assessments that are integrated into the practice setting. This presentation will provide a system and tools to carry out functional testing of older patients. The results of this testing can identify needs and improve medical decisions for older adults.

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