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PubMed1991

A randomised study of outcomes in a defined group of acutely ill elderly patients managed in a geriatric assessment unit or a general medical unit.

The aim of this study was to identify differences in the medical management and clinical outcome in a group of elderly patients admitted to a designated geriatric assessment unit (GAU) or to two general medical units (GMUs). A prospective randomised controlled trial was undertaken in 267 patients aged 70 years and over (mean age = 78.3 years). Following discharge from hospital, patients were followed up at three monthly intervals for a total of 12 months. At the time of discharge, no significant differences were found in inpatient management, length of stay, mortality rates, discharge rates to institutional care or utilisation of community services in patients admitted to the GAU and the GMUs. Similarly, no significant differences were found at three, six, nine, and 12 month follow up in case fatality, activities of daily living indices, mental health status, rates of institutional referral and the level of community service support in patients admitted to the GAU and the GMUs studied. These findings do not show any advantage for the unselected 70+ acutely ill elderly patient who is admitted to a designated geriatric assessment unit rather than to a general medical unit. Therefore, an admission policy to GAU, based solely on age 70+ is medically inappropriate and cost-inefficient. Evidence from other sources suggests that an age cohort of acutely admitted patients beyond 80 years may well have returned more optimistic findings for the GAU. In future, GAUs will require a more selective admission policy to maximise the benefits of their rehabilitative and interdisciplinary approach.

Acute Disease↗
PubMed2005

Comprehensive geriatric assessment for older hospital patients.

In-patient comprehensive geriatric assessment (CGA) may reduce short-term mortality, increase the chances of living at home at 1 year and improve physical and cognitive function. We systematically reviewed the literature and found 20 randomized controlled trials (10 427 participants) of in-patient CGA for a mixed elderly population. This includes seven more recent randomized controlled trials that update a previous review. Newer data confirm the benefit of in-patient CGA, increasing the chance of patients living at home in the long term. Overall, for every 100 patients undergoing CGA, three more will be alive and in their own homes compared with usual care [95% confidence interval (CI) 1-6]. Most of the benefit was seen for ward-based management units (four patients per 100 treated, 95% CI 1-7) with little contribution from team-based care (no patients per 100, 95% CI -4 to +5). However, CGA does not reduce long-term mortality. This evidence should inform future service developments.

Activities of Daily Living↗
PubMed1994

Ability of a computerized geriatric assessment to predict need for change in living status among elderly living at home.

The objective of this study was to determine the ability of a software program used in a primary care physician's office to predict the need for alternate living arrangement in a cohort of community-dwelling elderly. An analysis was conducted involving 124 consecutive patients between February 10, 1990, and December 20, 1991, in my private medical practice. These patients, all older than 65 years, underwent a computer-assisted geriatric assessment. Two scales--the Geriatric Functional Rating Scale (GFRS) and the Functional Assessment Screening Questionnaire (FASQ)--were compared for their accuracy at predicting change in living status during the 12- to 24-month period following the assessment. Similar analysis of the Tinetti gait and balance test was also performed. Ten and one-half percent of subjects (n = 13) required a change in living status during the study period. Ten went to nursing homes and three joined relatives' households. The GFRS was 62% accurate (8/13) and the FASQ was 54% (7/13) accurate in predicting this change. Abnormality in both gait and balance was predictive 77% (10/13) of the time. Combining all three parameters raised the successful prediction rate to 85% (11/13). Neither GFRS, FASQ, nor gait/balance testing was predictive of death. A computer software program designed to facilitate performance of geriatric assessments in primary care physicians' offices has a high rate of predictive capability relative to future need for change in living status among community-dwelling elderly. Further studies comparing this software program with traditional geriatric assessment protocols are suggested.

Activities of Daily Living↗
PubMed1990

Characteristics of an elderly driving population referred to a geriatric assessment center.

A retrospective, case-control study was performed to determine the characteristics of elderly drivers referred to an outpatient geriatric assessment center. It was hypothesized that the driving population was operating at a higher cognitive and functional level than nondrivers. One hundred eighty-two subjects meeting the entry criteria were studied. Twenty-three percent of the subjects were driving at the time of their assessment. Compared to nondrivers, drivers were younger (P = .0001), were more likely to be male (P = .003), scored higher on a mental status examination (P = .0001), and were more independent in Physical and Instrumental Activities of Daily Living (P less than .0001). Despite these findings, the mean Folstein Mini-Mental score for drivers (23.7) was below normal; 40% of drivers were diagnosed as having Alzheimer's dementia at the time of their evaluation, and over 26% of the drivers needed help with either dressing or bathing. The frequency of impaired elderly drivers in this referral setting was high. The authors conclude that conditions that affect the driving task are common in geriatric assessment centers. Prospective studies of elderly drivers are needed to answer the difficult question of who among the elderly should drive.

Activities of Daily Living↗
PubMed2004

[Geriatric assessment in the elderly with heart failure].

Despite recent advances in pharmacotherapy, heart failure represents the major cause of death and hospitalization for elderly people in developed countries. Clinical assessment and management of older patients are often more difficult than in younger ones. Epidemiological studies in geriatrics as well as cardiology setting have demonstrated that elderly heart failure patients are frail and complex individuals, in whom many clinical and non-clinical factors may play a role in determining clinical presentation and prognosis. Thus, management of heart failure in the elderly requires a coordinated, multidimensional and multidisciplinary approach. This article describes the principles of geriatric assessment. Assessment should include the evaluation of comorbidity, cognitive status, functional ability in activities of daily living, psychosocial, environmental and financial factors, and quality of life. Available evidence suggests that geriatric assessment can have a positive effect on patient outcome and overall quality and cost of care.

Aged↗
PubMed2004

Operationalizing a frailty index from a standardized comprehensive geriatric assessment.

OBJECTIVES: To construct and validate a frailty index (FI) that is clinically sensible and practical for geriatricians by basing it on a routinely used comprehensive geriatric assessment (CGA) instrument. DESIGN: Secondary analysis of a 3-month randomized, controlled trial of a specialized mobile geriatric assessment team. SETTING: Rural Nova Scotia. Participants were seen in their homes. PARTICIPANTS: Frail older adults, of whom 92 were in the intervention group and 77 in the control group. MEASUREMENTS: A standard CGA form that accounts for impairment, disability, and comorbidity burden was scored and summed as a frailty index (FI-CGA). The FI-GCA was stratified to describe three levels of frailty. Patients were followed for up to 12 months to determine how well the index predicted adverse outcomes (institutionalization or mortality, whichever came first). RESULTS: The three levels of frailty were mild (FI-CGA 0-7), moderate (FI-CGA 7-13), and severe (FI-CGA>13). Demographic and social traits were similar across groups, but greater frailty was associated with worse function (r=0.55) and mental status (r=0.33). Those with moderate and severe frailty had a greater risk of adverse outcomes than those with mild frailty (unadjusted hazard ratio=1.9 and 5.5, respectively). There was no difference between frailty groups in mean 3-month goal-attainment scaling scores. Intrarater reliability was 0.95. CONCLUSION: The FI-CGA is a valid, reliable, and sensible clinical measure of frailty that permits risk stratification of future adverse outcomes.

Aged↗
PubMed1990

Comprehensive geriatric assessment recommendations: adherence of family practice residents.

A study was performed to determine whether family practice residents followed recommendations made by a comprehensive geriatric assessment clinic. Of 109 consecutive consultations, 27 patients had follow-up visits with family practice residents who participated in the assessment and who subsequently served as their primary care physicians. Adherence of residents to 437 clinic recommendations was monitored for 90 days by medical record review. Although recommendations to begin or increase a medication were followed 85.4% of the time, residents followed recommendations to stop or decrease medications less than 65% of the time. Recommendations to order a specific laboratory test or x-ray examination were acted on 70.3% of the time. Preventive recommendations were followed only 54.3% of the time. Residents' adherence to team-based care plans varied widely by type of recommendation. Special efforts are needed to increase compliance with comprehensive geriatric assessment clinic recommendations, particularly those for preventive services.

Aged↗
PubMedDate not supplied

[Identification of functional deficits in the acute hospital by geriatric assessment].

Functional deficits of elderly patients are often not recognized during routine treatment in acute hospital care. In Germany, there are only limited experiences with the use of standardized assessment-scales in this health care setting. In this study, 112 patients were recruited for a very broad geriatric assessment focused on methodological and practical questions. There were 38.8% with deficits in the ADL and 12.6% with depressive symptoms. Many patients showed low motivational factors such as energy, efficacy and will. Geriatric syndromes such as malnutrition were also very common. In general, many patients in acute care hospitals have functional deficits which are not recognized by the physicians. For many patients, short instruments are sufficient for screening purposes. The effectiveness of a complete geriatric assessment depends mostly on the use of good selection criteria.

Activities of Daily Living↗
PubMedDate not supplied

Rationale to integrate comprehensive geriatric assessment for older olds presenting gastro-intestinal disorders.

The prevalence of chronic gastrointestinal symptoms is underestimated. However, complaints consistent with functional gastrointestinal disorders are common in the elderly, but symptoms are a poor predictor of presentation for medical care. Moreover, chronic colonic symptoms appear to interfere with daily living and quality of life in the elderly. Clinicians are questioning about the diagnostic management of frail older adults presenting these common and non specific symptoms. This paper proposes a definition of the "geriatric patient" and gives an overview of recently published literature concerning the concept of comprehensive geriatric assessment. The rationale to integrate comprehensive geriatric assessment for older adults presenting gastro-intestinal disorders is pointed out.

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PubMed1987

Integration of geriatric assessment into the community.

The integration of geriatric assessment into the community calls for more than effective communication. There should be a defined approach to comprehensive care, of which the assessment service is a regular part, and the assessment process should have a predictable influence on further care decisions. Three types of integrating approaches are described: the "recognized specialty" approach, which is typical of several other developed countries; the "consolidated model," such as the On Lok program in San Francisco; and the "brokerage" model, such as the ACCESS program in Rochester, New York. Each approach has strengths and limitations. We may expect further evolution toward fully integrated programs.

Aged↗
PubMed1997

The process of care in preventive in-home comprehensive geriatric assessment.

OBJECTIVES: To describe the process of care of a program of in-home comprehensive geriatric assessment (CGA) and to determine: (1) if there are major findings in all domains of CGA (medical, functional, mental health, and social/ environmental), (2) if there is a continued clinical yield when CGA is repeated annually, and (3) factors that affect patient adherence with recommendations from CGA. DESIGN: Descriptive prospective study of subjects allocated to the intervention group of a 3-year randomized trial of preventive in-home CGA. SETTING: Homes of participants living in an urban setting. PARTICIPANTS: Persons aged 75 years or older and living at home who received the intervention (N = 202 subjects, mean age 80.8 years, 70% female, 95% white, 64% living alone). INTERVENTION: Annual in-home CGA and quarterly home visits by gerontologic nurse practitioners for 3 years. MEASUREMENTS: Detailed data were collected prospectively on clinical problems detected by CGA, and specific recommendations were made for these problems using an instrument developed explicitly for this project to study the CGA process. Subject adherence with these recommendations was also recorded. RESULTS: Major problems were identified in all domains of CGA; the most common problems were medical. In the first year, 76.7% of subjects had at least one major problem identified that was either previously unknown or suboptimally treated. One-third of subjects had additional major problems identified during the second and third years. A constant number of therapeutic and preventive recommendations was made each year (11.5 per subject annually). Subject adherence varied by type of recommendation (ANOVA, F = 108.4, P < .001); adherence was better for referrals to a physician than for referrals to a non-physician professional or community service or for recommendations involving self-care activities (Scheffe's test, P < .001). CONCLUSION: In these community-dwelling older people, there was a continued yield of problems identified and recommendations made when CGA was repeated annually for 3 years, supporting the practice of repeat CGA in older people in the community. Subject adherence with recommendations from CGA varied by type of recommendation, but further work is needed to determine additional factors that affect this adherence and to determine the association between the yield of CGA (i.e., problems identified, recommendations given and adherence with these recommendations) and important clinical outcomes.

Aged↗
PubMed1987

A geriatric assessment and rehabilitation unit in a rehabilitation hospital.

This paper presents process and outcome data for a geriatric assessment unit in a rehabilitation hospital whose focus is on short-term rehabilitation. While the results presented here are positive, they are descriptive and do not prove a cause and effect relationship between the geriatric assessment and rehabilitation unit care and the outcomes described. This unit is currently being evaluated by a prospective randomized controlled clinical trial.

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PubMed1994

A computerized geriatric assessment designed for use in primary care physicians' offices.

Comprehensive geriatric assessments have generally been recognized as beneficial for frail elderly patients. However, the complexity of these evaluations has usually required that they be performed in a multidisciplinary setting. Staffing requirements, time commitment, new skill requirements, and reimbursement problems serve as impediments for primary care physicians performing these examinations. Computer technology may be the solution to these problems. A software program has been developed which allows primary care physicians to perform a sophisticated functional assessment on an outpatient basis without the use of a multidisciplinary team. Problems are identified by the computer-assisted protocol and patients are referred for appropriate management. Thus, the physician maintains a primary role in case management. The program is cost effective because it does not require additional staff to operate it and it effectively uses CPT and ICD9 coding.

Aged↗
PubMed1998

How the principles of geriatric assessment are shaping managed care.

In traditional geriatric medicine, comprehensive assessment is considered crucial to the care of frail older patients. The principles of geriatric assessment--identifying high-risk patients and targeting them for preventive interventions--are also practiced by managed care organizations (MCOs). Self-reported health surveys and administrative data are two methods used by MCOs to identify members at high risk for adverse health outcomes and functional decline who may benefit from geriatric case management. For a successful partnership with primary care physicians, it is very important that geriatric care managers should be knowledgeable in the principles of geriatric medicine.

Activities of Daily Living↗
PubMedDate not supplied

The influence of outpatient comprehensive geriatric assessment on survival: a meta-analysis.

Although outpatient Comprehensive Geriatric Assessment (CGA) has shown certain benefits in functional status and quality of life by many randomized controlled trials, no survival benefit has been reported. We hypothesized that the lack of survival benefit may be due to insufficient power of individual trials. In order to assess the influence of outpatient CGA on survival of older persons, we performed a meta-analysis of all randomized controlled trials of outpatient CGA. Nine studies consisting of 3750 subjects fulfilled the predetermined eligible criteria and were included in the meta-analysis. Combined mortality risk ratio with outpatient CGA intervention compared to usual care group was 0.95 (95% confidence interval, CI 0.82-1.12, P = 0.62). Treatment effects were homogeneous across the trials. This meta-analysis did not demonstrate survival benefit for outpatient CGA. Inadequate statistical power is unlikely to explain the results. Future researches of outpatient CGA should focus on coordinated and standardized measurement of outcomes related to functional status, institutionalization rate, and quality of life.

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PubMed1995

A simple geriatric assessment measure to assist a consultative team decision for nursing home placement.

In this study, Barthel and Mini-mental State Examination scores were combined and examined for their ability to predict a geriatric assessment team's decisions for nursing home care. We examined cross-sectional data from a project of consultative geriatric assessment for nursing home applicants in a high socioeconomic status area of Sydney, Australia. The maximum combined score was 160, and a "grey zone" between 100 and 140 was identified where classification errors were greater than 30%. Above 140, most patients were assigned by the team to other care, and below 100, nursing home care was recommended for most. The effectiveness of a classification test will be increased by identification of a grey zone so that if patients fall within this zone, greater care can be taken in the decision-making process. Given the select nature of subjects in this analysis, the generalizability of the derived combined score will be limited. However, the study illustrates one approach that may be taken in the development of classification methods to aid decision-making in the clinical or screening settings.

Geriatric Assessment↗
PubMed2002

Comprehensive geriatric assessment adds information to Eastern Cooperative Oncology Group performance status in elderly cancer patients: an Italian Group for Geriatric Oncology Study.

PURPOSE: To appraise the performance of Comprehensive Geriatric Assessment (CGA) in elderly cancer patients (> or = 65 years) and to evaluate whether it could add further information with respect to the Eastern Cooperative Oncology Group performance status (PS). PATIENTS AND METHODS: We studied 363 elderly cancer patients (195 males, 168 females; median age, 72 years) with solid (n = 271) or hematologic (n = 92) tumors. In addition to PS, their physical function was assessed by means of the activity of daily living (ADL) and instrumental activities of daily living (IADL) scales. Comorbidities were categorized according to Satariano's index. The association between PS, comorbidity, and the items of the CGA was assessed by means of logistic regression analysis. RESULTS: These 363 elderly cancer patients had a good functional and mental status: 74% had a good PS (ie, lower than 2), 86% were ADL-independent, and 52% were IADL-independent. Forty-one percent of patients had one or more comorbid conditions. Of the patients with a good PS, 13.0% had two or more comorbidities; 9.3% and 37.7% had ADL or IADL limitations, respectively. By multivariate analysis, elderly cancer patients who were ADL-dependent or IADL-dependent had a nearly two-fold higher probability of having an elevated Satariano's index than independent patients. A strong association emerged between PS and CGA, with a nearly five-fold increased probability of having a poor PS (ie, > or = 2) recorded in patients dependent for ADL or IADL. CONCLUSION: The CGA adds substantial information on the functional assessment of elderly cancer patients, including patients with a good PS. The role of PS as unique marker of functional status needs to be reappraised among elderly cancer patients.

Activities of Daily Living↗