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A study was made of the Emergency Department records of 49 elderly (65 years old or older) and 49 middle-aged (40-64 years old) patients seen in an urban hospital's psychiatric emergency service. The data were compared for demographic and admission information, psychiatric treatment history, presenting complaints, symptoms, diagnoses, and final disposition status. For the elderly patients, the referral was more likely to be their first contact with psychiatric treatment, and they were more likely to be referred (accompanied) by family or friends than to be self-referred. Among the middle-aged patients, "substance abuse" (e.g., drugs, alcohol) disorders and schizophrenic disorders were more common. The elderly, however, were much more likely to be regarded as having an organic brain syndrome of unspecified cause (34.7 per cent vs 0). Access to treatment was fairly consistent for both groups as measured by the hospital's priority code, total time spent in the emergency department, and final disposition. These results raise important issues concerning the unique psychosocial characteristics and psychiatric treatment needs of elderly patients. This applies particularly to the emergency-department medical clearance of elderly patients with symptoms of organic brain syndrome.
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The aim of the study was to evaluate if an experienced reduction in length of stay in a geriatric department had negative influence on rehabilitation in terms of more readmissions, nursing home replacements or deaths in the first six months after discharge from the geriatric department. In a retrospective study all inpatients discharged from geriatric department RL, Kommunehospitalet, in the first six months of 1990 and 1992 respectively were evaluated. The main contributor to reduction in hospital length of stay was found to be an earlier geriatric intervention combined with shorter waiting time for transfer to the geriatric department. In the study populations we found no significant difference in the number and time of readmissions, the number of nursing home replacements or deaths in the first six months after discharge. Short length of stay is not in itself an aim of a geriatric department. We conclude that geriatric assessment should take place as soon as possible after admission to hospital and acute/subacute admission to the geriatric department is to be intensified.
The medical needs of the aging population, accentuated by demographic changes, are poorly reflected by the present academic medical training programs. Geriatric medicine does not receive the attention it should have to meet the rapidly increasing demands of the aging population. This is true for Germany but also for Switzerland and Austria as well as many other European countries. The Robert Bosch Foundation with the goal of improving social conditions and scientific competence through innovative projects is engaged in improving the situation of the aging population by a number of projects. Aware of the deficits in geriatric medicine and in response to the need of a training program in academic geriatric medicine, the Foundation initiated a research training program in Geriatrics in 2002 together with initially five now seven academic centers in Germany and Switzerland. The program is aimed at young researchers having graduated in medicine and interested in a career in academic geriatric medicine. Two types of grants are given: an early career award for young postdocs at the beginning of their scientific training for two years and a mid career stipend for medical scientists coming from other disciplines and interested in a career in geriatric medicine. The goal of the training program is developing competence in clinical research and in geriatric medicine. A research council advises the Foundation in the grant allocation and monitors the program as well as the individual progress of the award recipients. Currently, 10 trainees are in the program. The initiative of the Robert Bosch Foundation is an enormous help to establish academic geriatric medicine in Germany.
OBJECTIVES: To increase recognition of geriatric rehabilitation and to provide recommendations for practice and future research. DATA SOURCES: A CINAHL and 2 MEDLINE searches were conducted for 1980 to 2001. A fourth search used the Cochrane database. STUDY SELECTION: One author reviewed the reference for relevance and another for quality. A total of 336 articles were selected. Excluded articles were unrelated to geriatric rehabilitation or were anecdotal or descriptive reports. DATA EXTRACTION: The following major geriatric rehabilitation subtopics were identified: frailty, comprehensive geriatric assessment, admission screening, assessment tools, interdisciplinary teams, hip fracture, stroke, nutrition, dementia, and depression. Part I describes the first 5 subtopics on concepts and processes in geriatric rehabilitation. Part II focuses on the latter 5 subtopics of common clinical problems in frail older persons. A level-of-evidence framework was used to review the literature. Level 1 evidence was a randomized controlled trial (RCT) or a meta-analysis or systematic review of RCTs. Level 2 evidence included controlled trials without randomization, cohort, or case-control studies. Level 3 evidence involved consensus statements from experts or descriptive studies. DATA SYNTHESIS: Of the 336 articles evaluated, 108 were level 1, 39 were level 2, and 189 were level 3. Recommendations were made for each subtopic. In cases in which several articles were written on the same topic and drew similar conclusions, the authors chose those articles with the strongest level of evidence, reducing the total number of references. CONCLUSIONS: Frail elderly patients should be screened for rehabilitation potential. Standardized tools are recommended to aid diagnosis, assessment, and outcome measurement. The team approach to geriatric rehabilitation should be interdisciplinary and use a comprehensive geriatric assessment. Medication reviews and self-medication programs may be beneficial. Future research should address cost effectiveness, consensus on outcome measures, which components of geriatric rehabilitation are most effective, screening, and what outcomes are sustainable.
OBJECTIVES: To evaluate the attitudes and knowledge of medical students (MS1-3), internal medicine residents (postgraduate years 1 to 3 (PGY1-3)), and geriatric medicine fellows about elderly patients before implementation of a new geriatrics curriculum. DESIGN: Cross-sectional study. SETTING: An academic medical center. PARTICIPANTS: Two hundred eleven people participated: 54 MS1, 52 MS2, 50 MS3, 20 PGY1, 12 PGY2, 12 PGY3, and 11 geriatric medicine fellows. MEASUREMENTS: Each participant completed a questionnaire, including a 16-item geriatrics attitude scale, and a 23-item knowledge test (both revised versions of the University of California at Los Angeles (UCLA) Geriatrics Survey). Pearson correlation coefficients and t tests were used for statistical analyses. RESULTS: Both surveys demonstrated high internal consistency (alpha=0.70 and 0.71, respectively). Knowledge test scores increased with advancing level of training. MS1 and MS2 scored significantly lower and fellows scored significantly higher than others. PGY3 scored significantly higher than PGY1 on the knowledge test. All groups demonstrated positive attitudes toward geriatric patients (score>3.5). MS1 and fellows had significantly more favorable attitudes scores than more advanced students and residents. CONCLUSION: The results suggest that the UCLA Attitudes Scale and Knowledge Test can be used reliably to assess attitudes and knowledge level across all levels of medical education and training. The information from this study will be used to implement a more structured and comprehensive geriatrics curriculum across all trainee levels to improve attitudes and knowledge in the care of the geriatric patient.
Every system of payment of flat-rate case charges results in an economically determined optimizing of treatment processes. This presupposes a high level of co-operation between all those involved in the treatment process. Collaboration must extend over occupational groups (doctors, nursing staff and therapists), over departments (specialist geriatric competence and specialist knowledge) and must increasingly take place in a manner extending over sectors (inpatient, partly inpatient and outpatient). To this end, interdisciplinary, team-oriented modes of working provide the direction to be followed in geriatrics. What is essential for efficient patient management is for patient allocation control to be implemented in good time, with individual requirements regarding treatment being provided by the most suitable department. This will only be possible, in perspective, by implementing binding treatment guidelines and quality standards, as well as the timely interdisciplinary incorporation of acute geriatrics, e.g. by participation of the admission wards of the clinics. Geriatrics in acute hospitals has demonstrated its value and has become an indispensable element of appropriate health provision in Germany. The retention of this structure of geriatric care presupposes that, in the future, the DRG system of geriatric services will also be included with a sufficient measure of differentiation and that consequently an appropriate level of remuneration for geriatric services will be ensured. As the DRG system has not been applied internationally, up until now, in the area of acute geriatrics, suitable adjustments to the system of the basic Australian AR-DRG system are absolutely essential.
OBJECTIVE: To determine whether a geriatric pocket guide, Geriatrics At Your Fingertips, may be a useful tool in educating physiatrists about the care of their older patients. DESIGN: Geriatrics At Your Fingertips was distributed through the American Academy of Physical Medicine and Rehabilitation (AAPM&R) to physical medicine and rehabilitation (PM&R) residents and practicing physiatrists. Two questionnaires evaluated guide use. SETTING: Two academic PM&R departments and physiatrists in the United States. PARTICIPANTS: Two PM&R residency programs, members of AAPM&R's Geriatric Rehabilitation Special Interest Group (GR-SIG), and AAPM&R's membership. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Identification of clinically useful information by residents and GR-SIG members and frequency of guide use among AAPM&R membership. RESULTS: Forty-five PM&R residents and 17 GR-SIG members reported examples of useful information. Geriatrics At Your Fingertips was requested by 483 AAPM&R members. Forty-six percent returned questionnaires (N=223). Seventy percent had used the guide at least once and 49% 4 or more times. CONCLUSIONS: Geriatrics At Your Fingertips is a useful tool with which to educate PM&R residents and physiatrists about geriatric care.
Given a growing number of elderly people and the related consequences for the health care system, such as increasing numbers of persons with chronic diseases or in need of long-term nursing care, the present rehabilitation system must be extended and new services be introduced. Hospitals in Cologne report that an average 48% of their geriatric patients are in need of rehabilitation measures. Taking into account the patients' willingness and capacity to undergo rehabilitation treatment, the figure reduces to 30%. Based on the number of geriatric patients treated in hospital each year, rehabilitation facilities for 15416 geriatric patients a year have to be provided. About two thirds of the patients require continued hospital treatment after the acute phase. Obviously, these treatments are not only performed in the geriatric departments of the hospitals, as only 161 geriatric beds are available in Cologne. One third of the patients could be taken care of on a partial hospitalization or outpatient basis after the acute phase. Thus, limiting a patient's length of stay in hospital could have a cost-containment effect. As partial hospitalization and outpatient rehabilitation facilities are lacking, the Cologne "Geriatrics" study group has developed a concept of "integrated geriatric rehabilitation", suggesting the establishment of mobile rehabilitation teams. The concept aims at developing a cooperative network linking outpatient with partial hospitalization and inpatient services, and including the physicians at community level.
Patients aged 65 and older account for 39% of ambulatory visits to internal medicine physicians. This article describes the progress made in training internal medicine residents to care for older Americans. Program directors in internal medicine residency programs accredited by the Accreditation Council for Graduate Medical Education were surveyed in the spring of 2005. Findings from this survey were compared with those from a similar 2002 survey to determine whether any changes had occurred. A 60% response rate was achieved (n=235). In these 3-year residency training programs, 20 programs (9%) required less than 2 weeks of clinical instruction that was specifically structured to teach geriatric care principles, 48 (21%) at least 2 weeks but less than 4 weeks, 144 (62%) at least 4 weeks but less than 6 weeks, and 21 (9%) required 6 or more weeks. As in 2002, internal medicine residency programs continue to depend on nursing home facilities, geriatric preceptors in nongeriatric clinical ambulatory settings, and outpatient geriatric assessment centers for their geriatrics training. Training was most often offered in a block format. The mean number of physician faculty per residency program dedicated to teaching geriatric medicine was 3.5 full-time equivalents (FTEs) (range 0-50), compared with a mean of 2.2 FTE faculty in 2002 (P<or=.001). Internal medicine educators are continuing to improve the training of residents so that, as they become practicing physicians, they will have the knowledge and skills in geriatric medicine to care for older adults.
Geriatric education and training are most successful when taught in a setting that provides the medical and social services that elderly persons often require. At Mount Zion Hospital and Medical Center, medical students and trainees participate in several geriatric services that introduce them to the special health needs of the elderly, including the ambulant and the homebound. In the Mount Zion/University of California, San Francisco, geriatric education and training program, we have defined three principles of geriatric medicine that are unique to the field and are best applied directly within the service setting. This setting emphasizes (1) the special body of knowledge regarding aging and health care of the elderly, (2) the importance of assessing functional capacity and (3) the role of the health team. Our experience indicates that when students and trainees observe the application of these principles in a range of geriatric services they begin to understand the complex health problems with which geriatric medicine is concerned.
The aim of this randomized controlled trial was to describe and evaluate a model of regular follow-up by home visits to selected elderly patients discharged from a geriatric ward. Ninety-seven patients were randomized to receive regular follow-up visits by a geriatric team at 1, 3, 8 and 16 weeks after discharge, and 96 patients to receive standard care. Based on the geriatric evaluation, medical and social adjustment was carried out, if indicated. Six months after discharge, significantly more patients in the intervention group were allocated to home help (p < 0.05), but only 42 (44%) were readmitted to a hospital, vs 62 (64%) in the control group (p < 0.005). Differences between the groups in mortality and nursing-home placement were not statistically significant. Regular follow-up home visits by a geriatric team after in-patient geriatric evaluation and management reduce the risk of hospital readmissions among highly selected frail geriatric patients.