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PubMed2000

Using the comprehensive geriatric assessment technique to assess elderly patients.

OBJECTIVE: To review the concept, components, and characteristics of the Comprehensive Geriatric Assessment technique. DATA SOURCES: Medline and non-Medline literature search. STUDY SELECTION: The following key words were used: Comprehensive Geriatric Assessment; all available years of study were reviewed. DATA EXTRACTION: Studies that assessed the Comprehensive Geriatric Assessment technique's benefits were examined. DATA SYNTHESIS: By using the Comprehensive Geriatric Assessment programme, accurate diagnoses can be made, treatable illness can be screened for, therapeutic plans can be formulated, and the optimal placements of patients can be achieved. Assessment should be performed at each level of geriatric care; various well-validated scales are used to measure the activity of daily living of patients. The Comprehensive Geriatric Assessment programme can improve functional status; reduce the use of medications, nursing homes, and medical services; and reduce mortality rates. Most studies confirm that a successful programme requires careful patient targeting, implementation of the programme by attending physicians, and patient adherence to the recommendations made. CONCLUSION: A well-targeted Comprehensive Geriatric Assessment programme and the control of patients' adherence to recommendations are effective in improving the well-being of elderly patients.

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PubMedDate not supplied

[Geriatric assessment: possibilities and limits].

A recent meta-analysis has shown that comprehensive geriatric assessment can reduce mortality, increase survival at home, and improve functional status in elderly patients. Despite their high effectiveness, geriatric assessment programs have not yet been widely introduced into clinical practice. This review discusses the following four factors potentially explaining the limited spread of geriatric assessment programs. 1) There is a lack of accepted targeting criteria to select patients who need evaluation and management in costly in patient geriatric units. 2) There are effectiveness gaps in current knowledge on modifiable disability risk factors. 3) Geriatric assessment programs have been insufficiently integrated into the continuity of primary care. 4) More data are needed for evaluating the cost of geriatric assessment. Interdisciplinary research might help to optimize geriatric assessment programs and, at the same time, might ensure access of elderly patients to appropriate geriatric assessment programs despite current restraints in health care costs.

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PubMed1996

What influences physician practice behavior? An interview study of physicians who received consultative geriatric assessment recommendations.

BACKGROUND: Comprehensive geriatric assessment (CGA) in outpatient settings has not been shown to be as effective in reducing mortality and improving health as in hospital settings; this difference has been attributed in part to a lack of direct control over recommendation implementation. OBJECTIVE: To identify inhibiting and facilitating factors in physicians' compliance with consultative CGA recommendations, so that the effectiveness of outpatient CGA might be improved. METHODS: A 49-item questionnaire was administered via the telephone to 87 eligible community primary care physicians in Los Angeles, Calif, whose patients had received consultative outpatient CGAs as part of a study of CGA (response rate, 96%). The questionnaire assessed physician compliance with CGA recommendations, reasons for implementing or not implementing the recommendations, and specific physician attitudes, perceptions, and characteristics. The focus of the interview was the CGA recommendation that was determined to be the "most important" by the evaluating geriatrician. Recommendations addressed geriatric syndromes, general medical problems, or psychiatric conditions. RESULTS: Of the 87 physician respondents, 62 (71%) implemented the most important recommendation. In multivariate analysis, 4 variables were predictive of physician compliance: (1) a patient's request that the recommendation be implemented (odds ratio [OR], 10.8; 95% confidence interval [CI], 1.9-61.3; P = .007); (2) perceived legal liability resulting from nonimplementation of the recommendation (OR, 10.8; 95% CI, 1.1-108.2; P = .04); (3) female physician gender (OR, 9.6; 95% CI, 1.4-67.9; P = .04); and (4) perceived cost-effectiveness of the recommendation (OR, 7.0; 95% CI, 1.6-30.5; P = .01). CONCLUSIONS: Patient behavior, which may be modifiable, was among the strongest determinants of physician compliance with recommended care. Specifically, when patients requested that a recommendation be implemented, physicians were highly likely to comply. Changing patient behavior within the physician-patient relationship as a way of effecting desired changes in physician health care practices merits further attention.

Ambulatory Care↗

PubMed2001

Geriatric assessment in primary care: formulating best practice.

Comprehensive geriatric assessment (CGA) is a structured approach to measuring physical, mental and social functioning of older people to identify needs and to plan care. Meta-analysis of trials of CGA suggest that it is cost-effective, but there is no agreed approach to its implementation in primary care. Our aim was to develop a best-practice model for geriatric assessment in primary care. We took an iterative approach to development, combining expert and local stakeholder opinion, and using semi-structured interviews to assess patient and practitioner experience in nine general practices in Sheffield. Patients were aged 75 and over, living at home. The best-practice model was the use of a standardized instrument (EASY-Care) to unselected patients aged 75 years and over living at home or in residential care, administered by a practice nurse in the context of an over-75s health check. There was high patient and practitioner acceptability, and significant cost savings were noted. Key beneficial features were the assessment of mental health and sources of support; goal-setting; generation of a disability score; and high patient satisfaction from contact with nursing staff. We conclude that geriatric assessment in primary care is feasible, economical and beneficial to patients and practitioners. Nursing staff are central to successful implementation of geriatric assessment in primary care.

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PubMed2004

[Present status and perspective of comprehensive geriatric assessment in Japan].

Comprehensive geriatric assessment (CGA) is an important strategy to maintain activities of daily living and quality of life of elderly patients. It assesses physiological, psychosocial, and cognitive aspects of elderly. To carry it out effectively, not only is accurate the assessment but also to do appropriate recommendation and implementation are essential. In Japan, although the concept of CGA has been introduced and evaluated for elderly patients and also employed essentially in long-term care insurance, its application in the acute care setting of the elderly is still limited. This report, examines the present status and perspective of CGA application in Japan, through experiences in our university hospital and analysis of presentations from the Annual Meeting of the Japan Geriatric Society 2003.

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PubMed1995

Evaluation of outpatient geriatric assessment: a randomized multi-site trial.

OBJECTIVE: To evaluate the process and outcome of outpatient consultative geriatric assessment compared with traditional community care. DESIGN: Randomized, controlled clinical trial, with 12-month follow-up. SETTING: Four hospital-based ambulatory geriatric assessment clinics and community physicians' offices. PARTICIPANTS: 442 recruited older adults with a health problem or recent change in health status. INTERVENTION: Outpatient consultative geriatric assessment or usual physician assessment. MAIN OUTCOME MEASURES: Identification of health problems, mortality, nursing home admissions, health status, health services utilization, satisfaction with care, and caregiver well-being. RESULTS: Geriatric assessment, in comparison with usual community care, resulted in the identification of a significantly greater number of patients with cognitive impairment (P < .0001), depression (P = .0004) and incontinence (P < .0001). The group receiving a geriatric assessment had greater improvement in anxiety levels at 1 year (P = .036). Caregivers of participants in the geriatric assessment group had less caregiver stress at 1 year (P = .002). No outcome differences in mortality, nursing home admissions, cognitive health, functional health, or health services utilization were observed. Some evidence of greater patient satisfaction with respect to qualities of the physician was found for the geriatric assessment group. CONCLUSIONS: Consultative outpatient geriatric assessment led to significantly improved diagnosis of the common health problems of cognitive impairment, depression, and incontinence, to psychological and emotional benefits for patients, and to reduced levels of caregiver stress. Even with limited follow-up care and control of treatment, outpatient geriatric assessment has potential for significant positive effects.

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PubMed2006

[Comprehensive geriatric assessment in hospitalized patients aged 80 years and more].

Comprehensive geriatric assessment during hospitalization, taking into account the specificity of geriatric patients could be used both in acute and long-term care. We analyzed 63 patients aged at least 80 years, born on odd days and hospitalized at the Department of Internal Medicine and Geriatrics, University Hospital, Kraków. We examined patients using Geriatric Assessment Chart which consisted of Barthel Index (used to determinate motor activity), MMSE, GDS (Geriatric Depression Scale), abbreviated Tinetti Test, Waterlow Index (used to determine the risk of pressure sore development), delirium risk factors scale, and social evaluation. The data were analyzed according to sex, marital status, level of mood, and residence status (free living or institutionalized). The mean age of 47 women and 16 men was 85.0 +/- 4.34 years. Dementia was been found in 60% of examined patients. Depression (usually mild) was encountered in 55.4%. Motor activity was moderately to severely impaired in the entire group, with high level of risk of falls and development of pressure sores. Thirteen per cent of the patients have been admitted with already developed ulcers. The results suggest the need for the comprehensive geriatric assessment both in hospitalized patients and in post-hospital phase of care.

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PubMed1998

[Ambulatory geriatric assessment of 2116 in poor elderly].

BACKGROUND: Geriatric assessment quantifies medical, functional, mental and social capabilities and alterations of elders and is the first step to initiate specific intervention programs. AIM: To report the initial geriatric assessment of a program aimed to help poor elders living in Metropolitan Santiago. SUBJECTS AND METHODS: Two thousand one hundred sixteen free living subjects aged 65 to 99 years old (711 males) were subjected to an assessment using a simple geriatric score validated abroad and used previously in Chile. The resulting score ranges from 0 (better) to 5 (worst). RESULTS: Eighty eight percent of elders did not have problems in the functional evaluation. Subjects over 75 years old needed occasional support for the daily activities with higher frequency than younger subjects (12 and 5.4% respectively, p < 0.001) and had a higher frequency of major functional limitations (7.8 and 3.2% respectively, p < 0.001). Mental assessment was considered normal in 89.4% of subjects. Those over 75 years old had a higher frequency of memory disturbances (11.4 and 6.5% respectively) and cognitive alterations (4.6 and 1.8% respectively). Indefinite social support could be received by 84% of subjects, but 7.4% did not have access to this resource. CONCLUSIONS: Geriatric assessment of poor elders gives useful information to identify those subjects that require community help.

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PubMed1996

Postdischarge geriatric assessment of hospitalized frail elderly patients.

BACKGROUND: The diffusion of comprehensive geriatric assessment services has been rather limited in North America partly because of reimbursement and organizational constraints. OBJECTIVE: To evaluate the impact of a comprehensive geriatric assessment intervention for frail older patients that is started before hospital discharge and is continued at home. METHODS: Patients older than 65 years were selected who had either unstable medical problems, recent functional limitations, or potentially reversible geriatric clinical problems. Patients (n = 354) were randomly assigned to either the intervention group or a control group. Information on survival, readmissions, nursing home placement, medication use, and health status was collected at 30 and 60 days after hospital discharge. RESULTS: No differences were observed between the two treatment groups in survival, hospital readmission, or nursing home placement by 60 days. After adjustment for baseline characteristics, no significant differences were observed between the two groups on measures of physical functioning, social functioning, role limitations, health perceptions, pain, mental health, energy and/or fatigue, health change, or overall well-being. CONCLUSIONS: Although efficacy has been demonstrated for some forms of comprehensive geriatric assessment, the types of services that are easier to establish (inpatient consultation services and ambulatory assessment) have not been shown to improve outcomes. Our results indicate that outcomes are unaffected by a limited form of comprehensive geriatric assessment begun in the hospital and completed at home. Further efforts are needed to develop and to evaluate realistic approaches to comprehensive geriatric assessment.

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PubMed1992

A prospective evaluation of the Geriatric Depression Scale in an outpatient geriatric assessment center.

OBJECTIVE: To prospectively evaluate the Geriatric Depression Scale (GDS) in cognitively intact and impaired patients undergoing outpatient geriatric assessment. SUBJECTS: One hundred ninety-four geriatric patients evaluated in a 1-year period. SETTING: The outpatient Geriatric Assessment Center of the University of Nebraska Medical Center. MEASUREMENTS: The 30-item GDS was completed by all patients. The patients were then evaluated by one of three geriatric psychiatrists who were blind to the GDS results. The prospective clinical diagnosis of major depression was compared to the GDS results. Patients were categorized as cognitively impaired or intact on the basis of the Mini-Mental State Examination. Data were analyzed using ROC curves. An optimal cutoff was identified which was the total score on the GDS with the highest combined sensitivity and specificity. RESULTS: ROC curve analyses showed good agreement between the clinical diagnosis and the GDS in both cognitively intact and impaired subjects. Cognitively intact, euthymic patients reported a mean of 8.4 symptoms, while cognitively impaired, euthymic patients, reported a mean of 8.7. Cognitively intact, depressed patients reported a mean of 14.7 symptoms, while cognitively impaired, depressed patients reported a mean of 15.0. CONCLUSIONS: This study provides further evidence that the GDS is as accurate a screening test for depression in cognitively impaired as in intact patients.

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PubMed1995

A geriatric assessment and intervention team for hospital inpatients awaiting transfer to a geriatric unit: a randomized trial.

The objective of this study, designed as a randomized controlled trial, was to decrease the length-of-stay (LOS) of hospitalized patients on a waiting list for admission to an inpatient geriatric assessment unit (GAU), and to optimize use of the GAU and other hospital services. The participants included 108 elderly, functionally impaired inpatients referred for geriatric consultation, and appropriate for GAU admission, stratified into high and low ADL functioning groups. They were admitted to a 354-bed acute hospital, with a 31-bed long-stay ward and a 15-bed GAU; a 25-30 day delay occurred between screening and admission of inpatients to the GAU. Experimental subjects (N = 25) received the consultative services of a geriatric assessment and intervention team (GAIT) immediately after being qualified for GAU admission, in place of waiting for GAU services. Controls (N = 52) received usual hospital care until admitted to the GAU. While high-function patients randomized to the GAIT had significantly shorter hospital LOS than comparable controls (41.4 vs 56.5 days; p = 0.03), LOS reduction was even greater in the low-function stratum (44.5 vs 74.5 days; p = 0.001). Further, significantly more GAIT than control patients were discharged home (28% vs 11%; p = 0.044). A trend toward reduced mortality in the GAIT group was non-significant. We conclude that for Canadian hospitals in which extensive stays of frail elderly patients, "bed blockage", and thus access to unit-based geriatric services are common problems, the GAIT can efficiently decrease hospital LOS, increase home placement, and may improve outcomes.

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PubMed1987

An acute inpatient geriatric assessment and treatment unit.

The inpatient geriatric assessment unit (GAU) is an important component of the Geriatric Assessment and Treatment Centre (GATC) at the Royal Jubilee Hospital in Victoria, British Columbia. The Centre attempts to accomplish the following: to provide, at the request of the attending physician, diagnostic, treatment, and management services where it best suits the patient (ie, at home, in the outpatient service, or following admission to the ward); and to provide, if necessary, follow-up service after discharge to help prevent readmission to the acute hospital or any part of the geriatric service.

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PubMed2002

[Relation between destination on discharge in the elderly patients and comprehensive geriatric assessment at admission in the ward of the Geriatric Department of University Hospital].

To determine the factors related to the destination on discharge from the geriatric ward of Nagoya University Hospital, we analyzed the relationship between the scores of comprehensive geriatric assessment at admission and the destination in patients who had dwelled in home. The scores of basic activity of daily living (Barthel index), instrumental activity of daily living (Lowton scale), and cognitive function (Mini-Mental State Examination) were significantly lower in the patients who moved to institutions than those in the patients who returned home. The proportion of disabilities in all items, except eating, in the Barthel index, and all items but washing in the Lowton scale were significantly higher in patients who moved to institutions than in patients who returned home. Space orientation, calculation, and drawing in the Mini-Mental State Examination were related to the destination. In items for social life communication and group behavior were related to the destination. In multiple logistic regression models, it was suggested that activity of daily living, specifically independence of excretion, and ability in communication were significantly related to the destination on discharge.

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PubMed1992

Use of comprehensive geriatric assessment techniques by community physicians.

BACKGROUND: Research has shown that comprehensive assessment techniques have several clinical benefits for geriatric patients. The purpose of this study was to determine how frequently community practitioners used comprehensive geriatric assessment techniques to identify factors related to use of those techniques. METHODS: The study group included 54% of the 100 community-based family physician preceptors who participate in the University of Mississippi's family medicine training programs. On-site interviews were conducted in each physician's office to measure the percentage of physicians who performed comprehensive geriatric assessment. RESULTS: The majority of physicians employed some selected age-related assessment techniques, but less than 25% performed functional assessment techniques considered unique to the geriatric patient, such as mental status assessment and evaluation of activities of daily living. Most physicians' personal and practice characteristics were unrelated to the use of assessment techniques. CONCLUSIONS: Although many physicians use some techniques of geriatric assessment, most practicing physicians do not perform comprehensive assessment of geriatric patients.

Adult↗

PubMed2002

[Comprehensive geriatric assessment: a useful tool for prevention of acute situations in the elderly].

Comprehensive geriatric assessment is a useful complement to the standard clinical examination of elderly people. It focuses on a systematic evaluation of functional status, dependency, cognitive functions, psychological status, continence, nutritional status and social way of life, administered by a multidisciplinary team. Standardized test, well-validated in the elderly, are used. Most studies have demonstrated the efficacy of geriatric assessment programs in outpatients, hospitalized patients or in emergency unit patients. Mostly useful in frail elderly patients, geriatric assessment results in a decrease in morbidity and dependency, shorter hospital stays and fewer referrals to nursing homes. By introducing adequate medical and social interventions, comprehensive geriatric assessment, even in very old people, is useful in preventing acute situations leading to emergency referrals.

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PubMed1996

Nutritional assessment: a primary component of multidimensional geriatric assessment in the acute care setting.

OBJECTIVE: To test the prognostic role of nutritional variables as a component of geriatric multidimensional assessment and to study the effect of hospitalization on nutritional status. DESIGN: Validation cohort study: multidimensional assessment on admission and at discharge and a weekly nutritional assessment. SETTING: General Medicine and Geriatrics wards in an acute-care university hospital. PATIENTS: A consecutive sample of 302 patients aged 79 +/- 6 years, range 70-96 years. MAIN OUTCOME MEASURES: Mortality, longstay (> 29 days), loss of lean body mass as expressed by a negative change in mid-arm muscle circumference (MAMC). RESULTS: Incidence of mortality, longstay, and decreased MAMC was 6.9%, 24.8%, and 64.2%, respectively. According to logistic regression analysis, mortality was independently predicted by preadmission dependency in at least one Activity of Daily Living (odds ratio = 2.08, confidence limits = 1.19-3.65), clinical diagnosis of malnutrition (OR = 1.89, CL = 1.11-3.21), serum albumin < 3.5 g/dL (OR = 1.82, CL = 1.06-3.14). This predictive model allowed us to recognize 75% of the patients at risk of death by targeting 23% of the population. Longstay was independently predicted by stroke (OR = 1.54, CL = 1.01-2.35), clinical diagnosis of malnutrition (OR = 1.41, CL = 1.04-1.93), and more than five comorbid diseases (OR = 1.39, CL = 1.01-1.94). Dependency in at least one ADL was the only independent predictor of decreased MAMC (OR = 1.71, CL = 1.27-2.30). CONCLUSIONS: Nutrition variables are a cardinal component of multidimensional assessment in the acute-care setting. Nutritional status deteriorates during the hospital stay, mostly in physically dependent patients.

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PubMed1997

[Multidimensional geriatric assessment in the acute hospital and ambulatory practice].

Comprehensive geriatric assessment (CGA) is defined as a multidimensional medical, functional, psychosocial and environmental evaluation of an older person's problems and resources, linked with an overall plan for treatment and follow-up. It is well established that CGA implemented in specialized geriatric evaluation and management units improves function and survival in frail older patients. The results of new randomized controlled trials, however, show that the application of CGA does not only improve outcomes in selected older persons, but probably in most. A randomized controlled study in unselected older patients admitted to an acute care hospital found that patients function at hospital discharge was improved, and the risk of nursing home admissions decreased, in patients receiving integrated geriatric care as compared to patients receiving the usual acute hospital care. Another trial examined the impact of follow-up geriatric home-visits in patients with unstable cardiac failure discharged from the hospital. This trial found a statistically significant reduction of hospital readmissions and cost savings in the intervention group as compared with controls. A new application for CGA emerges in the preventive arena. Annual comprehensive geriatric assessments with preventive home visits in older people living at home resulted in fewer nursing home admissions and delayed or prevented the onset of disability in the activities of daily living in persons of the intervention group as compared to controls. One of the roles of geriatricians is teaching CGA and conducting further research with a view to refining CGA methodology and its application. Practical application of the principles of geriatric assessment and management, however, should not remain in the hand of specialists alone, but should become an integrated part of primary care medicine in the ambulatory and hospital settings.

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PubMed1990

Consultative geriatric assessment for ambulatory patients. A randomized trial in a health maintenance organization.

Previous studies have shown that comprehensive geriatric assessment and follow-up can improve the health of hospitalized elderly patients. To evaluate the effectiveness of consultative geriatric assessment and limited follow-up for ambulatory patients, we randomized 600 elderly patients who were enrolled in a health maintenance organization into three groups: (1) consultation by a geriatric assessment team, (2) consultation by a "second opinion" internist, and (3) only traditional health maintenance organization services (control patients). The geriatric assessment team identified previously unrecognized problems in 35% of patients and advised changes in medication regimens for more than 40%. Nevertheless, patients who received assessment achieved only a small benefit in cognitive function after 3 months, which was not sustained for 1 year. There was no difference among groups in other measures of health status. Consultative geriatric assessment with limited follow-up did not benefit most older ambulatory patients in a health maintenance organization; if such care can be used effectively for ambulatory patients, it will require either additional targeting or continuing care or both.

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