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PubMed1990

The Senior Care Study. A controlled trial of a consultative/unit-based geriatric assessment program in acute care.

Successful models of inpatient geriatric assessment have often involved long hospital stays, specialized interdisciplinary care, and prolonged follow-up, which are difficult to achieve within a prospective payment system. A randomized clinical trial was undertaken to evaluate the efficacy (maintenance or improvement in mental, emotional, and physical function) of using a geriatric assessment process in acute hospital care without increasing hospital charges or lengths of stay. Four hundred thirty-six patients greater than or equal to 75 years of age were randomly allocated to treatment (n = 221) or control (n = 215) conditions. Patients in the treatment group were admitted to a special unit and evaluated on admission by an interdisciplinary team, which developed a care plan. Although primary care was provided by the patient's own physician, the team followed the patients as consultants on the unit in the hospital, and by telephone for 2 months after discharge. The control group was placed on other units and received usual hospital care. The treatment and control groups were similar at study entry. At follow-up, there were no significant differences between the groups with respect to lengths of stay, hospital charges, mortality, change in physical function, or change in mental function. The treatment group changed more often in measured emotional function (chi 2 = 6.213, P = .045). This study indicates that it is feasible to implement consultative interdisciplinary team care in the acute-care hospital, but that its efficacy may be limited when applied to an unselected group of older patients.

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PubMed2004

Geriatric assessment in elderly patients with prostate cancer.

As a result of demographic evolution, oncologists will treat more and more elderly patients with prostate cancer. Aging is frequently associated with the coexistence of several medical complications that can increase the complexity of cancer treatment decision-making. Unfortunately, clinical oncologists need to be more familiar with the multidimensional assessment of elderly patients. To acquire this skill, we implemented a multidimensional geriatric assessment program at our cancer center. This instrument prospectively assessed 60 elderly patients with prostate cancer. Herein, we describe geriatric aspects detected in our patient sample and report treatment options proposed to elderly patients with prostate cancer at different disease stages. The minimal comprehensive geriatric assessment (mini-CGA) procedure revealed that 66% of our patient population was dependent in one or more of the Katz Activities of Daily Living and 87% were dependent in 1 or more of the Lawton Instrumental Activities of Daily Living; all patients had significant comorbidity according to the Cumulative Illness Rating Scale-Geriatrics, 75% having at least one severe comorbidity. We identified 19 cases of drug interaction. We also observed that half of these patients had a risk of falling and some physical disability; 45% had cognitive disorders requiring more investigation; one third had depressive symptoms. Finally, 65% of the patients were either malnourished or at risk of malnutrition. Many of these problems were unknown before the mini-CGA processing and may interfere with cancer and cancer treatment. Thus, the correct management of elderly patients with cancer requires comprehensive geriatric assessment as well as relevant disease staging at diagnosis. This approach will help us to propose the most appropriate treatment with the main aim of preserving quality of life.

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PubMedDate not supplied

Comprehensive geriatric assessment basics for the cancer professional.

A comprehensive geriatric assessment (CGA) has been a cornerstone of geriatric practice for many years. However, oncology practitioners are still unfamiliar with it. Yet, recent research has shown an important potential to improve the daily care of older cancer patients. The purpose of this article is to review the basic nature of a CGA, its effectiveness, its applicability to cancer patients, and its cost-effectiveness. Cancer is one of the major health problems in our society. Furthermore, the incidence of cancer increases with age. Nowadays, half of the cancers occur beyond the age of 70. Given the aging of the US population, this proportion is expected to increase in the next decades. A challenge for the oncologists is that older people can have a highly variable health status. Yet little is known yet about how to best assess and integrate into decision making the various health problems patients may have. Taking their clues from the experience of geriatricians, geriatric oncologists advocate the use of a comprehensive geriatric assessment (CGA) as one of the tools to deal with this problem. It is, for example, part of the National Comprehensive Cancer Network (NCCN) guidelines for the elderly'. This article offers a primer on CGA for the reader unfamiliar with the approach in an oncologic setting.

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PubMed2004

Geriatric assessment and comorbidity.

Elderly persons, a rapidly growing population segment, have an increased incidence of cancer. The older cancer patient's clinical evaluation and treatment is influenced by conditions such as disabilities, comorbidity, and functional status, along with tumor type and stage. These conditions and other geriatric syndromes can be identified by comprehensive geriatric assessment to guide therapy and affect prognosis and quality of life. Comprehensive geriatric assessment involves the medical, functional, affective, social, spiritual, and environmental assessments. The medical assessment, which includes a nutrition, vision, hearing, continence, gait and balance, and cognition evaluation, can provide additional information to performance status and comorbidity. Although there are many assessment domains using several instruments, comprehensive geriatric assessment can be focused and efficient, especially with a multidisciplinary team of nurses, social workers, pharmacists, and other personnel. Comorbid illnesses may have complex interactions, with the underlying cancer influencing cancer diagnosis, disease course, treatment-related side effects, and mortality. Many instruments are available for comorbidity measurement, and retrospective studies in elderly cancer cohorts have shown comorbidity to influence survival. However, the ultimate aim would be to use comorbidity and comprehensive geriatric assessments prospectively in the older cancer patient to help predict the suitability and success of treatment with various antineoplastic modalities.

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PubMedDate not supplied

Comprehensive geriatric assessment for non-geriatricians.

Comprehensive geriatric assessment (CGA) consists of medical history taking, medication review, physical examination with special attention to sensory and neurological evaluation, and use of assessment instruments to measure cognitive, affective, functional, social, and economic status. CGA is most often beneficial when applied to frail elders at risk of functional decline. Beneficial outcomes may include decreased risks of falls, cognitive decline, and nursing home placement--in addition to improved sense of well-being and satisfaction with care.

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PubMed2001

Medical dominance in multidisciplinary teamwork: a case study of discharge decision-making in a geriatric assessment unit.

AIM: To investigate the degree of medical dominance in multidisciplinary teams in a geriatric assessment unit by focusing on decision-making with regard to patient discharge. BACKGROUND: The persistence of medical dominance in multidisciplinary teamwork has been widely assumed but insufficiently researched, particularly through close observation of team practice. The present study seeks to rectify this by examining the extent of medical dominance in two multidisciplinary teams working in a hospital-based geriatric assessment unit. METHODS: Team practice was analysed by observing and audiotaping five case review meetings in each team and by semi-structured interviews with team members. RESULTS: In terms of level of contribution, the issues raised at meetings, and the team responses to discharge initiation, a lower than expected level of medical dominance was identified. This lower than expected level is related to consultants' views on the nature of rehabilitation, leading to a consensus amongst team members as to the purpose of geriatric assessment, and to a high level of team stability. CONCLUSION: Reducing the level of medical dominance encourages the contributions of all team members and thus enhances patient care. More training in team skills would also be beneficial, including interprofessional training.

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PubMed1996

Geriatric work-up in the Nordic countries. The Nordic approach to comprehensive geriatric assessment.

A group established by the Nordic professors of geriatrics has developed a position document presenting a shared and updated review of geriatric work-up as a way of comprehensive geriatric assessment in the Nordic countries. The main intention is that the document will serve as support and help for the clinician concerned with hospital based geriatric medicine. It may also be useful for quality control and teaching. Not least, it may be useful for health professionals other than geriatricians. To some extent, the position of geriatric medicine in the Nordic countries varies between the countries. However, the background for developing a Nordic version of geriatric work-up is shared attitudes and principally the same organization of the health care system, and collaboration within geriatrics for many years. Several trials on comprehensive geriatric assessment and management performed in different settings have shown favourable outcomes. Results from controlled Nordic trials are compiled and summaries of meta-analyses are presented. The concept of Nordic geriatric work-up is based on a model defining health and disease in old age as dimensions of pathology, impairments, functional limitations, and disability, all being modified by extra- and intraindividual factors. Handicap is defined as the disability gap. Different health professionals have varying responsibilities in the geriatric team-work, but all should be dedicated to establish common goals. The geriatric work-up is presented with success factors and barriers, stating important differences between multidisciplinary and interdisciplinary processes. Checklists and assessment scales may be very useful when performing a geriatric work-up, but they should be used with caution. Specific scales covering different functional areas of the geriatric patient are recommended for clinical practice. Such scales must be valid, reliable, acceptable to the patient, responsive to change, and should be in an appropriate format, as well as easy to administer. Prior to the use among geriatric teams in the Nordic countries the scales should be translated into all the Nordic languages, and the translated versions should ideally have been subjected to validity and reliability testing. However, so far no scale meets these demands regarding all the five Nordic languages.

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PubMed2005

Interventions from home-based geriatric assessments of adult protective service clients suffering elder mistreatment.

OBJECTIVES: To describe the interventions for adult protective service (APS) clients referred for geriatric assessment. DESIGN: Retrospective cohort study. SETTING: In-home geriatric assessments conducted in two New Jersey counties. PARTICIPANTS: Two hundred eleven APS clients; 74% female; mean age 77. MEASUREMENTS: Cognition, affect, nutrition, prevalence of selected medical diagnoses and functional conditions, and categories of interventions. RESULTS: Home health agency services were initiated for 46% of APS clients suffering from all forms of mistreatment. Institutional placements (36%) and guardianship interventions (36%) were correlated with caregiver neglect, especially in female APS clients and those diagnosed with dementia. Urgent medications (25%) were prescribed across all mistreatment classifications, and acute hospitalization (20%) was correlated with circumstances of physical abuse. CONCLUSION: An in-home geriatric assessment service was able to contribute at least one relevant intervention for 81% of referred APS clients to collaboratively help mitigate elder mistreatment circumstances.

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PubMed1993

Alcohol use disorders in cognitively impaired patients referred for geriatric assessment.

Alcohol Use Disorders are thought to be underdiagnosed in the geriatric population. A retrospective medical record review was performed on 383 patients who presented for outpatient geriatric assessment from 1985-1990. The record review included data on the alcohol consumption history, age, sex, presence of alcoholic beverages in the home, geriatric psychiatry evaluation, and alcohol-related diagnoses. Alcohol Use Disorders were recognized as contributing to medical problems in 10% of patients having a mean age of 78 years. All except one patient were found to be cognitively impaired. In addition, 9% of patients consumed alcohol on a regular basis and this consumption was not considered in the diagnosis, despite the presence of cognitive impairment. Twenty-five percent of cognitively impaired patients were consuming alcohol at the time of evaluation. These results indicate that alcohol consumption and AUD are common in cognitively impaired patients presenting for geriatric assessment. Recognition of Alcohol Use Disorders is essential, as chronic alcohol toxicity represents one cause of potentially reversible dementia. Because there are no validated instruments for alcoholism screening in cognitively impaired elderly patients, evaluation should include a past and present consumption history, a search for alcoholic beverages at the home visit, and possible psychiatric referral.

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PubMedDate not supplied

[Geriatric assessment--case finding by screening hospitalized patients].

The effectiveness of geriatric assessment depends on patient selection. A simple screening procedure should facilitate the detection of appropriate patients by recording functional impairments and geriatric risks. We studied the feasibility of, and the information from the screening, and the recommendations of assessments derived from the screening. The screening revealed an average of five findings in 245 of 247 patients consecutively admitted. The most frequent problems were impaired activities of daily living and mobility, and impaired memory. Geriatric assessment was recommended to 44% of newly hospitalized patients. These patients were older, with more of them living at home and alone, and nearly half of them had five or more findings in the screening with chronic problems being predominant. The screening procedure is feasible. It appears useful and reasonable to select patients for geriatric assessment while they are in hospital.

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PubMedDate not supplied

Formal geriatric assessment, An imperative for the older person with cancer.

PURPOSE: The authors evaluate the role of cognitive, functional, and affective geriatric assessment measures in elderly cancer patients, and analyze the associations between these factors, stage of malignancy, and cancer treatment choices. DESCRIPTION: Fifty consecutive patients older than 65 years of age who were referred to the Geriatric Oncology Clinic at the University of New Mexico Health Sciences Center in Albuquerque were evaluated using standard geriatric assessment tools. Each person underwent a complete history and physical examination. An extensive chart review established the type of cancer, stage at diagnosis, and treatment modalities used. The Karnofsky performance status scale score also was determined at this initial evaluation. RESULTS: The group had a mean age of 74.9 years; 60% were women and 40% were men. The most common cancers were breast (28%) and prostate (16%). Fifty-two percent of the patients had localized disease and 48% had distant disease. Seventy-four percent had received treatment by the time of the initial assessment, with 62% undergoing combination therapy. The most common noncancer diagnoses were cardiovascular disease, hypertension, and osteoarthritis. Scores on standardized measures indicated that the majority of patients were independent. Those who did not receive treatment were more functionally impaired than those who received treatment. Twenty-seven percent of the sample were impaired cognitively and 24% were depressed. There were no statistical differences in functional, cognitive, or affective status between stages of disease for specific malignancies. CLINICAL IMPLICATIONS: Age alone is a poor predictor of outcome in cancer treatment and is an inappropriate factor by which to exclude persons with cancer from clinical trials. Treatment decisions based on age alone may lead to inadequate treatment. In this report, functional dependence was more prevalent in nontreated patients and was unrelated to the stage of disease. These results support the need for formal geriatric assessment, including measures of cognitive, functional, and affective status, in elderly persons with cancer. Further studies on the role of functional, cognitive, and affective status at the time of cancer diagnosis, as well as how these parameters might alter treatment decisions, are warranted. In addition, further investigation to identify which of these multiple variables influence treatment outcome are needed.

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PubMed2005

Developing a cancer-specific geriatric assessment: a feasibility study.

BACKGROUND: As the U.S. population ages, there is an emerging need to characterize the "functional age" of older patients with cancer to tailor treatment decisions and stratify outcomes based on factors other than chronologic age. The goals of the current study were to develop a brief, but comprehensive, primarily self-administered cancer-specific geriatric assessment measure and to determine its feasibility as measured by 1) the percentage of patients able to complete the measure on their own, 2) the length of time to complete, and 3) patient satisfaction with the measure. METHODS: The geriatric and oncology literature was reviewed to choose validated measures of geriatric assessment across the following domains: functional status, comorbidity, cognition, psychological status, social functioning and support, and nutritional status. Criteria applied to geriatric assessment measurements included reliability, validity, brevity, and ability to self-administer. The measure was administered to patients with breast carcinoma, lung carcinoma, colorectal carcinoma, or lymphoma who were fluent in English and receiving chemotherapy at Memorial Sloan-Kettering Cancer Center (New York, NY) or the University of Chicago (Chicago, IL). RESULTS: The instrument was completed by 43 patients (mean age, 74 yrs; range, 65-87 yrs). The majority had AJCC Stage IV disease (68%). The mean time to completion of the assessment was 27 minutes (range, 8-45 mins). Most patients were able to complete the self-administered portion of the assessment without assistance (78%) and were satisfied with the questionnaire length (90%). There was no association noted between age (P = 0.56) or educational level (P = 0.99) and the ability to complete the assessment without assistance. CONCLUSIONS: In this cohort, this brief but comprehensive geriatric assessment could be completed by the majority of patients without assistance. Prospective trials of its generalizability, reliability, and validity are justified.

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PubMed1987

Geriatric assessment: an overview of its impacts.

Geriatric assessment programs of various types have become an increasingly important component of the geriatric health care delivery system in the United States. Such programs provide interdisciplinary assessment, treatment planning, case management, and, often, rehabilitation for frail elderly persons and are especially important for those suspected of needing long-term institutional care. A growing body of literature, summarized in this chapter, documents many proven benefits to health care outcomes. Among these benefits are better diagnostic accuracy and treatment planning, more appropriate placement decisions with less referral to nursing homes, improved patient functional and mental status, prolonged patient survival, and lower overall use of costly institutional care services.

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PubMed2000

Goals in geriatric assessment: are we measuring the right outcomes?

Previous evaluative studies of outpatient geriatric assessment have focused on a limited set of outcomes related to functioning, health services utilization, and costs. The purpose of this study was to identify important goals for care as described by patients and family caregivers being cared for in this setting. Using a cross-section of 226 consecutive sets of patients and their primary family caregivers, physicians, and case managers, goals of care for individual patients were coded from open-ended interview responses. The most common categories of goals expressed by family caregivers were obtaining education and referrals (57.5%) and improving social and family relationships (53.0%). The process of establishing and meeting such goals should be explicitly included in the design of future evaluations of outpatient geriatric assessment.

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PubMed2001

The development and evolution of geriatric assessment teams over the past 25 years: a cross-cultural comparison of the US and the UK.

Findings from a literature synthesis and content analysis of the geriatric assessment team literature from the US and the UK over the past 25 years (1974-1999) are presented. Eighty-one geriatric assessment teams identified from the literature are analyzed (52 from the US and 29 from the UK). Geriatric assessment team characteristics are examined including team purpose, team setting, treatment link, team orientation, team composition, team size, and the client group targeted. The results show that teams in both the US and UK primarily have testing treatment effectiveness as their stated purpose, have strong treatment links, and are patient-oriented. Significant differences exist between the US and UK in terms of team setting, team composition, team size, and patients targeted by team. The US teams examined are more likely to operate in inpatient settings, include more disciplines and have more members on the team, and target specific subgroups of older people than those from the UK.

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PubMed2006

Geriatric assessment for oncologists: rationale and future directions.

Sixty percent of all cancer occurrences and seventy percent of cancer mortalities occur in people over the age of 65. As the population ages, there is an emerging need to develop a means for oncologists to characterize the "functional age" of older patients with cancer in order to tailor treatment decisions and stratify outcomes based on factors other than chronological age and to develop interventions to optimize cancer treatment. In this paper, we discuss the formulation of a geriatric assessment for older patients with cancer. The measures included in this assessment were chosen based on their validity, reliability, brevity, adaptability for self-administration, and ability to prognosticate risk for morbidity or mortality in an older patient. The proposed geriatric assessment covers the essential domains of assessment predictive of survival in the geriatric population, is primarily self-administered, and limited personnel time is required. Our eventual goal is to determine if this geriatric assessment measure can identify factors independent of age that predict cancer treatment morbidity and mortality and result in rationale interventions to optimize oncologic care.

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PubMed1999

A randomized clinical trial of outpatient comprehensive geriatric assessment coupled with an intervention to increase adherence to recommendations.

BACKGROUND: Although comprehensive geriatric assessment (CGA) has been demonstrated to confer health benefits in some settings, its value in outpatient or office settings is uncertain. OBJECTIVE: To assess the effectiveness of outpatient CGA consultation coupled with an adherence intervention on 15-month health outcomes. DESIGN: A randomized controlled trial. SETTING: Community-based sites. PATIENTS: 363 community-dwelling older persons who had failed a screen for at least one of four conditions (falls, urinary incontinence, depressive symptoms, or functional impairment) INTERVENTION: A single outpatient CGA consultation coupled with an intervention to improve primary care physician and patient adherence with CGA recommendations. MEASUREMENTS: Medical Outcomes Study Short Form-36 (MOS SF-36), restricted activity and bed days, Physical Performance Test, NIA lower-extremity battery. RESULTS: In complete case analysis (excluding the five control group subjects who died during the follow-up period), the adjusted difference in change scores (4.69 points) for physical functioning between treatment and control groups indicated a significant benefit of treatment (P = .021). Similar benefits were demonstrated for number of restricted activity days and MOS SF-36 energy/fatigue, social functioning, and physical health summary scales. In analyses assigning scores of 0 to those who died, these benefits were greater, and significant benefits for the Physical Performance Test and MOS SF-36 emotional/well being, pain, and mental health summary scales were also demonstrated. CONCLUSIONS: A single outpatient comprehensive geriatric assessment coupled with an adherence intervention can prevent functional and health-related quality-of-life decline among community-dwelling older persons who have specific geriatric conditions.

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PubMed2006

[Limited geriatric assessment of the elderly in Kibbutzim of the Upper Galilee].

BACKGROUND: Since comprehensive geriatric assessment (CGA) is very time and money consuming, its implementation is limited in Israel. OBJECTIVE: Implementation of the ambulatory limited geriatric assessment (LGA). TARGET POPULATION: Persons over 65 years of age living in Kibbutzim in the Upper Galilee. METHODS: As in the case of CGA, the emphasis in LGA is mainly placed on the functional status of the elderly. In order to identify geriatric syndromes, we used routine screening methods. According to the agreement with Clalit Health Services, a geriatrician is allowed to spend one hour per person. The elderly to be checked were selected by the medical staff. At the time of LGA, medical staff and patients' relatives supplied all information needed, including this data in computerized ambulatory cards. In such a way, a considerable amount of medical, functional, epidemiological, and psychosocial information was retrieved thus enabling a geriatrician to elaborate individual programs of follow-up and treatment. A geriatrician could request additional consultations and analyses. Two years later the medical staff in the kibbutzim completed anonymous questionnaires referring to the remote results of LGA. RESULTS: A total of 121 elderly persons were included in the LGA, performed during the period 2001-2003. The main causes of patients' referral to LGA were the known geriatric syndromes, namely functional and cognitive decline, anxiety and depression, falls etc. We assessed: (1) epidemiological data: age, gender, familial state, education, number of children, place of residence, (2) clinical data: number of both geriatric syndromes and drugs, recent changes in weight, hearing, and vision, (3) functional status: activities of daily living (ADL) and instrumental activities of daily living (IADL), falls, risk of self-inflicted injury, work, hobbies, social activity, the need for familial and social support, (4) cognitive and psychosocial status including depressive symptoms and anxiety, sleep disturbances, casualties in families or among friends, changes in mood and fears. After conducting the LGA, we recommended changes in the drug treatment, nursing, rehabilitation, institutionalization, and social help, if needed. Analysis of anonymous questionnaires showed that both medical staff and elderly in kibbutzim were satisfied with LGA implemented at the old persons' residence, they noted availability and high professional levels of LGA, additionally, they reported on the successful implementation of recommendations. The method became routine in the Upper Galilee. CONCLUSION: Since CGA is a very time- and money-consuming procedure, LGA has been tested and appears to be effective in the identification of geriatric syndromes. Within one hour of assessment, a geriatrician could retrieve a lot of the relevant information that allowed him to build individual programs for follow-up, prophylactic measures, drug and rehabilitation treatment and institutionalization.

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