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PubMed1998

Pulse oximetry as a fifth vital sign in emergency geriatric assessment.

OBJECTIVE: To determine the utility of pulse oximetry as a routine fifth vital sign in emergency geriatric assessment. METHODS: Prospective study using pulse oximetry to measure O2 saturation in geriatric patients presenting to ED triage. Saturation values were disclosed to clinicians only after they had completed medical evaluations and were ready to release or admit each patient. The authors measured changes in medical management and diagnoses initiated after the disclosure of pulse oximetry values. The study included 1,963 consecutive adults aged > or = 65 years presenting to triage at a university ED. Measurements included changes in select diagnostic tests: chest radiography, complete blood count (CBC), spirometry, arterial blood gases (ABGs), pulse oximetry, and ventilation-perfusion scans; treatments: antibiotics, beta-agonists, and supplemental O2; and hospital admission and final diagnoses that occurred after complete ED evaluation when physicians were informed of triage pulse oximetry values. RESULTS: 397 (20.2%) geriatric patients had triage pulse oximetry values <95%. Physicians ordered repeat oximetry for 51 patients, additional chest radiography for 23, CBC for 16, ABGs for 15, spirometry for 5, and ventilation-perfusion scans for none. Physicians ordered 49 new therapies for 44 patients, including antibiotics for 14, supplemental O2 for 29, and beta-agonists for 6. Nine patients initially scheduled for ED release were subsequently admitted to the hospital. Physicians changed or added diagnoses for 27 patients. CONCLUSIONS: Using pulse oximetry as a routine fifth vital sign resulted in important changes in the diagnoses and treatments of a small proportion of emergency geriatric patients.

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PubMedDate not supplied

Screening instruments for use in a complete geriatric assessment.

The rapid population growth of individuals 65 years and older in the United States is predicted to continue through 2050. As people age, the complexity of their healthcare needs increase and can be attributed to the normal aging process as well as an increased frequency of chronic illness with associated morbidity. There are many geriatric assessment instruments that can be used to evaluate the complex health needs of the older adult, but there is a need for a geriatric screening assessment process that can address the domains of the aging individual in a practical, holistic, and cost-effective manner. There are multiple quality-of-life instruments that can be used for this screening of health needs in the aging population, and 3 will be discussed, the LEIPAD instrument, the Medical Short Form-36, and the WHOQOL-BREF. The rationale for introducing a screening assessment into the clinical practice of the clinical nurse specialist for positive patient outcomes will be examined.

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PubMed2005

Effectiveness of outpatient geriatric assessment programs: exploring caregiver needs, goals, and outcomes.

In this study, the authors examined the goals and outcomes of 141 caregivers of older adults with cognitive impairment who attended a comprehensive geriatric assessment program (CGA). The vast majority of caregivers expressed at least one assessment goal, suggesting that the concept was relevant to them. Most caregiver goals focused on patient needs, with only 10% expressing goals specifically related to their own coping needs. At follow up, more than two-thirds of caregiver goals were attained. The findings confirm the great potential of CGA programs in promoting positive outcomes and point to the opportunities for nurses to improve the process of care.

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PubMed1991

Recommendations for a change in living situation resulting from an outpatient geriatric assessment: type, frequency and risk factors.

We analyzed the outcomes of 480 comprehensive outpatient geriatric assessments to determine the frequency of recommendations for home help or a change in residence and to determine whether simple clinical observations could predict such recommendations. Fifty-eight percent (280) of the patients received no recommendation for a change in the living situation. Of the 200 patients receiving a recommendation for a change in living situation, 97 (49%) were felt to be able to stay at home with increased in-home support and/or day care, and 51.5% (103) were advised to seek placement. After adjusting for age and gender, risk factors predicting a recommendation for change were dementia (odds-ratio = 9.98), vision deficits (odds ratio = 2.02), lower education level compared to college (odds-ratio = 1.88 high school, 1.42 for less than high school), an increasing number of medical diagnoses (odds-ratio = 1.49 per diagnosis), and a functional impairment on the Katz index (odds-ratio = 1.09). The presence of these risk factors should lead to consideration of further evaluation of the home environment in this study. We conclude that geriatric patients presenting for a comprehensive outpatient evaluation commonly need a change in home situation, though most can remain in their home, and that simple clinical observations can be helpful in screening patients for further evaluation of their home environment.

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PubMed2003

Teaching geriatric assessment in home visits: the family physician/geriatrician attachment.

BACKGROUND: Geriatric clinical clerkships in Israel teach mostly about the hospitalized elder patient with almost no ambulatory experience. Meanwhile, primary care physicians provide most of the health care to the elderly in the community. This article describes an innovation in the curriculum of the 5th-year family medicine clerkship at the Goldman Medical School of Ben-Gurion University in Israel designed to improve the teaching of geriatrics in the ambulatory setting. DESCRIPTION: During the clerkship, family physicians perform a home visit to one of their home-ridden elderly patients with a small group of medical students. During this visit, a geriatrician from the local hospital is included to the group for teaching purposes. EVALUATION: Most students rated this experience positively as did the family physicians and geriatricians who participated in this experience. CONCLUSIONS: This liaison-attachment teaching experience allows the students to learn aspects of geriatrics that are spared during their geriatric clerkship, allows the family physician to use this opportunity as a consultation for homebound patients, and allows the tertiary care geriatrician to teach in the community.

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PubMed1999

[The radar chart method and its analysis as a comprehensive geriatric assessment system for elderly disabled patients].

In order to simply express the results of comprehensive geriatric assessment (CGA) for elderly disabled patients, we tried to develop a CGA system using a radar chart method in 50 patients (age 73-101, mean 85 +/- 5.4) admitted to our hospital during May 1997. Our clinical database for CGA included 7 major factors (diagnosis, mental function, physical function, nutritional state, complication, coronary risk factors, social background). Finally, the radar chart was made from the results of 6 scored factors other than diagnosis and the correlation was examined statistically between these factors. This study suggests that: (1) the radar chart method display of CGA is useful for all medical staff to understand the results of CGA for elderly disabled patients and the characteristic patterns of each disease, (2) because significant positive correlations were found between 3 factors (mental, physical, nutritional) in patients with cerebrovascular disease (CVD), a more global strategy for medical care planning, especially for treatment, nursing care and rehabilitation program is necessary in patients with CVD, (3) in patients with Alzheimer's disease (AD), significant positive correlation was found only between physical and nutritional factors; mental factors showed significant negative correlation only with the duration of morbidity and as a result, quality of life is a more important problem for planning care of patients with AD, (4) for elderly disabled patients, nutritional assessment and nutritional care planning are very important as well as mental and physical care planning.

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PubMed2004

Management and geriatric assessment of cancer in the elderly.

Due to the demographic evolution, the management of elderly patients with cancer currently represents a major challenge for the medical community. Aging may be associated with an increased rate of health problems possibly resulting in a loss of independence. These problems can interfere with cancer treatment strategies. Therefore, treatment decision making requires a multidisciplinary and multidimensional assessment of both the characteristics of the malignant disease and the host's general health status. Several oncological groups have developed specific programs for elderly cancer patients. Based on a multidimensional geriatric assessment tool, they aim to establish the best pattern of care for the population of elderly patients with cancer. Clinical research in geriatric oncology is also a very exciting field, particularly regarding the conception of clinical trials specifically designed for elderly patients. The particular aspects of the management of elderly patients with cancer and some critical challenges of clinical research will be presented and discussed in this review.

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PubMed2000

Geriatric assessment in the elderly cancer patient.

Lost and remaining functions are of special importance in geriatric medicine. The level of functional deficits ultimately determines the remaining quality of life and the patient's ability to continue independently. In contrast, the actual severity of a disease measured by common standards becomes less important. Geriatric assessment is increasingly used to describe the impact of disease and to focus on the functional losses and problems that are particularly relevant to the individual elderly patient. When developing a treatment plan for older cancer patients, it is essential to consider the functional deficits caused by age-related changes or comorbidity, the remaining compensation mechanisms and the patient's expectations. Cancer treatment has to be adapted to the individual needs of elderly patients. As the number of cancer patients is rising in all areas of medical practice, a close collaboration between oncologists and geriatricians will become increasingly important.

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PubMed1995

Predictors of length of stay in a geriatric assessment and rehabilitation unit.

This study aimed to determine predictors of length of stay within a geriatric assessment and rehabilitation unit at Bundoora Extended Care Centre. We conducted a retrospective examination of demographic and medical characteristics of the patients, and the characteristics of admission care programs (assessment, rehabilitation, booked and emergency respite care, and interim care), and determinants and predictors of length of stay. The mean length of stay was 28 days, varying from 12 to 50 days between care programs. Diagnostic category, stream of care and activities of daily living score were the major predictors of length of stay, together accounting for 20 per cent of the variance (R2 = 0.20).

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PubMedDate not supplied

[Social aspects in diagnosis and therapy of very elderly patients. Initial experiences with a newly developed questionnaire within the scope of geriatric assessment].

To evaluate social aspects of elderly patients which are important for diagnosis and therapy within geriatric assessment, a questionnaire was developed and validated. Raters showed a high degree of agreement on the scale, which contains social contacts and support, activities, economic situation, and housing conditions (0.92-0.97; p < 0.05). Compared to the interrater reliability the test-retest reliability was somewhat lower (0.75), but also significant at the 5% level. The internal consistency showed high values between 0.72-0.89. In order to evaluate the validity of the screening test the answers of the patients were compared with the assessment of the therapeutic team. The team had information from a home visit, patients spouse, relatives, neighbors, community nurses and/or general practitioners. There was a significant relationship (p < 0.01) between therapeutic assessment and the scale (r = 0.51). Sensitivity, specificity, and total efficiency also attained sufficiently high values at a cut-off of 16/17 for the complete scale (max. 25 points). The test is easily and quickly performed; its acceptance is high. Social data relevant for treatment and discharge planning can thus be obtained and patients can be identified, for whom a home visit seems to be useful.

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PubMed2003

[Effectiveness of comprehensive geriatric assessment in primary care].

OBJECTIVE: To review and update evidence on the effectiveness of the comprehensive geriatric assessment (CGA) of the elderly in the community environment. DESIGN: Systematic review. DATA SOURCES: MEDLINE (January 1997 to November 2001) and The Cochrane Library, completed with a manual search. SELECTION OF STUDIES: Randomised clinical trials (RCT) to study the effects of a CGA in people over 64 and not in an institution. Trials that assessed mortality, institutionalisation and functional status were included. Those conducted after hospital discharge or not in a community environment were excluded. 133 summaries were reviewed and 16 articles analysed. DATA EXTRACTION: Methodological quality assessed with adapted Jadad scale. A data archive was worked out to collect information on characteristics of the population and the intervention and on the main findings. RESULTS: The quality of the trials was adequate, though they had important methodological differences. Eleven trials found no favourable effects in the result variables studied. Five of the twelve trials which assessed functional status and one of the twelve that evaluated admissions to institutions found some favourable effect. None of the nine studies with mortality data found favourable results. CONCLUSIONS: Evidence for the effectiveness of the CGA for the elderly not in institutions continues to be inconsistent and insufficient. Nevertheless, given the complexity of this intervention, it seems prudent to continue to conduct CGAs of the elderly in the PC environment until such time as further studies clarify the role of these programmes.

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PubMedDate not supplied

Mobility screening as part of a community-based geriatric assessment.

This article provides an overview of the basic components of mobility and encourages home care practitioners to include mobility screening as a part of geriatric assessment. Mobility is viewed as an integrated and interdependent function of physical, mental, emotional, and social capacities, and therefore encourages an interdisciplinary approach to assessment of basic mobility problems and needs. The discussion includes mobility-related operational definitions and measurements, reasons to perform a mobility screen, how to incorporate the components of basic mobility into a geriatric mobility screen, and factors that significantly distinguish in-home assessment from a clinic- or institution-based geriatric mobility assessment.

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PubMed2002

Geriatric assessment--lessons from personal experience.

The aim of this study was to develop a framework for comprehensive specialist geriatric assessment in rural settings. A protocol that used a number of standardised assessment instruments was developed and applied routinely. Data from two rural centres in South Australia over a two-year period were analysed. Study results offer important insights and have implications for clinical practice and policy development. They particularly reinforce the need for a comprehensive assessment irrespective of the information received from the referrer.

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PubMedDate not supplied

Comprehensive geriatric assessment.

BACKGROUND: As an adjunct to the general and cancer-specific clinical and diagnostic examinations, comprehensive geriatric assessment (CGA) is an integral tool that examines factors affecting the course of disease and the outcome of treatment. The principal areas of focus of the CGA include the patient's functional, physical, mental, emotional, pharmacotherapeutic, and socioeconomic status. METHODS: We describe the role of CGA in the identification and management of frail elderly patients. The literature is reviewed to outline the components, programmatic configurations, and process of CGA. Information from systematic reviews of clinical trials of different CGA program models is summarized, and observations relating to the research agenda concerning the applicability of CGA and CGA principles to management of older cancer patients are discussed. RESULTS: Since age itself is not predictive of outcome in an elderly cancer patient, the CGA helps to distinguish between elderly patients who should be treated with intent to cure and those who will benefit from clinical oncologic and geriatric co-management. CONCLUSIONS: A more accurate evaluation of prognostic indicators that includes CGA parameters could lead to a higher number of older patients being included in clinical cancer trials and being treated effectively in practice. It would also identify those who would benefit from gero-oncologic CGA and ongoing management aimed at maintaining function and community living.

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PubMed2007

A pilot study of the vulnerable elders survey-13 compared with the comprehensive geriatric assessment for identifying disability in older patients with prostate cancer who receive androgen ablation.

BACKGROUND: Impairments in geriatric domains adversely affect health outcomes of the elderly. The Comprehensive Geriatric Assessment (CGA) is a key component of the treatment approach for older cancer patients, but it is time consuming. In this pilot study, the authors evaluated the validity of a brief, functionally based screening tool, the Vulnerable Elders Survey-13 (VES-13), for identifying older patients with prostate cancer (PCa) with impairment in the oncology clinic setting. METHODS: Patients with PCa aged >or=70 years who actively were receiving androgen ablation treatment and who were followed within the clinics at the University of Chicago were eligible. Patients self-completed the VES-13 and CGA instruments and repeated the VES-13 1 month later. Physical performance and cognitive assessments were administered by a research assistant. RESULTS: Of 50 participating patients, 50% were identified as impaired by the VES-13 (score >or=3). Sixty percent of patients scored as impaired on >or=2 tests within the CGA, exhibiting deficits in multiple domains. The reliability of the VES-13 (Pearson correlation coefficient) was 0.92. The cut-off score of 3 on the VES-13 had 72.7% sensitivity and 85.7% specificity for CGA deficits and was highly predictive for identifying impairment (area under the receiver operating characteristic curve, 0.90). Patients who had mean VES-13 scores >or=3 performed significantly worse on evaluations of activities of daily living (P = .001), physical performance (P = .002), comorbidity (P = .004), and cognitive impairment (P = .003). CONCLUSIONS: Functional and cognitive impairments are highly prevalent among older patients with PCa who receive androgen ablation in oncology clinics. The current results indicated that the brief VES-13 performed nearly as well as a conventional CGA in detecting geriatric impairment in this population.

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PubMed1994

Rationale and design of a multi-center randomized trial of comprehensive geriatric assessment consultation for hospitalized patients in an HMO.

OBJECTIVE: To describe the evaluation of an interdisciplinary comprehensive geriatric assessment (CGA) consultation program for targeted hospitalized patients. DESIGN: Multi-center randomized clinical trial (RCT) at four hospitals where patients were randomly assigned to CGA consultation or usual care by the attending physician, and a non-equivalent control group (NCG) at two hospitals. SETTING: Six hospitals in a multi-specialty group practice model health maintenance organization (HMO). PARTICIPANTS: 3593 patients age 65 years or older meeting at least one of 13 inclusionary criteria at admission. INTERVENTION: Screening by hospital staff and standardized CGA consultation conducted by a nurse practitioner, social worker, and geriatrician at the four RCT hospitals. MAIN OUTCOME MEASURES: Functional and health status, mortality, rehospitalization, and cost-effectiveness of the CGA program at 1 year post-randomization; validation of targeting (inclusionary) criteria that identify subgroups of patients deriving benefit from CGA; and physician contamination (learning from CGA and changing treatment provided to control patients). CONCLUSIONS: A number of methodological issues need to be considered when conducting effectiveness trials of CGA. The concurrent design of a multi-center RCT, coupled with the NCG to determine physician contamination, is an innovative approach intended to determine more precisely the cost-effectiveness of CGA for frail hospitalized elderly persons. The large and heterogeneous patient population and the broad array of inclusionary criteria will permit the evaluation of the benefit of CGA for subgroups. All these features are intended to enhance the generalizability of study results.

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PubMed1996

Looking inside the black box of comprehensive geriatric assessment: a classification system for problems, recommendations, and implementation strategies.

OBJECTIVE: To develop and test the inter-rater reliability of a coding system for geriatric problems identified through Comprehensive Geriatric Assessment (CGA) of hospitalized older persons, recommendations generated by the assessment, and implementation strategies for these recommendations. DESIGN: Validation study. SETTING: A health maintenance organization and a geriatrics academic program. PARTICIPANTS: A total of 49 hospitalized older persons, who met at least 1 of 13 inclusionary "targeting" criteria, two geriatricians, and one social worker who coded forms. MEASUREMENTS: Standardized coding of CGA consultation sheets into (1) geriatric problems identified, (2) recommendations, and (3) implementation strategies; inter-rater reliability testing of coding system using two physicians and a social worker. RESULTS: On average, each assessed patient had 4.8 recommendations. The largest percentages of recommendations were for non-physician referrals (18.2%), advance directives (13.4%), medication adjustments (11.5%), diagnostic evaluation/monitoring (11.5%), and community services (10.9%). The proportions of agreement between raters in coding problems ranged from 0.77 to 0.90, in coding recommendations from 0.69 to 0.86, and in coding implementation strategies from 0.68 to 0.83. CONCLUSION: A classification system for measuring some components of the process of care of CGA has satisfactory inter-rater reliability, can be adapted for other settings, and may provide valuable insight into determining which components of CGA confer health benefits.

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