Geriatric

Organization Design for Geriatrics: An Evidence Based Approach
Regional Geriatric Programs of Ontario July
DR. DAVID LE WIS, EDITOR
The views expressed in this document are the authors and do not necessarily reflect the opinions of the Regional Geriatric Programs of Ontario
Contents
ContributingAuthors 1
Introduction
1. 2. AboutThisHandbook DavidLewis AHistoryofSpecializedGeriatricServices RoryFisherandBarryGoldlist
PartA:InpatientServices
3. 4. 5. 6. 7.

12 13
InpatientConsults DavidLewis CliniciansPerspectivebyAnneCrowe GeriatricAssessmentandRehabilitationUnits JennieWells,MichaelBorrie,andPaulStolee CliniciansPerspectivebyChristopherFrank EvidenceBasedBestPracticesforCommonClinicalProblemsinGeriatric Rehabilitation JennieWells,MichaelBorrie,andPaulStolee
31
59
PartB:OutpatientServices
GeriatricPrimaryCare DavidLewis CliniciansPerspectivebyPatriciaWoo GeriatricDayHospital DavidLewisandMarleneAwad CliniciansPerspectivebyIreneTurpie
73 74
88
8.
SpecializedGeriatricOutreachServices:AnOverviewoftheRandomized ControlledTrials DavidRyanandJacquelinEsbaugh CliniciansPerspectivebyBarbaraLiu,MD
99
Conclusion
9.

112
SettinganAgendaforFutureResearchinDeliveryofSpecializedGeriatric MedicineServices WilliamMolloyandDavidLewis
ContributingAuthors
MarleneAwad,BSc,MHA Director,Administration&InformationManagement RegionalGeriatricProgramofToronto Toronto,Ontario MichaelJ.Borrie,MB,ChB Chair,DivisionofGeriatricmedicine,DepartmentofMedicine,FacultyofMedicine, UniversityofWesternOntario ParkwoodHospital,StJoseph'sHealthCare,London,OntarioAging,Rehabilitationand GeriatricCareProgram,LawsonHealthResearchInstitute ProgramDirector,SouthWesternOntarioRegionalGeriatricProgram London,Ontario AnneRosemaryCrowe,BSc,MD,FCFP,MBA Familyphysicianandrehabilitationhospitalist MedicalDirectorofComplexContinuingCareandRehabilitation,GrandRiverHospital CentralRegionalGeriatricProgram Kitchener,Ontario JacquelinEsbaugh,MA St.JosephsHealthCareLondon Aging,RehabilitationandGeriatricCareResearchCentreoftheLawsonHealthResearch Institute SouthWesternOntarioRegionalGeriatricProgram London,Ontario RoryFisherMB,FRCP(Ed)(C) ProfessorEmeritus,DepartmentofMedicine,UniversityofToronto DivisionofGeriatrics,SunnybrookHealthScienceCentre RegionalGeriatricProgramofToronto Toronto,Ontario ChrisFrankMD,FCFP AssociateProfessor,DepartmentofMedicine Queen'sUniversity,Kingston ProvidenceCareCentre,StMary'softheLakeHospital RegionalGeriatricProgramofKingston Kingston,Ontario
BarryGoldlist,MD,FRCPC,FACP,AGSF ProfessorofMedicineandDirector,GeriatricMedicine,UniversityofToronto MedicalDirector,GeriatricRehabilitation,TorontoRehabilitationInstitute StaffPhysician,UniversityHealthNetwork/MountSinai,DepartmentofMedicine RegionalGeriatricProgramofToronto Toronto,Ontario DavidLewis,BA,MA,PhD AssistantClinicalProfessorFamilyMedicineMcMasterUniversity SeniorPolicyAdviserOntarioMinistryofEducation FormerlyoftheCentralRegionalGeriatricProgram Hamilton,Ontario BarbaraLiu,MD,FRCPC AssociateProfessor,DepartmentofMedicine,FacultyofMedicine,UniversityofToronto ExecutiveDirector,RegionalGeriatricProgramofToronto Toronto,Ontario D.WilliamMolloy,MB,MRCP(I),FRCPInt.MedandGeriatrics. ProfessorofMedicine,St.PetersMcMasterChairinAging,McMasterUniversity CentralRegionalGeriatricProgram Hamilton,Ontario DavidPatrickRyan,Ph.D.,C.Psych. DirectorofEducation&KnowledgeProcesses RegionalGeriatricProgramofToronto AssistantProfessor,FacultyofMedicine,UniversityofToronto RegionalGeriatricProgramofToronto Toronto,Ontario PaulStolee,PhD AssociateProfessorandGrahamTrustResearchChairinHealthInformatics DepartmentofHealthStudiesandGerontology UniversityofWaterloo,Waterloo,Ontario FormerlyoftheSouthWesternOntarioRegionalGeriatricProgram London,Ontario IreneTurpie,MB,ChB,MSc,FRCP(C),FRCP(Glas) ProfessorEmerita,GeriatricMedicine,McMasterUniversity CentralRegionalGeriatricProgram Hamilton,Ontario

JennieL.Wells,MD,MSc,FACP,FRCPC AssociateScientist,LawsonResearchInstitute AssociateProfessorofMedicine DepartmentofMedicine,DivisionofGeriatricMedicine UniversityofWesternOntarioSchulichSchoolofMedicine SouthWesternOntarioRegionalGeriatricProgram London,Ontario TriciaK.W.Woo,MD,MSc,FRCPC AssistantProfessor DepartmentofMedicine,St.PetersHospitalMcMasterUniversity CentralRegionalGeriatricProgram Hamilton,Ontario

AboutThisHandbook
Chapter1
AboutThisHandbook
DavidLewis
ExecutiveSummary Thishandbookisaimedatprovidinganevidencebasedapproachtoservicedelivery fortheelderlypatientincorespecializedgeriatricservices. Coreinpatientservicesincludegeriatricrehabilitation,assessmentandconsultation services.Coreoutpatientprogramsincludegeriatricoutreach,outpatientclinics andgeriatricdayhospitals.Inaddition,thereareanumberofconditionspecific units,focusedorinnovativeareasofcare. Eachchapterfollowsthesamebroadlayout: anexecutivesummary adefinitionanddescriptionoftheservice adescriptionoftheinformationsourcesused therecommendationsfromtheliterature,alongwiththeevidencelevelforeach. Somechaptersalsocontaintoolsforclinicalassessment. Introduction Ahospitaldirector,mandatedtodesignanewgeriatricassessmentunitonalimited budget,wonderswhatstaffingmixisrequired.Doestheunitneedapsychiatrist?Social worker?Recreationtherapist?Ifthereisonlytheminimumnumberofstaff,willpatients beatrisk? Themedicaldirectorofanoutreachservicefortheelderlyneedstoknowwhetherthe servicecouldberedesignedtoincreasethenumberofpatientswhoareseen.Ifthatis done,willthequalityofcarebeaffected? DecisionSupportServicepersonnelatageneralinternalmedicinecareunithavefound thatelderlypatientshavetwicetheusuallengthofstay,anditisincreasing.Theyare arguingforanacutecarefortheelderlyunittoreduceelderlypatientslengthsofstay. ButthehospitalsCEOnotesthateveryefforttoreduceelderslengthofstayhasmerely resultedinincreasedreadmissions.Canlengthsofstaybereducedbereducedwithout increasingadmissions.
OrganizationDesignforGeriatrics:AnEvidenceBasedApproach 1
AboutThisHandbook
Background Thenumberofolderadultsisincreasingaroundtheworld.Thecostsofproviding healthcaretothisportionofthepopulationcontinuestoincrease.Olderadultsrequirea varietyofdifferentservicesdependingontheirneeds,resourcesandlocation.Someof thesearespecializedgeriatricservices(SGS)thatincludebothdirectservicesprovidedby geriatriciansand/orgeriatricpsychiatristsandservicesprovidedinaffiliationwithoneof thesemedicalspecialists.Coreclinicalareasincludeinpatientprogramslikegeriatric rehabilitation,assessmentunitsandconsultationservices.Outpatientprogramsinclude geriatricoutreach,outpatientclinicsandgeriatricdayhospitals.Eligibilitycriteriavaryand theseservicesareprovidedinawidevarietyofsettingssuchasacutecare,community, clinicsandlongtermcare.Assessmentprocessesandtheprovisionofcaretypicallyarenot standardized. ThereareforcesatworkinOntarioandelsewherethatmilitateinfavourofmore systematicprovisionofSGS.Forexample,akeychallengetoanyhealthserviceplanning concernedwiththeelderlyistheongoingdifficultyinrecruitmentandretentionof geriatricians,geriatricpsychiatristsandalliedhealthspecialists(Hogan,2001).Shortagesin alltheseareas,alongwithhistoricimbalancesinOntario,atleastinwhereSGScan locate,leadtodifficultiesinensuringequitableaccessbythoseinneed. PlannedandexistingSGSmustalsopaycloseattentiontogrowingdemandsfor accountabilityortransparency.TheRomanowCommissionReportentitledBuildingon Values:TheFutureofHealthCareinCanadacontainednofewerthan33referencestothis theme(CommissionontheFutureofCanada,2002).TheCommissionnoted: Canadiansaretheshareholdersofthepublichealthcaresystem.Theyownitandarethe solereasonthehealthcaresystemexists.Yetdespitethis,Canadiansareoftenleftout inthecold,expectedtoblindlyacceptassertionasfactandtoldtosimplytrust governmentsandproviderstodothejob.Theydeserveaccesstothefacts.Canadians nolongeracceptbeingtoldthingsareorwillgetbetter;theywanttoseetheproof. Theyhavearighttoknowwhatishappeningwithwaitlists;whatishappeningwith healthcarebudgets,hospitalbeds,doctors,andnurses,andwhetherthegapsinhome andcommunitycareservicesarebeingclosed;whetherthenumberofdiagnostic machinesandtestsisadequate;andwhethertreatmentoutcomesareimproving(p. 20). Thishandbookisaimedatcollatingsomeofthatevidence.Inaneraofconstrained resources,wecannolongeraffordtoengageinactivitieswhichareineffectiveorinefficient. Andinanageofaccountability,wecannotaskourstakeholderstofundserviceswhose efficacyandreturnoninvestmentarenotclear. Agenerationago,theprovinceofOntariodevelopedaplanforacomprehensivesystemof healthservicesfortheelderly(ANewAGEnda;OntarioMinistryofHealthandLongTerm Care,1986).Partoftheplanwastousetheexpertisedevelopedbytheacademichealth sciencescentrestohelpimprovethequalityofgeriatricservicesprovidedbyOntario'sacute andchronichospitals.Thus,theMinistryofHealthestablishedregionalgeriatricprogramsin theprovince'sfiveacademichealthsciencescentres.Theseweredefinedas:A
AboutThisHandbook
comprehensive,coordinatedsystemofhealthservicesfortheelderlywithinaregion[with theobjectiveof]assistingtheelderlytoliveindependentlyintheirowncommunities, therebypreventingunnecessaryandinappropriateinstitutionalization.Tofurtherthat objective,DrD.W.Molloy,ageriatricianandchairoftheRegionalGeriatricsProgramcentral (RGPc,locatedinHamilton)suggestedaguidetobestpracticesinthedeliveryofservicesto theelderly.TheRGPcSteeringCommitteeendorsedtheidea,andsotheRGPsofOntario determinedtodevelopapracticemanualontheorganizationofallSGS.Thisistobea handbookforadministrators,managersandplannersofSGSprogramsonhowtoorganize coreservices,includingstaffingrequirements,assessmenttools,evaluationstrategies,and soon.ItistobuildonthecombinedresearchandevaluationexpertiseofthefiveRGPs,and isintendedtoidentifyareaswhereresearchsupportsagivenstrategy,alongwithgapsin theevidence. Thishandbookistheresultofthatplan.Itisintendedto: ProduceguidelinesonhoweffectivecoreSGScouldbeconstituted.Thatis,to gathertogethertheevidencesupportedelementsofeachgeriatricservice. Buildlocalcapacity.Usingthishandbook,plannersandproviderscanincrease theirknowledgeofwhathasbeendemonstratedtobeeffectiveinother settings. IntroduceasetofstandardstoSGSservicedelivery.Thisdoesnotmeanthat allSGSservicesmustconformtoaonesizefitsallmodel,forthatwould eliminateallinnovation.Rather,itmeansthatserviceswillbeabletomakea consciousdecisionaboutwhethertodepartfromthebeatenpath. Identifyareaswhereresearchisneeded.Therearesubstantialgaps. Provideanexpertresourceforhealthservicesmanagersandadministrators. Reduceredundantorineffectiveeffort.Ultimately,suchimprovements shouldhavetheeffectofreducingcostsperpatient. Inhealthservicesresearch,therehavebeensystematicreviewsofcomprehensive geriatricassessment,geriatricdayhospitals,inpatientgeriatricconsultationservices,of inpatientgeriatricrehabilitationandoutpatientcare.Thus,itisoftenpossibletoadducethe screening,assessment,staffing,treatmentand/orfollowupprocessesthatmaximize outcomes,effectivenessandefficiencyinthesesettings. TheobjectiveofthisexerciseistoidentifyanddescribecomponentsofSGSthathave beendemonstratedtobeeffective.Basedonthisinformation,weprovideadministrators andclinicianswithevidencebasedrecommendationsregardingprotocols,screeningcriteria, assessment,treatment,followupstrategies,andteammakeup.Isolatingthoseactivities thathavebeendemonstratedtoenhancethequalityofgeriatricoutpatientcarewillhave particularvalueforthosewhoneedtochooseandoperationalizemodelsofservice. Ourintendedaudienceincludesstudents,administratorsormanagersincluding medicaldirectors,alongwithplanners,cliniciansresponsibleforprogramdesign,andthe like.Wehopethehandbookwillbeusefultodecisionmakerswhoareinvolvedinthe planningandexecutionofnewgeriatricsservices,alongwiththosewhomaywishto reconfigureanexistingSGS.
AboutThisHandbook
Thehandbookisaimedattheprogramorservicelevel;itdoesnotinclude informationonstructuralfactorssuchashospitalgovernanceorhowtoorganize communitycare.Weoffernoadviceonneedsassessment,becausewepresumethatthe needfortheservicehasalreadybeenestablished.Noristhisareplacementforclinical manualsorskills:thereisnoinformationonmedications,forexample. DesignoftheWork Eachchapterisorganizedaccordingtoaflowofpatientsfromeligibility/targeting, throughscreening,assessment,treatment,dischargeand/orfollowup,alongwithstaffing. Ineachinstance,ourconcerniswiththoseprocessesthatdemonstrablymaximizethe desiredoutcomes,effectivenessandefficiencyinthesettingunderdiscussion.Moreover, eachchapterfollowsthesamebroadlayout: Anexecutivesummarysectionwhichproducesadigestofthechapterinformation foruseasaquickanddirtymanual. Adefinitionanddescriptionoftheservice,programorspecialtytobeaddressedin thechapter.Thisincludesbothwhattheserviceisandwhatitisnot.Asalready noted,realworldservicesvaryenormously,andmaynotusethesamenames employedherein. Adescriptionoftheinformationsourceswhichwereaccessedandofthesearch strategiesused.Wherepossible,weuseCochranedata,metaanalyses,and structuredreviews(Oxman,1994;Sachs,Berrier,Reitman,AnconaBerk,&Chalmers, 1987).Otherwise,weuserandomizedtrialsorotherhighqualityresearchcomparing specializedgeriatricoutpatientserviceswithalternativeformsofcare(Moheretal., 1995).Inaddition,weconsidertheweightoftheevidence,thatis,thenumberof researcharticleswhichconsistentlysupportagivenapproach.Gapsintheavailable informationarealsodescribed.Wherethereisnoevidence,orwheretheevidence thatexistsisoflesserquality,wesometimesmakesuggestionsbasedonlocal experience. Information,intextandtabularform,ontherecommendationsfromtheliterature, alongwiththeevidencelevel(seeTable1.1)whichsupportseachrecommendation. Wherepossible,asetofrecommended,oratleastacceptable,toolsforclinical assessmentandpatientevaluationarepresented.Ourminimumcriteriaforeachof theseisthattheybevalidated,availablefreeoratfairlylowcost,andinvolvelittle burdentopatientsorclinicians.Inaddition,werecommendthat,insofarasitis possible,thesetoolsshouldbeuseableinavarietyofclinicalsettingsinorderto smoothpatienttransitionsacrossthecontinuumofcare. LevelsofEvidenceinthisWork Bandolier,thejournalonusingevidencebasedmedicinetechniques,describes evidencebasedmedicineas: Theconscientious,explicitandjudicioususeofcurrentbestevidenceinmaking decisionsaboutthecareofindividualpatients.Thepracticeofevidencebasedmedicinemeans
AboutThisHandbook
integratingindividualclinicalexpertisewiththebestavailableexternalclinicalevidencefrom systematicresearch.Evidencebasedmedicinedoesnotmean"cookbook"medicine,orthe unthinkinguseofguidelines.Itdoesimplythatevidenceshouldbereasonablyreadilyavailable inaneasilyunderstoodanduseableformtoprovideadviceaboutparticulartreatmentsor diseasesforhealthcareprofessionalsandconsumers. 1 Evidencebasedhealthcareextendstheapplicationoftheprinciplesofevidencebased medicinetoallprofessionsassociatedwithhealthcare,includingpurchasingand management.Usually,theevidencebeingusediscategorizedbyquality.Thereisa varietyofsuchclassifications,andtheyhavegrownincreasinglyelaborateovertime.Oneof theseispresentedinTable1.1;asimplerversionfromPattersonandcolleagues(1999)is presentedinChapter4(Table4.1).OnenotabledifferenceisthatPattersonandcolleagues gradeevidencefromatleastonerandomizedcontrolledtrialatLevelI.Wemightnote thatifevidenceispresentedfromonlyonetrial,ofanyquality,thenthereisnowayto detectwhetherthatevidencewasinerror.Injurisprudence,itiscommontoseek corroboration. Table1.1:RecommendationGradesandEvidenceLevels Gradeof recommendation A 1b 1c 2a B 2b 2c C D E 3a 3b 4 5 Levelof Evidence 1a
Methodology Systematicreview(withhomogeneity)ofrandomized controlledtrials Individualrandomizedcontrolledtrials(withnarrow ConfidenceInterval) Allornonestudies Systematicreview(withhomogeneity)ofcohort studies Individualcohortstudy(includinglowquality randomizedcontrolledtrials;e.g.,<80%followup) "Outcomes"Research;Ecologicalstudies Systematicreview(withhomogeneity)ofcasecontrol studies Individualcasecontrolstudy Caseseries(andpoorqualitycohortandcasecontrol studies) Expertopinionwithoutexplicitcriticalappraisal,or basedonphysiology,benchresearchor"first principles"
Adaptedfrom:http://www.eboncall.org/content/levels.html
1 Bandolierejournal.Retrievedfrom:http://www.jr2.ox.ac.uk/bandolier/booth/glossary/EBM.html. OrganizationDesignforGeriatrics:AnEvidenceBasedApproach 5
AboutThisHandbook
IfItAintBroke,DontFixIt Whiletherearemanyadvantagestoanevidencebasedapproachtoservicedesign, thereareafewdisadvantagesaswell.Normally,evidencereferstoresearchstudies. Healthresearchisoftendesignedtoinvestigatethemeritsofprocedures,interventions,or drugs,ratherthantheorganizationofhealthservice.Itfollowsthatthereisapaucityofhigh qualityevidence,whetherfororagainstparticularmechanismsfortheprovisionofhealth caretotheelderly. ForthisHandbook,theabsenceofsuchresearchcarriesseveralconsequences: Insomecases,itisdifficulttodistinguishwhatis(andisnot)encompassedbya particularlabel.Forexample,istheGeriatricRehabilitationUnitatHospitalX differentfromtheGeriatricAssessmentUnitatHospitalY?How? Inmanychapters,therearelargegapsinformsoforganizationwhichhavebeen thesubjectofanypublishedresearchatall.Someauthorsbridgethesegapswith relianceongreyliteratureoranecdote. Asaresult,individualformsofSGSservicemaynotbedescribedinthis Handbook.ThisisalsotrueofunitslikeAcuteCarefortheElderly(ACE)units whichhavebeenthesubjectofsomestudy,butarenotcoreSGS. Ironically,weareawareofnoresearchevidencesupportingtheuseofschemes(likethatin Table1.1)fororganizingevidence.Thestatureofthepersonswhoproducedthemisvery high,andtheirexpertiseisundeniable.Inotherwords,recommendationsforuseofTable1.1 are,atbest,LevelD(expertopinion).Thereisanotherschoolofthoughtthatstresses multimethodortriangulatedapproachesassuperiortoanyone(BrewerandHunter,2005). Withsomeexceptions,theliteratureonevidencebasedgeriatricsorganizationis simplynotverywelldeveloped.Hence,wecandistinguishbetweenonly3levelsof evidence: Highqualitysystematicliteraturereviews,metaanalyses,randomizedcontrolled trials,orotherhighqualitytrials(suchasquasiexperimentaldesigns) Lowerqualityresearchtrials Allotherevidence ThisHandbookisintendedasaguidetobestpracticeinorganization.However,therecould beformsoforganizationwhichworkquitewellbutarenotdescribedherein.Iftheywork, andthereisevidencethattheydo,thenpleasecontactanyoftheauthorsc/oinfo@rgpc.ca
AboutThisHandbook
References CommissionontheFutureofHealthCareinCanada.(2002)BuildingonValues:TheFutureof HealthCareinCanadaFinalReport.Ottawa:CommissionontheFutureofHealth CareinCanada. Hogan,B.(2001).HumanResourcesTrainingandGeriatrics.GeriatricsToday:Journalofthe CanadianGeriatricSociety,4,710. Moher,D.,Jadad,A.R.,Nichol,G.,Penman,M.,Tugwell,P.,&WalshS.(1995).Assessingthe qualityofrandomizedcontrolledtrials:anannotatedbibliographyofscalesand checklists.ControlledClinicalTrials,16(1),6273. OntarioMinistryofHealth.(1986).ANewAGEnda,HealthandSocialServiceStrategiesfor OntariosSeniors.Toronto,ON:QueensPrinter. Oxman,A.D.(1994).SectionVI:Preparingandmaintainingsystematicreviews.Cochrane CollaborationHandbook.Oxford:CochraneCollaboration. Patterson,C.J.,Gauthier,S.,Bergman,H.,Cohen,C.A.,Feighther,J.W.,Feldman,H.,etal. (1999).Therecognition,assessmentandmanagementofdementingdisorders: ConclusionsfortheCanadianConsensusConferenceonDementia.CanadianMedical AssociationJournal,160(12),115. Sacks,H.S.,Berrier,J.,Reitman,D.,AnconaBerk,V.A.,&Chalmers,T.C.(1987).Meta analysisofrandomizedcontrolledtrials.NewEnglandJournalofMedicine,316(8),450 5.
OrganizationDesignforGeriatrics:AnEvidenceBasedApproach
HistoryofGeriatrics
Chapter2
HistoryofGeriatrics
RoryFisherandBarryGoldlist
TheFrenchphysicianCharcot(1881)wasthefirsttoadvocateforaspecialtyof geriatricmedicineinhislectureseriesonmedicineofoldage,whichweretranslatedand publishedinEnglishin1881(Charcot,Hunt,&Loomis,1881).Thesearousedscientificinterest inthefield.ThetermgeriatricscomesfromtwoGreekwords;iatrosahealerand gerosanoldman,andwascoinedbyIgnatzL.Nascher(1909),aViennesebornimmigrant totheUnitedStates.InthenextfiveyearsNascherpublished30articlesinthefield,along withatextbookcalledGeriatrics:TheDiseasesofOldAgeandtheirTreatmentin1914 (Clarfield,2001).Thistextbookwaswellreceived,withareviewintheCanadianMedical AssociationJournalstatingthat,Dr.Nascherhasmadethesubjecthisownandhasnow writtenamostinterestingandvaluablebookbesides.Healsoconsideredtheneedfora separatespecialty,usedtheanalogyofpaediatrics,andsuggestedthatgeriatricsshouldbe consideredinasimilarfashion(Barton,&Mulley,2003).ThoughNaschersworkprovideda stimulusfordevelopmentofresearchonagingandthecareoftheelderly,thedevelopment oftheclinicalspecialtyoccurredintheUnitedKingdom,muchinfluencedbytheintroduction oftheNationalHealthSystem(NHS)aftertheendoftheSecondWorldWar. IfNascherwasthefatherofgeriatrics,theBritishphysicianMarjoryWarrenwasits mother(Grimley,1997).Shetookaninterestinthecareoftheelderly,unusualforthetime, andwasamajorforceinpioneeringcareoftheelderly.SheworkedattheWestMiddlesex Hospital,whichin1935tookoveranearbyworkhousewith714beds.Sheassessedevery patientfromtheoldworkhouse,madeappropriatediagnoses,andinstitutedtreatmentand rehabilitationwhereappropriate.Inamajorchangeinapproach,dischargeswereplanned whenfeasible.Environmentalchangeswereinstituted,andpatientswereencouragedtobe mobile.Asaresultofherwork,shewasabletoreducethenumberofchronicbedsto240 andgavetheunwantedbedstochestphysiciansforthetreatmentoftuberculosis(Barton, 2003).Shewasanadvocateforaspecialtyofgeriatricmedicine,forgeriatricunitsinacute hospitals,andfortheeducationofmedicalstudentsaboutcareoftheelderly(Warren,1943; Warren,1946).Asaresultofherworkandthatofotherpioneers,thefirstgeriatric consultantswereappointedintheUKwiththeintroductionoftheNHSin1948. Geriatriciansinitiallytookoverresponsibilityforpatientsintheworkhousesand municipalhospitals,whichhadbecometheresponsibilityoftheNHS.Herethey concentratedonimprovingboththecareandtheenvironmentforpatientsandthey introducedthecomprehensiveassessmentandthemultidisciplinaryapproachtocarethat arethehallmarksofthespecialty.Averyvaluablelinktothecommunitywasdeveloped throughtheestablishmentofgeriatricdayhospitals,firstintroducedbyLionelCosin(1954)
HistoryofGeriatrics inOxfordinthe1950s.Asthevalueofgeriatricservicesbecameestablished,geriatricians becamemoreinvolvedintheacutecareofpatientsingeneralhospitals.Later,theconcept ofacloseclinicalrelationshipbetweengeriatricsandorthopaedicswasinstitutedinHastings (Devas,1974;Irvine,1983).ThefirstchairofgeriatricmedicinewasestablishedinGlasgowin 1965(Wykes,2001).Geriatricservicesgraduallyevolvedintothreemodels.Thefirstmodel wastraditional,orneedsbased,wheregeriatricianstookselectedreferralsfromother consultantsforrehabilitation,or,ifappropriate,placementinlongtermcare.Thesecond modelwasagedefinedcare,basedonanarbitraryagecutoff,usually75yearsandover,and thethirdwasofgeriatricservicesfullyintegratedwithgeneralmedicine(Barton,2003).The specialtyhasgrownsubstantiallyovertheyearsand,by2003,therewere894consultant geriatriciansintheUnitedKingdom(HouseofCommonsHansard,2004).Thecareofthe elderlyhasalsobeenaidedbytheintroductionofaNationalServiceFrameworkforOlder People(DepartmentofHealth,2001).Thisframeworksetsoutevidencebasedstandards, whichaddresssuchissuesasagediscrimination,patientcentredcare,stroke,falls,mental healthinolderpeople,andpromotionofhealthandactivelifeinolderage. InCanada,thedevelopmentofgeriatricsfoundafertilegroundinhospitalsrunby VeteransAffairsCanada,sincethisDepartmenthadaresponsibilityforthecomprehensive careofentitledveteransbeforetheintroductionofanationwidehealthcaresystem.Inthe 1960s,therewasaneedtofocusoncareoftheelderly,sincetheveteranpopulationfrom theFirstWorldWarwasaging.Thistrendwashelpedbytheexpertiseinrehabilitation developedfromthecareofSecondWorldWarveterans.DeerLodgeinWinnipegwasa leaderinimplementingspecializedgeriatricservicesforveterans,followedbySunnybrookin Torontointhe1970s.Therewerealsoinnovationsmadeduringthefollowingyears,from CampHillinHalifaxintheeast,throughSt.AnnedeBellevueinMontreal,Parkwoodin London,toShaughnessyinBritishColumbia.Thesehospitalshadtheadvantageofa combinedresponsibilityforbothacuteandchroniccare,bringinggeriatricsintotheacute fieldfromthestart.ThehandoveroftheVeteranshospitalstothevariousprovincesallowed thesegeriatricservicestobemadeavailabletothepublicatlarge.Also,sincethetransfers usuallyinvolvedteachinghospitalsandUniversityconnections,itallowedgeriatricstohave afootintheacademicdoor.Theintroductionofuniversalhealthandhospitalinsurance removedfinancialbarrierstotheprovisionofgeriatriccaretothegeneralpublic. Innovationsalsotookplaceinlongtermcarehomeswhichhadreligiousaffiliations suchasBaycrestinToronto,andMaimonidesinMontreal,representingtheJewish community.St.MarysontheLakeinKingston,andProvidenceCentreinToronto,are examplesofsitessupportedbytheCatholiccommunityinOntario,whileSt.PetersHospital inHamiltonwasfoundedbytheAnglicanChurch. TheHomesfortheAgedprograminOntarioappointedaconsultantingeriatricsin 1953,andadecadelateranacutecarewardwasopenedattheTorontoWesternHospitalfor patientsfromtheHomesfortheAged. GeriatricserviceswereveryinfluencedbyBritishmodels,introducedbyCanadian physicians,whohadvisitedandtrainedintheUnitedKingdom,andbygeriatriciansfromthe BritishIsleswhoimmigratedtoCanada.InSaskatoonandOttawa,geriatricserviceswere developedbyprominentBritishgeriatricians,JohnBrocklehurstandJohnDall,whothen returnedtotheUK.
HistoryofGeriatrics ThenumberofgeriatriciansinCanadahasbeenincreasingovertheyears.There were107in1995,andthishadrisento204in2006(CanadianMedicalAssociation,2006).In spiteofthisincrease,thenumbersfallshortofthebenchmarkofonegeriatricianforevery 4000people75yearsandoverendorsedbytheBritishGeriatricSociety(BritishGeriatric Society,1998).TheCanadianHoganstandard(2001)is1.25geriatriciansper10,000 populationaged65orolder,andactualnumbersarefarshortofthatstandardaswell. Recruitmentofnewgeriatriciansalsoremainsanongoingissue. InOntario,ANewAGEnda,HealthandSocialServiceStrategiesforOntariosSeniors wasintroducedbythegovernmentin1986(OntarioMinistryofHealth,1986).Inthis document,thegovernmentannounceditsintentionofintroducingspecializedgeriatric servicesonaregionalbasisthroughouttheProvince.Inthefollowingyear,theMinistryof HealthinOntarioissueditsGuidelinesfortheEstablishmentofRegionalGeriatricPrograms inTeachingHospitals,whichledtothecurrentfiveRegionalGeriatricPrograms(RGPs)in Hamilton,Kingston,London,Ottawa,andToronto.In1995,theRGPspublishedadocument entitled,UnderstandingtheFiveRegionalGeriatricProgramsinOntario,whichdescribed therole,functionsandbenefitsoftheprograms,andoutlinedtheservicecomponentsof geriatricassessmentunits,geriatricrehabilitationunits,consultationteams,outreachteams, dayhospitals,andgeriatricclinics.Sincethattime,theRGPsofOntariohavecontinuedto developservices,reachingouttocommunitiesoutsidetheusuallimitsoftheirteaching hospitalbase.Theyhavealsoactivelyadvocatedforimprovementsincareofthefrail elderly.ThroughtheAcademicDivisionsofGeriatricsattheirUniversities,theyhaveplayed animportantroleinundergraduateandpostgraduateeducation,andhavedevelopedan everincreasingroleinresearchrelatedtocareoftheelderly.Inspiteofthesuccessofthe RGPs,thereremainsaneedtoexpandspecializedgeriatricservicessothatallaging Canadianshavesuitableaccesstoappropriategeriatriccare.
10
HistoryofGeriatrics References Barton,A.,&MulleyG.(2003).HistoryofthedevelopmentofgeriatricmedicineintheUK. PostgraduateMedicalJournal,79,229234. BritishGeriatricSocietyNewsletter.(1998,November).p.21.Archived: http://www.bgsnet.org.uk CanadianMedicalAssociation.(n.d.).StatisticalInformationonCanadianPhysicians. RetrievedMay5,2006,fromhttp://www.cma.ca Charcot,J.M.(1881).Clinicallecturesonsenileandchronicdiseases.London:NewSydenham Society. Charcot,J.M.,Hunt,L.H.,&Loomis,A.L.(1881).Clinicallecturesonthediseasesofoldage. NewYork:WilliamWood. Clarfield,A.M.(2001,July).HistoryofGeriatrics.AnnalsofLongTermCare,9,(7).Retrieved May1,2008,fromhttp://www.annalsoflongtermcare.com/article/838. Cosin,L.(1954).Theplaceofthedayhospitalinthegeriatricunit.ThePractitioner,172,552 559. DepartmentofHealth(2001).NationalServiceFrameworkforOlderPeople.London,UK: StationeryOffice. Devas,M.B.(1974).Geriatricorthopaedics.BritishMedicalJournal,1(5900),190192. GrimleyEvans,J.(1997).Geriatricmedicine:Abriefhistory.BritishMedicalJournal,315,1075 1077. HouseofCommonsHansard.(2004,January5).HouseofCommonsDebatesSession2003 2004WrittenAnswers.RetrievedMay13,2008,from http://www.publications.parliament.uk/pa/cm/cmvol416.htm Hogan,B.(2001).HumanResourcesTrainingandGeriatrics.GeriatricsToday:Journalofthe CanadianGeriatricSociety,4,710. Irvine,R.E.(1983).GeriatricorthopaedicsinHastings:Thecollaborativemanagementof elderlywomenwithfracturedneckofthefemur.AdvancedGeriatricMedicine,1306. Nascher,I.L.(1909).Geriatrics.NewYorkJournalofMedicine,90,358359. OntarioMinistryofHealth.(1986).ANewAGEnda,HealthandSocialServiceStrategiesfor OntariosSeniors.Toronto,ON:QueensPrinter. Warren,M.W.(1943).Careofthechronicsick.Acasefortreatingchronicsickinblocksina generalhospital.BritishMedicalJournal,2,822823. Warren,M.W.(1946).Careofthechronicsick.Lancet,1,841843. Wykes,L.(2001).SirWilliamFergusonAnderson.BritishGeriatricsSociety.September,13. RetrievedMay13,2008fromhttp://www.bgsnet.org.uk/pdf/Sept2001.pdf.

11
PartA:InpatientServices
Inthissection,wereviewinpatientspecializedgeriatricservices(SGS),largelyin acutecare.TheseincludeconsultationservicesinChapter3,alongwithgeriatricassessment units(GAUs),geriatricrehabilitationunits(GRUs)andthecombinationsofthetwo (GARUs)inChapter4.Inaddition,wereviewsomemorespecializedservicessurrounding commonconditionsoftheelderlyinChapter5.JennieWells,MichaelBorrieandPaulStolee reviewawiderangingliteratureinChapters4and5.Inbrief,theysupportcarefulscreening andtargetingsothatpatientsareneithertoowell(sothattheycouldreceiveoutpatient care)nortoosick(sothattheyareunabletobenefitfromSGSinterventions).This combinedwithacomprehensivegeriatricassessment(CGA)andtreatmentusing standardizedtoolsandtechniqueshasbeenshowntobeeffective. Inpatientunitsareamenabletostudybyrandomizedcontrolledtrialinthatthey operateasselfcontainedtotalinstitutions;intheseinstitutions,itispossibleto manipulateandcontrolvariablesinwaysthatarelessavailableinothersettings.Theyare perhapsthebestresearchedelementsofSGS,bythenatureandtraditionsofhealthcare; theauthorsnoteseveralareasthatcouldbenefitfromfurtherresearch. GeriatricsconsultationsareanimportantelementofSGSintermsofthenumbersof patientsseen.Theyareoftenthepreludeadmissiontoageriatricsunit,inthesame institutionoranother.Inothercases,theyareintendedtoassesspatientsreadinessfor discharge,andifready,towhatlivingarrangements. Thiscanhaveanimpactonpatientlengthofstay,whichhasbeenthesubjectof considerableattention.InOntario,thereareextensiveprogramsandincentivestoshorten averagelengthsofstayandthereareanecdotalreportsthatsomestaffarehesitantto requestanSGSconsultbecauseitwillgenerateordersformoretestsandthereforean increasedlengthofstay. ItisdifficulttodetecttheimpactofSGSconsultsonpatients,buttheliteraturethat doesexistsuggests,again,thatcarefultargetingalongwithformalSGSfollowupis effective.

12
InpatientConsults
Chapter3
InpatientConsults
DavidLewis
CliniciansPerspective:AnneCrowe,MD
Theidealgeriatricconsultationisacollaborativeeffortbetweentheattending physician,thepatient,theirfamilycaregivers,andthegeriatricconsultationteam.The outcomeshouldbeadefineddiagnosisand/orproblemlistandanachievabletreatment plan.Consultationsarealsoaneducationalopportunityforrequestingphysicians,whomay havevaryingdegreesofskillingeriatricassessment.Whileroutinegeriatricconsultations havenotbeenproventoimproveoutcomes,thereisnodoubtthat,inselectedpatients, properlyrequestedandconductedconsultationsarebeneficial.Inanycase,giventhe currentshortageofgeriatriciansinCanada,routineconsultationsarehardlyfeasible. Toensurethataconsultationisworthwhile,therequestingphysicianshouldclearly communicatehisorherexpectationstotheconsultant,whetheritistodevelopalistof differentialdiagnosesorproblems;torecommendacourseofinvestigations;toidentifythe correctdiagnosis(es);ortodevelopatreatmentorcareplan.Insomecases,the expectationmaybethattheconsultantprovideasecondopiniontoconfirmthediagnosis andverifythattheplanisappropriate,especiallywhenadiagnosisisdevastatingorthe treatmentisrisky,orwhenthepatientorfamilyareparticularlyanxious.Therequesting physicianshouldalsoensurethatallrelevantinformationismadeavailabletothe consultant.Inaddition,theconsultantsshouldmakehim/herselfawareofthewidercontext withinwhichthepatientexists,sothatrecommendationsareachievablewithinthepatients circumstances.Thebetterthattheserequirementsaremet,thelikelieritisthatthe consultantsrecommendationswillbeimplemented. Thissoundssimple,butgeriatriccareisrarelysimple.Geriatricsinacutecaremustbe viewedinthecontextofthebroadercommunity.Twentyfiveyearsago,virtuallyall patientshadafamilyphysician.Inmostcommunityhospitals,theprimarycarephysician wastheattendingphysicianforallbutsurgicalcases,evenintheintensivecareunit.The familyphysicianusuallyassistedatsurgeryandfollowedthepatientdailyuntildischarge, interactingwiththeconsultantsonaregularbasisandcoordinatingmultipleconsultantsin complexcases.Followupafterdischargewasseamlessastheprimarycarepractitionerhad beeninvolvedateverystepoftheprocess.Todayhowever,inallbutthemostrural hospitals,patientsareattendedbyhospitalistswhoareunlikelytohavemetthem previously,andwhomayneverhavepracticedinthecommunity.Inaddition,increasing numbersofelderlypatientshavenoprimarycarephysician,asfamilyphysiciansretire withoutbeingabletofindareplacementandagingpatientsmovetodistantcommunitiesto beclosertofamily.Acutecarehospitalizationisgenerallyveryshortandthereislittletime
InpatientConsults toevaluateimplementationofthecareplan.Theremaybenofamilymembersclosebyto ensurethatfollowupappointmentsarekept.Outpatientservicesmaybelacking.Home careislimitedandvariesgreatlyfromonecommunitytoanother.Foryoungerpatientswith singlesystemepisodicillnesses,theincreasedskilllevelofthehospitalistmayoutweighany lossofcontinuityofcare.However,forthefrailelderlyorchronicallyillpatient,thelackofa bridgebetweeninpatientcareandthecommunitymaynegatethebenefitsof hospitalization. Asthepopulationagesandmorepeopledevelopchronicillnessesandbecomefrail, thehealthcaresystemwillneedtoaddressthedividebetweenacutecareandthe community.ThereisasevereshortageofprimarycarepractitionersinCanada.Withina publiclyfundedsystemlimitedresourcesshouldbedirectedtowardsthoseingreatestneed. Clearlychronicallyillpatientsandthefrailelderlyaremostinneedofcontinuityofcare. Becausecommunityphysiciansareunabletoaccommodatenewlydischargedpatients,at GrandRiverHospitalwehavedevelopedanursepractitionerrunprimarycareclinicfor chronicallyillandelderlypatientswhoseinpatientoroutpatientencounterrequiresfollow up.Newmodelsofprimarycareforvulnerablepatientsneedtobedevelopedeverywhere inCanada.Forinstance,primarycarereforminitiativesshouldgiveincentivestocommunity primarycareclinicstoacceptthemostneedyofourpopulationondischargefromacute care. Computerizationofhealthrecordsalsohasgreatpotentialtoimprovecontinuityof care,whichtodatehasnotbeenrealized.Duetorationalizationofhospitals,patientsare forcedtoseekcareatmultipleinstitutions,whichdonothavedirectaccesstotherecordsof otherhospitals.Mostfamilyphysiciansrecordsarestillusingpapercharts.Homecare agencieshavelittleaccesstoanyinformation.Ifapatienthasnofamilyphysician,thereis nooneoutsidethehospitalthathasanyrecordofpreviousencounters.Patientsoften cannotrecalldetailsofpastmedicalcare.Theoreticalconcernsaboutbreachesofprivacy havetrumpedtherealitythatlackofinformationandpoorcommunicationcausemedical errorsthatmayresultinsevereharmordeath.Patientswhoaredischargedmaystoptaking themedicationstheywereprescribedinhospital,oraddthenewmedicationstothe prescriptionstheyweretakingpriortohospitalization.Oftenthefamilyphysiciandoesnot receiveatimelydischargesummaryormedicationlist.Forinstance,Irecentlysawafrail, elderlydiabeticpatientinmyofficewhoseGlyburidehadbeenstoppedinhospital.Heleft hisdischargemedicationlistathome.HadInotcalledhispharmacyaboutanunrelated issue,Iwouldnothavelearnedthisinformation,andwouldhavewrittenhimaprescription renewalforGlyburide.Thedischargesummaryarriveddaysafterhisvisit.Itisessentialthat withineachhealthcareregionproperlyaccreditedprofessionalspracticinginhospitalsand inthecommunitybegivenaccesstocompletehealthcarerecords,withpatientconsent. Thiswouldsavemoneybypreventingduplicateconsultationsandinvestigations;reduce hospitalstaybygivinghospitalistsandconsultantsaheadstartinpatientcare;improve patientoutcomes;andreducetheriskofmedicalerrors. Wemuststrivetodevelopacollaborativemodelofgeriatriccarethatspansthe continuumofcare.Aconsultationissupposedtobeabriefencounterwiththepatient.For manysubspecialtiesthisisarealisticexpectation.However,geriatriciansdealwithcomplex poorlydefinedproblemsandmultiplechronicdiagnoses.Medicationsmayneedtobe
InpatientConsults titratedoverweeksormonths.Drugdruginteractionsmaysurface.Sideeffectsmaybe intolerable.Newproblemsemergecontinually.Newmodelsofcollaborativecarearebeing developedforpatientswithavarietyofwithchronicmedicalandpsychiatricconditionsto improveaccesstoscarcespecialistresources.Theseinvolvelongtermrelationships betweenaconsultationteamandcommunitycaregivers.Becausetheconsultantismore readilyavailable,itishopedthatprimarycarepractitionerswillbebetterabletomanage complexpatientsandthatqualityofpatientcarewillbeenhanced.Byincreasingthe likelihoodthatconsultantrecommendationswillbeimplementedandmodified appropriatelyovertime,hospitalizationandpermanentinstitutionalizationmaybe prevented.Existingcollaborativemodelsshouldbeadaptedtogeriatriccareand researchedtoensurethattheuseofgeriatricianresourcesisefficientandeffective,both withintheacutecaresettingandinthecommunity. ExecutiveSummary Functionaldeclineoccursin25%to60%ofolderpersonsafterenteringacutecare. Evidencehasshownthatcomprehensivegeriatricassessmentsareeffectiveinimproving survivalratesandreducingannualmedicalcostsinacutecaresettingsandnursinghomes. Geriatricconsultsinvolveageriatricianandnurseandoftenotheralliedhealth professionalstoassessthephysical,emotionalandcognitivefunctionofanolderpatient. Thetypesandcomprehensivenessofassessmentsarevariable. Aswithanyconsultants,therecommendationsspecializedgeriatricservices consultantsmakemayormaynotbefollowed.Thisconsultationcantakeplaceinavariety ofinpatientoroutpatientsettings;thischapterisfocusedonacutecareinpatients. Geriatricconsultscanbeusedtoproviderecommendationsforcare,managecurrentcare problems,assessapatientsreadinessfortransfer(toaspecializedgeriatricservice,orto rehabilitation),orplanforpostdischargecare.Geriatricconsultsoftenrevealcognitive impairmentinpatientsthatwerepreviouslyundiagnosed. Themosteffectivecomprehensivegeriatricassessmentsarethosethattarget patientsmorelikelytobenefitfromgeriatricinterventionsuchasthosewithremediable disabilities,olderpatients(age75andover)andthosefacingatransition.Followup servicesarealsoanintegralcomponenttosuccessfulgeriatricassessment.Thereis conflictingevidenceastowhethergeriatricconsultsimprovefunctionormortality,butthe evidenceseemstosuggestthatcomprehensivegeriatricassessmentswhichtargetfrailty andinvolvefollowupand/oroutpatientcarearemorelikelytoproducefavourableclinical effects.Consultationservicesshouldbedirectedatpatientswiththehighestrisk,while ensuringthatrecommendationsareimplemented. Implementingaconsultserviceinvolvesdeterminingtheneedamongelderly patientsandassessingthehumanresourcesavailable.Thepotentialdemandforgeriatric consultsandthebenefitofsuchaserviceshouldbeconsideredalongwiththe characteristicsoftheinstitution.Criteriatoconsiderare:patientpopulation;patient
15
InpatientConsults functionaldecline;andaveragelengthofstay.Apilotprogramshouldbeutilizedfor evaluationandrecommendations.Theoutcomescanassessthemeritorworthofthe programforthatspecificsetting. Effectiveconsultationsrequire:atargetingorscreeningsystem;quickresponseto referrals;identifyinggoalsandrecommendationsimmediately;planningforfollowup consults;andtrackingtheoutcomes.Standardizedassessmentswhichincludeastructured history,functionalassessment,andmeasuredcognitionarerecommended.Continuous evaluationoftheprogramwillassistindeterminingareasrequiringchange,services needingexpansionoralteration,andtoensuretheeffectivenessofthegeriatric assessmentprogram. Althoughevidenceprovingtheeffectivenessofgeriatricconsultsissparse,there arecleargoalsandrecommendationsoutlinedintheliteratureforbestpractices.Geriatric consultsshouldtargetpatientsthataremorelikelytobenefitfromassessment.A structuredassessmentshouldbeimplementedwithafastresponsetoreferral, recommendationsfortreatment,andafollowupplan.Theconsultationprogramshould becontinuallyevaluatedandadjustedtoprovideefficientandbeneficialservice. Definition Geriatricconsultsinvolveassessmentofphysical,emotional,cognitive,and functionalstatusinolderpersons.Aconsultcanrefertoinpatientorresidentcareat facilities,rangingfromacutecarehospitalstolongtermcarehomes,aswellastooutpatient oroutreachservices.ThereviewinthisChapterwillbeconfinedtogeriatricconsultationsin theacutecareinpatientsetting. Consultscanhaveseveralpurposes.Theycanbeusedto: assessapatientsreadinessforaninternaltransferfromamedicalorsurgical unitsuchascardiologyororthopaedicstoaspecializedgeriatricservice providerecommendationstothecareteamsregardingtheprimaryor secondarypreventionofcommongeriatricsyndromesorfunctionaldecline manageproblemsthathavealreadyemerged evaluateapatientsreadinessfortransfertorehabilitation,dischargehome, ordischargetolongtermcareandinthesecasescanoftenprovideimportant inputinthedevelopmentoftheplanforcarepostdischarge. assistintheformulationofaplanforcarepostdischarge. Ageriatricconsultationoftendealswithissuesbeyondthereasonforadmissiontohospital; forexample,apatientmaybeadmittedforhipfracturefollowingafall,andaconsult requestedtoinvestigatethereasonforthefall. Consultantsareneverthemostresponsiblephysician(MRP)forthepatientscareat thattimeandasaresulttherecommendationstheymakemayormaynotbefollowed.In partbecauseadherencetorecommendationsisanongoingissue(Allen,1998;Cefalu,1996; Fallonetal.,2006;Marcantonio,Flacker,Wright,&Resnick,2001;Fa),recommendationsare chartedandmaybecommunicatedtotheMRPmoredirectly;theremayalsobefollowup untilthepatientisdischargedandsometimespostdischarge.
InpatientConsults LiteratureSearchforthisChapter AMEDLINEsearchwasconducted,usingtheMeSHtermsConsultantsor"Referral andConsultationandGeriatrics.Inaddition,searcheswereconductedofBritish, American,andCanadianguidelinesclearinghouses,andoftheinternet.Thisyielded60 sources,ofwhich33werefocusedonreferralsratherthanconsultations,oronoutpatient ratherthaninpatientsettings.Oftheremaining27sources16wereempiricalstudies,i.e., evaluationstudies,clinicaltrials,reviews,etc. Table3.1:MEDLINESearchStrategy Step Term Yield 1 Consultants/orReferralandConsultation/ 36730 2 Geriatrics/(6505) 6505 3 1+2 154 4 Limitto(humansandEnglishlanguageandabstracts) 60 5 Excludeoutpatientandreferral 27 6 Limittoresearch(handsearch) 16 TheresultsofthissearchareshowninTable3.2 Theliteratureshowsthatavarietyofstrategiessharetherubricconsult.Ata minimum,however,geriatricconsultsinvolveageriatricianandanurse(usuallyaclinical practicenurse,nursepractitionerorotheradvanceddegreenurse),andoftenotherallied healthprofessionalsaswell.Thetypesandcomprehensivenessofconsultantsassessments mayvarybypurpose,byinstitutionandevenbyteam.Dependingonthepurposeofthe consult,assessmentsmayincludemeasuresofmobility,function,cognition,andscreening forgeriatricgiantssuchasmalnutrition,incontinence,polypharmacy,and/orsafety.Most oftenaconsultinvolvesanindepthcomprehensivegeriatricassessmentthatexaminesthe interplayofalloftheseaspectsintheolderpatient. RationaleforGeriatricConsultations Olderadultsaged65andovermakeup13%oftheCanadianpopulationandthey accountforonethirdofallhospitaladmissionsandmorethanhalfofallhospitaldays(CIHI, 1997,ascitedinLoeb,2005)Elderlyinpatientsareoftenfrailandrequiremorerecoverytime thantheiryoungercounterparts.Theliteratureshowsthatfunctionaldeclineoccursin25% to60%ofolderpersonsafterenteringacutecare(Agostini,etal.2001a). Regardlessofage,aninhospitalstayincreasestheriskofinfectionsandadverse eventssuchasfalls,buttheimpactofsucheventsisfarmoresevereamongolderpatients (Darchyetal.,1999;Hoffmanetal.,1995;Lautenbach,Bilker,&Brennan1999; Plouffe,etal.,1996;Simoretal.,2005).In2002,morethan20%ofeldersadmittedto16 hospitalsforhipfracture,pneumonia,deliriumanddementia,heartfailure,psychiatric disorderorstrokediedinhospitalorexperiencedanunplannedreadmissionwithin28days. Another10%,whohadbeenadmittedfromhome,weredischargedtolongtermcare(Lewis etal.,inpress).
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InpatientConsults Table3.2.Studies0fMultidisciplinaryGeriatricConsultationServices Study Allen,1998 Becker,McVey,Saltz,Feussner, &Cohen,1987 Saltz,McVey,&Becker,1988 McVey,Becker,Saltz,Feussner, &Cohen,1989 Fretwell,Raymond,& McGarvey,etal.19901 Gayton,1982 N 185 Levelof Evidence 1 Results Nosignificantdifferencesinhospitalacquiredcomplications(overall 38%forbothgroups) Nostatisticallysignificantimprovementinfunctionalstatus(activities ofdailyliving) Nostatisticallysignificantdifferencesinreadmissionorplacement Compliancewithrecommendations:71.7%overall(from4795%for selectedinterventions) Nosignificantdifferenceinmortalityatdischarge Nosignificantdifferencesinlengthofstay,physicalorcognitive function,orhospitalcharges Nosignificantmortalitydifferenceupto6monthsfollowup,buttrend favoringinterventiongroup Nosignificantdifferencesinfunctionalstatus,lengthofstay,ormental statusbetweenstudygroups Mortalityat4monthslowerintheinterventiongroup(p<0.05),butnot at12months Fewermedicationsondischarge(p<0.05)andimprovedmentalstatus (p<0.01)intheinterventiongroup Decreased6monthmortalityintheinterventiongroup(p<0.01) Nosignificantdifferenceinoutcomesatdischarge Improvedfunctionalabilityatoneyearbutnotat3or6monthsinthe interventiongroup Interventionpatientsmorefunctionallyindependent(p=0.005)at dischargeandweredischargedtohomeathigherrates(p=0.03) Occurrenceofdelirium:32%vs.50%incontrolgroup(p=0.04) Adherencetorecommendations:77%
436
222
Hogan,Fox,Badley,&Mann, 19871
113
Hogan,&Fox,1990
132
Kennie,Reid,Richardson, Kiamari,&Kelt,198817 Marcantonio,Flacker,Wright,& Resnick,2001
144 126
1 1
InpatientConsults Ray,Taylor,Meador,Thapa, Brown,Kajihara,etal.1997 Reuben,Borok,WoldeTsadik,et al.1995 Thomas,Brahan,&Haywood, 1993 82 2353 1 1 Lowerrateofrecurrentfalls:19%vs.54%incontrolgroup(p=0.03) Trendtowardlowermeanrateofinjuriousfalls Nostatisticallysignificantdifferencesinmortalityatuptooneyear followup Nosignificantchangeinfunctionalstatusat3or12months Reduced6monthmortality:6%vs.21%controls(p=0.01) Trendtowardimprovedfunctionalstatusintheinterventiongroup Hospitalreadmissionin6monthssignificantlylowerintheintervention group Nosignificantmortalitydifferencesbetweengroups Nosignificantchangeinphysicalfunction,lengthofstay,orplacement betweengroups Compliancewithallrecommendations:67% Standardizedselectionprogramimprovesoutcomesatlittlecost Inpatientassessmentgainsareminorandtransient
120
Winograd,Gerety,&Lai,1993
197
Trentinietal.,1995a,1995b
4510
19
InpatientConsults Thereissubstantialevidencethatcomprehensivegeriatricassessments(CGAs)arean effectivemechanismtopreventsuchadverseevents.Theyhavebeenshowntoimprove survivalandtoreduceannualmedicalcosts,acutecareutilization,andnursinghomeuse. The1987NIHConsensusStatementnotedthatCGAsimprovediagnosticaccuracy,guide careplans,directplacementsinanoptimalenvironmentforcare(e.g.,placementinlong termcare),predictoutcomes,andmonitorclinicalchanges.TheStatementconcludedthat comprehensivegeriatricassessmentiseffectivewhencoupledwithongoing implementationoftheresultingcareplan.(NIHConsensusStatement,1987).Ameta analyticreviewbyStuck,Siu,Wielandandcolleagues(1993)confirmedtheseresults(see Agostinietal.,2003b). Usage InpatientgeriatricconsultationisanimportantdevicefordeliveringCGAsto hospitalizedelders.Consultsfaroutweighmostotherservicesintermsofthenumbersof patientsseen.InregionscoveredbythefiveRegionalGeriatricProgramsofOntariofor instance,therewere5786geriatricconsultsin20034,comparedto3089admissionsto specializedinpatientgeriatricunits,1864todayhospital,and4910outreachvisits.Only outpatientclinicsenrollmorepatients(Table3.3). Table3.3:GeriatricServiceVolumesinOntario,20034 Sites Admissions/Visits AssessmentUnits 10 1591 RehabilitationUnits 7 1498 Consultations 19 5786 DayHospitals 12 1864 OutreachServices 11 4910 OutpatientClinics 20 11891
Note:Doesnotincludeallspecializedgeriatricservices
Agostiniandcolleagues(2001a)estimatethatonlyabouthalfofAmericanhospitals haveanySGSconsultservices.Localinformationsuggeststhattheproportioninsouth centralOntario 2isaboutthesame.InJanuary2002,forinstance,geriatriciansreported providingconsultsat11of20hospitalsintheregion.Theyservedall4localacademichealth

2 ThedistrictcoveredbyRGPSouthcentralincludesBrant,HaldimandandNorfolk,Halton,Hamilton,Niagara, WaterlooandWellingtonDufferin OrganizationDesignforGeriatrics:AnEvidenceBasedApproach 20
InpatientConsults sciencescentres,5of8largecommunityhospitals,butonly2of8smallcommunity hospitals. Dementiaandrelateddisordersmakesuptheleadingdiagnosisforalmosthalfofthe consultsinSouthcentralOntario(notjustthoseinacademichealthcentres)asshownin Table3.4. Table3.4:LeadingDiagnosticCategoriesReportedbyConsultants, SouthCentralOntario,20034 Diagnosis N % 1. Seniledementia,preseniledementia 1353 44.4 2. Convulsions,ataxia,vertigo,headache,excepttensionheadache? 216 7.1 3. Anxietyneurosis,hysteria,neurasthenia,obsessive 132 4.3 4. Osteoporosis,spontaneousfracture,otherdisordersofbone 116 3.8 5. Chestpain,tachycardia,syncope,shock,edema,masses 97 3.2 6. Epistaxis,hemoptysis,cough,dyspnea,masses,etc. 92 3.0 7. Psychosis,alcoholic,deliriumtremens,Korsakoff'spsychosis 93 3.0 8. Othercerebraldegenerations 71 2.3 9. Diabetesmellitus,includingcomplications 55 1.8 10. Pneumoniaalltypes 56 1.8 11. Cerebrovascularaccident,acute,CVA,stroke 51 1.7 12. Congestiveheartfailure 48 1.6 13. Chronicobstructivepulmonarydisease 47 1.5 14. Fractureotherfractures 42 1.4 15. Parkinson'sdisease 43 1.4 16. Hypertension,benign 39 1.3 17. Anorexia,nausea&vomiting,etc. 24 0.8 18. Asthma,allergicbronchitis 21 0.7 19. Legcramps,legpain,musclepain,etc. 22 0.7 20. Metabolicdisorders,other 20 0.7 21. Otherdiseasesofcentralnervoussystem,e.g.Brainabscess 21 0.7 22. Tachycardia(alsoshowsupin#5,paroxysmal,atrialorventricular flutteretc. 20 0.7 23. Coronaryinsufficiency,acute,anginapectoris,acute 18 0.6 24. Psychoses 18 0.6 25. Otherilldefinedconditions 15 0.5 26. Arteries,otherdisorders 12 0.4 27. Lumbarstrain,lumbago,coccydynia,sciatica 11 0.4 28. Allothers 297 9.7 Total 3050 100
InpatientConsults InpatientConsultationandComprehensiveGeriatricAssessments WhilesometargetedgeriatricconsultsmaynotrequireaCGA,mostdo.NotallCGAs areequal:theNIHStatement(1993)notesthatgoodevidencesupportsonlycombined assessmentandrehabilitationunitsorinpatientgeriatricassessmentunits.Resultsforother settingsincludinginpatientconsultationservicesweremixed;thatis,someshowed positiveeffectsandothersdidnot.Thisisbecausetherearetwomajorprerequisitestoan effectiveCGA: 1. Targetingtheassessmenttopersonsmostlikelytobenefit.Theseare: a. Theoldestold(generallyoverage75) b. Thosewithconditionsamenabletoageriatricintervention,suchas i. Falls,gaitandbalanceproblems ii. Functionallimitations iii. Confusion iv. Depression v. Incontinence c. Thosewithpotentiallyreversibleorremediabledisabilities d. Thoseatpointsoftransitionorinstability(Trentinietal.,1995a;Winograd, 1991). 2. Linkingassessmentandfollowupservices.Indeed,insomestudiesitisunclear whethertheconsultorthefollowupwasthesourceofchange. Theimpactofgeriatricassessmentonmortalityratesisnotyetclear.Amongthe largestandmostdetailedevaluationsofinpatientgeriatricassessmentwasReubenand colleagues(1995)multisitestudyinvolvingover2300patients.Theyfoundnosignificant differencesinmortalityorfunctionalstatusatuptooneyear.Although,twootherstudies alsofoundnodifferenceinmortalityassociatedwithgeriatricassessment(i.e.,Fretwell,et al.,1990;Winograd,etal.,1993),otherstudieshavefoundthatgeriatricassessmentis associatedwithimprovedsurvival.Hoganandcolleagues(1987),foundasignificant differenceinmortalityratesatfourmonthfollowup,favoringthosewhoreceivedgeriatric assessment.Similarly,otherstudies,HoganandFox(1990)andThomasandcolleagues (1993)foundthatgeriatricassessmentwasassociatedwithlowermortalityratesatsix monthfollowup.Gaytonandcolleagues(1982)alsofoundatrendtowardslowermortality ratesforthosewhoreceivedgeriatricassessment. Similarly,theimpactofgeriatricassessmentonreadmissionratesandhospitallength ofstayisnotclear.WhileCampionandcolleagues(1983)foundnoimprovementin readmissionrateswithconsults,Thomasandcolleagues(1993)foundthosewhoreceived geriatricassessmenthadsignificantlyfewerreadmissions(.3perpatient)thancontrol patients(.6perpatient).Consultshadnodetectableimpactonhospitallengthofstayin threestudies(i.e.,Fretwell,etal.,1990;Gayton,etal.,1982;Winograd,etal.,1993).In contrast,Germainandcolleagues(1995)foundthattheconsultativeservicesofageriatric assessmentandinterventionteam(GAIT),whenadministeredtoinpatientswaitingfor admissiontoaGeriatricAssessmentUnit(GAU)cansignificantlydecreasehospitallengthof stayandGAUburdenandincreasethelikelihoodofahomeratherthaninstitutional placement.Elliotandcolleagues(1996)alsofoundthatregularinputbyaconsulting
InpatientConsults geriatricianreducedlengthofstaybysevendayscomparedtousualcare,andreduced costs.Similarly,Barkerandcolleagues(1985)foundthatageriatricconsultationteamcould reducebacklogsofpatientsawaitingdischargetolongtermcare.Geriatricconsultationsfor patientsatriskforprolongedhospitalstays,reducedthemeanmonthlycensusofelderly patientsbackedupinhospitalby21%. Studiesexaminingtheimpactofinpatientconsultationandgeriatricassessmenton functionalstudieshavefoundcontradictoryresults.Whilesomeofthereviewedstudies (Allen,1998;Fretwell,etal.,1990;Gayton,1982;Ruebenetal.,1995;Winograd,etal.,1993) foundnoimprovementinfunctionalstatusasresultofgeriatricconsultationand assessment,othershaveidentifiedfunctionalimprovementsHoganandcolleagues(1987), inarandomizedcontrolledtrial,foundimprovedmentalstatusintheinterventiongroupand improvedfunctionalabilityatoneyear,butnotatthreeorsixmonths(Hoganetal.,1990 Postdischargefollowupbyageriatricteammayhaveaccountedforthisdifference,rather thaninhospitalconsults(Agostini,etal.,2001a).Kennieandcolleagues(1988)andThomas andcolleagues(1993)foundconsultpatientsweremorefunctionallyindependentat discharge. Inpatientconsultationandgeriatricassessmenthavethepotentialtoreduce complications.Although,onerandomizedcontrolledtrial(RCT)foundnodifferencein hospitalacquiredcomplications(i.e.,Allen,1998)othershavefoundthatgeriatric consultationandassessmentcanreducetheincidenceofdeliriumandfalls.Marcantonio andcolleagues(2001)foundthathipfracturepatientsrandomizedtogeriatricconsultation werelesslikelytodevelopdeliriumthanthosewhoreceivedusualcare;deliriumwas reducedbyoverthird,andseveredeliriumreducedbyoveronehalf.Inarandomized controltrialconductedinnursinghomes,Rayandcolleagues(1997)foundthattheincidence offallsinrecurrentfallerswassignificantlylower(19%)forthosewhoreceivedgeriatric assessmentthanthoseinthecontrolgroup(54%).ThismaysuggestthatCGA,ratherthan inpatientconsultsassuch,arethelocusofeffectiveness. Ingeneral,thereisstillsomeambiguityregardingthevalueofgeriatricconsultation andassessmentinacutecare,intermsofpatientoutcomes.Although,asreviewedabove, thereissomeevidenceofimprovementsinfunctionalandmentalstatusandsurvival associatedwithinpatientgeriatricconsultationandassociationithasbeensuggestedthat thebenefitsofinpatientCGAareminorandtransient;theycanbebetterachievedwith outpatientassessment(Karpi,1997).Highlightingtheimportantroleofcommunitybased screening,Hbert(1997)hasindicatedthatearlydetectionofolderadultsatriskfor functionalimpairment,viascreeninginEmergencyDepartments,athomebyhomeservices, andbyfamilyphysicians,andinitiationofgeriatricassessmentandinterventioncanprevent ordelayfunctionaldecline.ThisscreeningwilltargetCGAtothosewhowillbenefitmost fromassessment,rehabilitation,andinterventionprograms. Morerecentinterventionsincludingelderfriendlyenvironmentchanges, activationorprehabilitationprograms,andintensifiedeffortsatinfectioncontrolshow promiseofreducedemphasisonsomespecializedgeriatricservices(SGS)consultsby reducingtheincidenceofinhospitaleventslikedelirium,falls,deconditioning,and nosocomialinfection(Palmer,1995).
InpatientConsults StartingaConsultService Consultservicesareafamiliarelementofmanyhospitals.Comparedtoaspecialized unitorprogram,consultsareeasiertoimplementandarerarelydisruptivetothehospitals routine.Humanresourceissuesarethechiefdifficultyfacinganyinstitutioncontemplating theadditionorexpansionofanSGSconsultservice,becausegeriatricians,geriatric psychiatrists,andalliedhealthprofessionalswithagerontologicalfocusareinshortsupply. Forthesereasons,itisespeciallyimportanttoensurethattheconsultserviceisdirectedto whereitcandomostgood.Thatcanbedonebytargetingconsultsatthoseathighestrisk, andensuringthatrecommendationsareimplemented.Tostartaconsultservice: 1. DeterminetheneedforanSGSconsultservicebythelevelofiatrogenicand nosocomialillnessamongelderlyinpatients. 2. Determinetheavailabilityofhumanresources.Theteamshouldbesmall(e.g.a geriatricianandnursepractitioner,withalliedhealthprofessionalsavailable),with littlerotationamongmembersinordertoenhanceteamcohesionandcollaboration withhospitalstaff. 3. Tomaximizecoverage,usegeriatricnursespecialists(orasimilarlevelofskill)in consultationwithgeriatricmedicine. Foraconsultservicetobeeffective: 1. Useanonlinesystemtoflagatriskpatients.Useatrainedstaffmembertofurther screen.Thismaymeanthatsomerequestsforconsultsarerefused 2. Ensurecapacitytorespondtoarequestforconsultwithin24hoursofreceipt. 3. Identifythegoalsoftheconsultimmediately.Asalreadynoted,thesemaybe evaluationofreadinessfortransferordischarge,postdischargecareplanning,or controlorpreventionofgeriatricsyndromesandfunctionaldecline.Allconsults requireastructuredassessment,butthenatureofthatassessmentshouldbe targetedtotheconsultspurpose:ifthegoalistransfertoanSGSunit,theneedfora CGAislessened(sinceitwilltakeplaceintheunit). 4. Providewrittenrecommendationsatthetimeoftheconsult, 5. Planforfollowupconsultationstotakeplacebiweeklyataminimum,untilthe patientisdischargedortransferredtoanSGSservice. 6. Trackoutcomesamongthepatientsseenbytheteam. GiventhattheimpactofSGSconsultsremainsquestionable,apilotprogrammaybeuseful. Targeting StudiesbyRayandcolleagues(1997)andMarcantonioandcolleagues(2001)aretwo amongmanywhichemphasizethatSGSconsultsmustbedirectedathighriskeldersor theywillbeineffective(Winograd,1993;Stuck,etal.,1993).Manyconsultservicesare directedatthoseover75yearsofage,buttheremaybeother,moreeffectivetargeting strategies. AnIrishstudy(Todd,Crawford,&Stout,1993)foundsystematicdifferencesbetween geriatricandmedicalinpatientsovertheageof75:theformerweremoreoftenfemale, admittedduringbusinesshours,seenbytheirfamilyphysician,andhadmorechronicand
InpatientConsults multipleillnesswithnonspecificpresentations,andstayedlongerinhospital.Trentinietal., (1995a)showedthatastandardizedselectionplanwillhelptoidentifytheolderinpatientsin needofCGA.ThecostofidentifyingappropriatecandidateshasbeenreportedbyWinograd, Gerety,Brown,&Kolodny,(1988)asinvolvinga.25FTEtrainedemployeeperyear. RapidResponse AlthoughKatz,DubeandCalkins(1985)founduptakeofconsultants recommendationsaveraged33%;morerecentstudiesnotebetteradherence.Winograd (1996)found67%adherence,Cefalu(1996)55%,Allenetal.(1998)72%,andMarcantonioand colleagues(2001)71%.InCefaluschartreview,speedofteamresponsetotherequestfora consultprovedtobethemostimportantpredictorofimplementation(seealsoGermainet al.1995;Elliott,etal.,1996) StandardizedAssessmentandCare Standardizedassessmentsarerecommendedthroughoutgeriatriccare(Challiner,et al.,2003).Katzandcolleagues(1985),notedthatateamusingastructuredassessment formatwasanefficientcasefindingandpatientmanagementtool.Theassessmentwill includeastructuredhistoryandfunctionalassessmenttoolssuchastheKatzorLawton indexofactivitiesofdailyliving,theBarthelIndex,ortheFunctionalIndependenceMeasure. CognitivefunctionisusuallymeasuredusingtheMiniMentalStatusExam,butthereare manysuchinstrumentsavailableandwidelyaccepted. Otherelementsoftheassessment,whilestillstructured,canbecontingentonthe reasonforreferraltotheconsultteam.Forexample,deliriumcanbemeasuredusingthe ConfusionAssessmentMethodortheDeliriumRatingScale.VariousversionsoftheInterRAI CorporationsMDSinstrumentincludessubscalesforpressureulcers,functional performance,continence,falls,andmood. Thestructuredassessmentaidsindeterminingthepatientcareplan,butitrequiresa balancebetweenthoroughnessandbrevity.Averythoroughassessmentwillfatiguethe patient,whichinturnmayproducetounreliableresponsestoquestions.Itmayalsolimit theconsultteamscapacitytorespondtorequestsforconsults,effectivelyreducinghospital coverage.Conversely,averybriefconsultmayfailtodetectremediableissuesormayresult inrecommendationsthatarenotadequatelyunderstoodandthereforepoorly implemented. FocusedInterventionsandFollowup LichtensteinandWinograd(1984)foundthatwithafocusonreversibleconditions thataffectpatients'functionallevels,SGSconsultscanimprovecareandprevent unnecessarylongtermplacement.Similarly,Dellasegaandcolleagues(2001)foundthata geriatricassessmentteamwasmosteffectiveamonghighriskeldersiftherearefocused interventions(seealsoMacNeilandLichtenberg,1997).Bycontrast,Kennie(1988)foundno differencesindischargestatusbetweenpatientswhoreceivedageriatricconsultandthose whohadstandardcareonly.
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InpatientConsults TheNIHconsensusstatement(1993),Stuckandcolleagues(1993)metaanalysis,and allofthestudiesthatshowedsomeimpactfollowingconsultincludedfrequentfollowup. ThestudybyMarcantonioandcolleagues(2001)includeddailyfollowuptoreduce incidenceofdeliriumafterhipfracture.Gayton,WoodDauphinee,deLorimer,Tousignant, andHanley(1987)examinedaconsultservicewhichincludedbiweeklyfollowupandfound nosignificanteffects.Followupstakingplacetwiceaweekdidshowsomeeffects.In addition,someauthorshavedescribedadherencetoconsultantsrecommendationsasan issue(Allen,1998;Cefalu,1996;Marcantonioetal.2001). EvaluatingConsults Needsassessment BeforeimplementinganinpatientSGSconsultserviceaneedsassessmentshouldbe undertakentodeterminethepotentialdemandforandbenefitofsuchasservicewithinthe hospital.Thisshouldincludeconsiderationsofthecharacteristicsofthehospitalspatient population,lengthofstay,adverseevents,readmissionsandrepeatEDvisits,inhospital functionaldecline,andnumbersofdischargestolongtermcare.Discussionswithservices mostlikelytorequestaSGSconsultswilllikelyalsoyieldvaluableinformation. Fewinpatientunits,otherthanrehabilitationunits,routinelycollectdataonpatient function,buttheotherinformationshouldbeavailablefromhospitaladministrative databases.MortalityratesmayalsobeaffectedbySGSconsults.Thereisconsiderable variationinpatientdemographicsanddiagnosesovertimeandbetweenfacilities,sothese shouldbeincludedascontrols. PilotProgram Apilotprogramshouldbeinstitutedinordertoconductbothformativeand summativeevaluations.Aformativeevaluationaimsatidentifyingprocessissuesthatcanbe improved,andwouldfocusonvolumesandlengthsofstay,continuityofcare,timelinessof response,andproviderandpatient(orproxy)satisfaction.Summativeevaluationassesses themeritorworthoftheprogram.Init,theoutcomesandcostsofcareforpatientsseenby theconsultteamwouldbecomparedtoacontrol.Ideally,patientswillberandomly assignedtointerventionandcontrolgroup,butthatmaynotbepracticalorethical.A frequencymatchedintactgroup(forinstance,patientsatanotherhospital)canbeused instead. Acontinuousevaluation,gatheringtheessentialformativeandsummative informationasagreeduponbytheconsultteamandhospitaladministration,wouldthenbe inplace.Iftheserviceweretobeexpanded,altered,oreliminated,theimpactofthechange wouldbereadilydetectable. Evaluationoftheconsultservicedependsonitsobjectives,andthesemaynotbe readilyaccessible.Dependingonthosegoals,outcomesthatmaybeaffectedinclude iatrogeniccomplicationssuchasfunctionaldecline,delirium,falls,andperhapsmortality (Agostini,Baker,Inouye,&Bogardus,2001a),lengthofstayanddischargeratestolongterm care.
InpatientConsults Conclusion Consultationsuseupagooddealofgeriatricianandgeriatricnursingtime,yetthe evidencefortheireffectivenessissparse.Thosewhichhavebeenfoundtobeeffective generallypreventinhospitaladverseevents.Theyhavecleargoals,shortturnaroundtimes, carefulpatienttargeting,structuredassessment,andespeciallyfrequentfollowup.These factorsgenerallyresultinhigherlevelsofadherencetorecommendations.
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InpatientConsults References Agostini,J.V.,Baker,D.I.,Inouye,S.K.,&Bogardus,S.T.(2001a).MultidisciplinaryGeriatric ConsultationServices.InA.J.Markowitz(Ed.),MakingHealthCareSafer:ACritical AnalysisofPatientSafetyPractices.AgencyforHealthcareResearchandQuality. EvidenceReport/TechnologyAssessment,No.43.Retrievedfrom http://www.ahrq.gov/clinic/ptsafety/chap29.htm Agostini,J.V.,Baker,D.I.,&Bogardus,S.T.(2001b).GeriatricEvaluationandManagement UnitsforHospitalizedPatients.InA.J.Markowitz(Ed.),MakingHealthCareSafer:A CriticalAnalysisofPatientSafetyPractices.AgencyforHealthcareResearchand Quality.EvidenceReport/TechnologyAssessment,No.43.Retrievedfrom http://www.ahrq.gov/clinic/ptsafety/chap30.htm Allen,C.M.,Becker,P.M.,McVey,L.J.,Saltz,C.,Feussner,J.R.,Cohen,H.J.(1986).A randomized,controlledclinicaltrialofageriatricconsultationteam.Compliancewith recommendations.JournaloftheAmericanMedicalAssociation,255(19),261721 Barker,W.H.,Williams,T.F.,Zimmer,J.G.,VanBuren,C.,Vincent,S.J.,&Pickrel,S.G. (1985).Geriatricconsultationteamsinacutehospitals:impactonbackupofelderly patients.JournaloftheAmericanGeriatricsSociety,33(6),422428. Becker,P.M.,McVey,L.J.,Saltz,C.C.,Feussner,J.R.,&Cohen,H.J.(1987).Hospital acquiredcomplicationsinarandomizedcontrolledclinicaltrialofageriatric consultationteam.JournaloftheAmericanMedicalAssociation,257,23132317. Campion,E.W.,Jette,A.,&Berkman,B.(1983).Aninterdisciplinarygeriatricconsultation service:acontrolledtrial.JournaloftheAmericanGeriatricsSociety,31(12),7926. Cefalu,C.A.(1996).Adheringtoinpatientgeriatricconsultationrecommendations.Journal ofFamilyPractice,42(3),259263. Challiner,Y.,Carpenter,G.I.,Potter,J.,&Maxwell,C.(2003).Performanceindicatorsfor hospitalservicesforolderpeople.Age&Ageing,32(3),3436. Darchy,B.,LeMiere,E.,Figueredo,B.,Bavoux,E.,&Domart,Y.(1999).IatrogenicDiseases asaReasonforAdmissiontotheIntensiveCareUnit:Incidence,Causes,and Consequences.ArchivesofInternalMedicine,159,7178. Elliot,J.R.,Wilkinson,T.J.,Hanger,H.C.,Gilchrist,N.L.,Sainsbury,R.,Shamy,S.,etal. (1996).Theaddedeffectivenessofearlygeriatricianinvolvementonacute orthopaedicwardstoorthogeriatricrehabilitation.NewZealandMedicalJournal. 109(1017),7273. Fallon,W.F.Jr,Rader,E.,Zyzanski,S.,Mancuso,C.,Martin,B.,Breedlove,L.,DeGolia,P., Allen,K.,&Campbell,J.(2006).Geriatricoutcomesareimprovedbyageriatric traumaconsultationservice.JournalofTrauma,61(5),10406.; Fretwell,M.D.,Raymond,P.M.,McGarvey,S.T.,Owens,N.,Traines,M.,Silliman,R.A.,& Mor,V.(1990).TheSeniorCareStudy.Acontrolledtrialofaconsultative/unitbased geriatricassessmentprograminacutecare.JournaloftheAmericanGeriatricsSociety, 38,10731081.
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InpatientConsults Gayton,D.,WoodDauphinee,S.,deLorimer,M.,Tousignant,P.,&Hanley,J.(1987).Trialofa geriatricconsultationteaminanacutecarehospital.JournaloftheAmerican GeriatricsSociety,35,726736. Germain,M.,Knoeffel,F.,Wieland,D.,&Rubenstein,L.Z.(1995).Ageriatricassessmentand interventionteamforhospitalinpatientsawaitingtransfertoageriatricunit:a randomizedtrial.AgingClinical&ExperimentalResearch,7(1),5560. HbertR.(1997).Functionaldeclineinoldage.CanadianMedicalAssociationJournal,157(8), 103745. Hoffman,J.,Cetron,M.S.,Farley,M.M.,Baugham,W.S.,Facklam,R.R.,Elliott,J.A.,etal. (1995).TheprevalenceofdrugresistantStreptococcuspneumoniaeinAtlanta.New EnglandJournalofMedicine,333,4816. Hogan,D.B.,&Fox,R.A.(1990).Aprospectivecontrolledtrialofageriatricconsultation teaminanacutecarehospital.AgeAgeing,19,107113. Hogan,D.B.,Fox,R.A,Badley,B.W.,&Mann,O.E.(1987).Effectofageriatricconsultation serviceonmanagementofpatientsinanacutecarehospital.CanadianMedical AssociationJournal,136,713717. Katz,P.R.,Dube,D.H.,&Calkins,E.(1985).Useofastructuredfunctionalassessmentformat inageriatricconsultativeservice.JournaloftheAmericanGeriatricsSociety,33(10), 6816. Kennie,D.C.,Ried,J.,Richardson,I.R.,Kiamari,A.A.,&Kelt,C.(1988).Effectivenessof geriatricrehabilitativecareafterfracturesoftheproximalfemurinelderlywomen:A randomisedclinicaltrial.BritishMedicalJournal,297,10831086. Keeler,E.B.,Robalino,D.A.,Frank,J.C.,Hirsch,S.H.,Maly,R.C.,&Reuben,D.B.(1999).Cost effectivenessofoutpatientgeriatricassessmentwithaninterventiontoincrease adherence.MedicalCare,37(12),1199206. Lautenbach,E.,Bilker,W.B.,&Brennan,P.J.(1999).Enterococcalbacteremia:riskfactorsfor vancomycinresistanceandpredictorsofmortality.InfectionControlandHospital Epidemiology,20,31823. LoebM.Epidemiologyofcommunityandnursinghomeacquiredpneumoniainolder adults.ExpertRevAntiInfectTher2005;3(2):26370 Lichtenstein,H.,&Winograd,C.H.(1984).Geriatricconsultation:Afunctionalapproach. JournaloftheAmericanGeriatricsSociety,32(5),356361. MacNeill,S.E.,&Lichtenberg,P.A.(1997).Homealone:theroleofcognitioninreturnto independentliving.ArchivesofPhysicalMedicine&Rehabilitation,78(7),7558. Marcantonio,E.R.,Flacker,J.M.,Wright,R.J.,&Resnick,N.M.(2001).Reducingdelirium afterhipfracture:Arandomizedtrial.JournaloftheAmericanGeriatricsSociety,49, 516522. McVey,L.J.,Becker,P.M.,Saltz,C.C.,Feussner,J.R.,&Cohen,H.J.(1989).Effectofa geriatricconsultationteamonfunctionalstatusofelderlyhospitalizedpatients. AnnalsofInternalMedicine,110,7984. NIHConsensusStatement(1987).GeriatricAssessmentMethodsforClinicalDecision making.Online1921[cited2008June11];6(13):121.
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InpatientConsults Palmer,R.M.(1995).Acutehospitalcareoftheelderly:minimizingtheriskoffunctional decline.ClevelandClinicalJournalofMedicine,62,117128. Plouffe,J.F.,Breiman,R.F.,&Facklam,R.R.(1996).BacteremiawithStreptococcus pneumoniae:implicationsfortherapyandprevention.JournaloftheAmerican MedicalAssociation,275,194198. Ray,W.A.,Taylor,J.A.,Meador,K.G.,Thapa,P.B.,Brown,A.K.,Kajihara,H.K.,etal.(1997). Arandomizedtrialofaconsultationservicetoreducefallsinnursinghomes.Journal oftheAmericanMedicalAssociation,278,557562. Reuben,D.B.,Borok,G.M.,WoldeTsadikG.,Ershoff,D.H.,Fishman,L.K.,Ambrosini,V.L., Liu,Y.,Rubenstein,L.Z.,&Beck,J.C.(1995).Arandomizedtrialofcomprehensive geriatricassessmentinthecareofhospitalizedpatients.NewEnglandJournalof Medicine,332,13451350. Saltz,C.C.,McVey,L.J.,Becker,P.M.,Feussner,J.R.,&Cohen,H.J.(1988).Impactofa geriatricconsultationteamondischargeplacementandrepeathospitalization. Gerontologist,28,344350. Simor,A.E.,OfnerAgostini,M.,Paton,S.,McGeerA.,Loeb,M.,Bryce,E.,&Mulvey,M. (2005).CanadianNosocomialInfectionSurveillanceProgram.Clinicaland epidemiologicfeaturesofmethicillinresistantStaphylococcusaureusinelderly hospitalizedpatients.InfectionControl&HospitalEpidemiology,26(10),83841. Stuck,A.E.,Siu,A.L.,Wieland,G.D.,Adams,J.,&Rubenstein,L.Z.(1993).Comprehensive geriatricassessment:Ametaanalysisofcontrolledtrials.Lancet,342,10321036. Thomas,D.R.,Brahan,R.,&Haywood,B.P.(1993).Inpatientcommunitybasedgeriatric assessmentreducessubsequentmortality.JournaloftheAmericanGeriatricsSociety, 41,101104. Todd,M.,Crawford,V.,&Stout,R.W.(1993).Differencesbetweengeriatricandmedical patientsaged75andover.UlsterMedicalJournal,62(1),410. Trentini,M.,Semeraro,S.,Rossi,E.,Giannandrea,E.,Vanelli,M.,Pandiani,G.,etal.(1995).A multicenterrandomizedtrialofcomprehensivegeriatricassessmentand management:experimentaldesign,baselinedata,andsixmonthpreliminaryresults. AgingClinical&ExperimentalResearch,7(3),22433. TrentiniM,SemeraroS,MottaM;ItalianStudyGroupforGeriatricAssessmentand Management.Effectivenessofgeriatricevaluationandcare.Oneyearresultsofa multicenterrandomizedclinicaltrial.Aging(Milano)2001;13(5):395405. Winograd,C.H.(1991).Targetingstrategies:Anoverviewofcriteriaandoutcomes.Journalof theAmericanGeriatricsSociety,9,2535. Winograd,C.H.,Gerety,M.B.,Brown,E.,&Kolodny,V.(1988).Targetingthehospitalized elderlyforgeriatricconsultation.JournaloftheAmericanGeriatricsSociety,36,1113 1119. Winograd,C.H.,Gerety,M.B.,&Lai,N.(1993).A.Anegativetrialofinpatientgeriatric consultation.Lessonslearnedandrecommendationsforfutureresearch.Archivesof InternalMedicine,153,20172023.
GeriatricAssessmentandRehabilitation
Chapter4
GeriatricAssessmentandRehabilitationUnits
JennieWells,MichaelBorrie,andPaulStolee
CliniciansPerspective:ChristopherFrank,MD
Frailolderpatientscommonlymanifestillnessbyfunctionaldecline.Admissionto acutecarehospitalmayaccentuatethisfunctionallossbylimitedaccesstotherapyservices, byiatrogenicillnesssuchasmedicationsideeffectsandbymisdiagnosisofillnessinthe elderly.Giventhecurrentbedshortageinmanyhospitals,olderpatientsmaybedischarged assoonasthepresentingmedicalproblemisstable,withlittlerecognitionoffunctional limitationsandothergeriatricconcerns.Thismeansthatmanyolderpatientsinhospitaland patientsafterdischargehaveproblemsthatmaybenefitfromgeriatricrehabilitation. Patientsinthecommunitymayhavedifficultyrecoveringfromanillnessthatdidnot necessitateadmission.Itisnotunusualtoseeolderpatientsathomeseveralmonthsafter anepisodeoffluwhoarelessmobileandlessindependentthanbeforetheillness.Even withoutaspecificillnesstoprecipitatefunctionaldecline,patientswithmultiplemedical conditionsoftenfacechallengesthatcouldbelessenedbyinpatientrehabilitation.In additiontotheemphasisonfunction,inpatientgeriatricrehabilitationoffersanopportunity tooptimizemedicalconditions,toassesscognitiveimpairmentanddepressionandto providerespiteforcaregivers. Weknowgeriatricrehabilitationisbeneficialgiventheworkdonebytheauthorsof thischapter.However,whattheirresearchdoesnotreflectistheimmensesatisfactionthat workingingeriatricrehabilitationcanprovide.Itisverygratifyingtoconductafamily conferencewherethefamilyandpatientcommentthattheycannotbelievehowmuch betterthepatientisthanbeforeadmission.Geriatricrehabilitationprovideshealth professionalswiththeintellectualchallengeofmedicalcomplexity,thepositiveexperience ofinterdisciplinaryteamwork,andtherealpleasureofworkingwitholderpatientsina settingwhereyoucangettoknowthemwhiletheyaregettingmoreindependentand functional. Geriatricrehabilitationunitsarealsoanexcellentsettingforintroducingjunior traineestotheworldofgeriatriccare.Onarehabilitationunittheyareexposedto complicatedmedicalissues,getrolemodelingfromexperiencedseniorstaff,andseetrue teamworkinaction.Theyalsoseetheolderpatientinamorepositivelightcomparedwith someclinicalexperiencesinacutecaresettings.Aninpatientgeriatricunitcanactasthe primaryclinicalexposureingeriatricsformedicalstudentsandlearnersinoccupationaland physicaltherapy,nursingandmanyotherdisciplines.Giventhehighrateofcognitiveissues
GeriatricAssessmentandRehabilitation anddepressionthataremanifestedbypatientsintheseunits,rehabilitationmaybean opportunitytoexposetraineestocommongeriatricpsychiatryissuesaswell. Despitethesebenefits,inpatientgeriatricrehabilitationdoesnothaveahighprofile inhealthcare.Thismaybeinpartbecausethereislittleworktosystematicallymeasure outcomesasrecommendedinthechapterthatfollows.Manygeriatricrehabilitationunits arenotfundedasrehabilitationatall,andareinsteadfundedfromcomplexcontinuingcare. Thismeansthatprofessionalandnonprofessionalservicesmaybelimitedbyfunding,and thefacilitiesavailableinagivendistrictmaynotbeoptimalforprovidingrehabilitation.In consequence,equitableaccesstoappropriaterehabilitationmaybedeniedinsomeareas whattheBritishcalltreatmentbypostalcodetherebyimpairingqualityofcare. Moreover,theissueofwaittimesforgeriatricrehabilitationhasnotbeenincludedin anyoftherecentreportsonwaittimes.AprojectfundedbytheOntarioNeurotrauma FoundationfoundthatprovidersofrehabilitationservicesinOntarioviewwaittimesasa concern.Despitethisconcernandtheevidenceprovidedinthischapterforeffectiveness, hospitalsandgovernmentsometimesdonotappeartoviewgeriatricrehabilitationasa potentialstrategytodecreaseratesofAlternateLevelofCare(ALC)patientsinacutecare hospitals,thesocalledbedblockers.Untilstakeholdersrecognizetheneedtoprovide consistentfundingforgeriatricrehabilitationunitsandquickaccesstoservicesfor communityandhospitalpatients,geriatricrehabilitationwillcontinuetoplayarelevant,but limitedroleinhealthcareinOntario.
ExecutiveSummary Althoughtherearevariousservicesprovidinggeriatricrehabilitation,geriatric assessmentandrehabilitationunitshavebeenassociatedwithgreaterbenefitsincluding improvedphysicalperformanceandmobility;improvedindependencewithactivitiesof dailyliving;reducedlikelihoodofbeinginstitutionalized;lowermortalityrates;and improvedqualityoflife.Basedontheliteraturereview,itisrecommendedthat Patientsarescreenedforrehabilitationpotentialbeforeadmissiontoaunit o Medicalassessmentshouldbeanessentialcomponentofpreadmission screening. o Assessingcognition,motivationanddepressionareimportantfactorsin determiningrehabilitationpotential.Comprehensivegeriatricassessments (CGA)shouldalsoincludeanutritionalassessment(seeChapter5). Furtherresearchisneededtodeterminespecificscreeningcriteriaforgeriatric rehabilitation. Welldefined,patientfocusedgoalsforrehabilitationareestablishedpriorto admission/transfer.Theseimprovethelikelihoodofpositiveoutcomesandpossibly reducenetcosts. Inaddition: Designationofastandardizedmethodtoassessinstrumentalfunctionalitywould assistinobjectivelydocumentingphysical,cognitive,emotional,andfunctional
GeriatricAssessmentandRehabilitation conditionsandaidinthediagnosisandmeasurementofrehabilitativeoutcome. Interdisciplinaryteamsincreasepatientsatisfaction,lowerlengthofstayinhospitals, lowerhospitalcosts,andreducedeclinesinfunctionalhealth.Theevidencesupports thefollowingrecommendations: o theteamshouldbetrainedincareoftheelderlyandmanagedbyaphysician o thephysicianandpharmacistshouldcompleteamedicationreview Someissuesofcaringforseniorsinarehabilitationsettingarenotwellunderstood. MoreresearchisneededtoidentifywhicholderpersonswillbenefitmostfromCGAand geriatricrehabilitation.Furtherresearchisalsoneededtohelpdefinewhichrehabilitation settingsaremostappropriateandcosteffectiveandtohelpdefinewhichbenefitsof rehabilitationareachievedandsustained. Introduction Geriatricrehabilitationhasbeendefinedasevaluation,diagnostic,andtherapeutic interventionswhosepurposeistorestorefunctionalabilityorenhanceresidualfunctional capabilityinelderlypeoplewithdisablingimpairments(BostonWorkingGroup,1997,p.4). Ingeneral,thebenefitsofgeriatricrehabilitationarewelldocumented(Ettingeretal.,1997; Goldstein,Strasser,Woodard,&Roberts,1997;Joseph&Wanlass,1993;Reid&Kennie, 1989).Althoughvariousservicesprovidingrehabilitationforfrailolderpersonshavebeen describedintheliterature,suchashospitalbasedgeriatricassessmentandrehabilitation units(Applegate,etal.,1990b),inpatientgeriatricconsultationservicesprovidedtopatients innondesignatedunits(Reubenetal.,1995;seeChapter5),communitybasedgeriatric assessmentandinterventionprograms(Hendriksen,Lund,&Stromgard,1984),and outpatientgeriatricclinics(Cohen,etal.,2002;seeChapter7),greaterbenefitshavebeen associatedwithgeriatricassessmentandrehabilitationunits(Applegateetal.,1990b; Rubensteinetal.,1984). Outcomesassociatedwithgeriatricrehabilitationunits(GRUs)includeimproved physicalperformanceandmobility,improvedindependencewithactivitiesofdailyliving (Cohenetal.,2002;Liem,Chernoff,&Carter,1986),reducedlikelihoodofbeing institutionalized,andlowermortalityrates(Applegateetal.,1990b;Rubensteinetal.,1984), improvedqualityoflife(Cohenetal.,2002),improvedcontinence(Karppi,1995;Liem, Chernoff,&Carter,1986),andreducedtime(subsequenttodischarge)innursinghomeor acutecarefacilities(Rubenstein,etal.,1984). Muchoftheevidencesupportinggeriatricassessmentandrehabilitationstemsfrom theevaluationofgeriatricassessmentunits(GAUs).GAUsandGRUshavemanysimilarities. Bothproviderehabilitationwithaninterdisciplinaryteamtrainedinthecareoftheelderly, withattentiontomedical,psychosocial,andfunctionalissues.Treatmentplansare establishedandreviewedinregularteammeetingswiththerapeuticandrehabilitativegoals (Rubenstein,etal.,1986).InGAUs,thereismoreemphasisonmedicaltreatmentand evaluation,andrehabilitationgoalsareusuallyshortterm.InGRUs,thereisagreater emphasisonrehabilitationandachievingmaximalfunction.SpecializedGAUsandGRUsare designedtoapproachthemedicalevaluationofthefrailelderlyfromaninterdisciplinary
GeriatricAssessmentandRehabilitation perspective.Ingeriatricrehabilitation,smallgainsinseveralareasmayresultinimproved functionalstatus.Attentionisgiventomedicalillnesses,aswellastothepreservationand restorationoffunctionalstatus. Despitethesupportforgeriatricrehabilitation,thepracticesthataccountfor enhancedoutcomesarenotwelldescribedandthereisnogoldstandardforrehabilitation ofgeriatricpatients(Lokk,1999).Ithasbeensuggestedthatthereisagreaterneedfor moreresearchingeriatricrehabilitationtoaddressbestpractices,aswellasconsensuson interventionsandoutcomemeasures(Hoenig,Nusbaum,BrummelSmith,1997;Lokk,1999). Theobjectivesofthischapterare:1)toidentifyevidencebasedpracticesingeriatric rehabilitationand,basedonthis,toproviderecommendationsaboutsomeoftheprocesses ofgeriatricrehabilitation;and2)todescribecurrentrehabilitationpracticesinGRUsin Canadaandtodeterminewhetherthesepracticesareconsistentwiththeliterature. LiteratureReview Acomprehensiveliteraturereviewwasconductedtoinvestigateevidencebasedbest practicesingeriatricrehabilitation.Thesearchstrategyforthisreviewincludedthe systematicsearchofseveralcomputerizedbibliographicdatabases(MedLine,CINAHL,and theCochraneLibrary),usingthefollowingkeywords:geriatric,elderly,frail,geriatric rehabilitation,rehabilitation,inpatientandoutpatientgeriatricrehabilitation,assessment, outcomes,outcomemeasures,longtermcare,homecare,community,andgeriatricday hospital.Thesearchwaslimitedtoarticlespublishedbetween1980and2005andtoEnglish andFrenchlanguagejournals.Asecondsearchstrategylimitedparameterstorandomised controltrials(RCTs),ageover65years,usednolanguageexclusion,andusedthekeyword: geriatricrehabilitation.Articleswereretainedforreviewwhentheyfocusedongeriatric rehabilitationandinpatientgeriatricrehabilitation.Articleswereexcludedfromreview whentheywereunrelatedtogeriatricrehabilitation,wereanecdotalordescriptivereports onasmallnumberofpatients,orwererelatedtogeriatricdayhospitals(forasystematic reviewofgeriatricdayhospitalsseeForster,Young&Langhorne,1999;seealsoChapter7). Atotalof336articleswereretainedforreviewandwereassignedastandardized levelofevidenceconsistentwiththoseusedinaCanadianconsensusconferenceon dementia(Patterson,etal.,1999).TheselevelsofevidencearedescribedinTable4.1. Systematicreviewsandmetaanalyseswereassignedalevel1.Ofthearticlesreviewed,116 werelevel1evidence,39werelevel2,and189werelevel3evidence. Theclinicalthemesderivedfromthisliteratureweredefinedbythenumberand qualityofpublishedarticles.Thesethemeswereorganizedtorepresenttheclinical processesofgeriatricrehabilitationfrompreadmissionassessmenttoclinicalmanagement (screeningforadmission,comprehensivegeriatricassessment,assessmenttools, interdisciplinaryteams)andpatientcareofcommonclinicalproblemsforfrailolderpersons (hipfracture,stroke,nutrition,dementia,anddepression).
GeriatricAssessmentandRehabilitation Table4.1:LevelsofEvidence(Pattersonetal.,1999) LevelsofEvidence Level1: Evidencefromatleastonerandomizedcontroltrial Level2: Evidencefromwelldesignedcontrolledtrialswithoutrandomizationor fromwelldesignedcohortorcasecontrolanalyticstudies Level3: Evidencesupportedbyconsensusstatementsfromexperts,opinions fromrespectedauthorities,descriptivestudies,orreportsofexpert committees. EvidenceBasedClinicalProcessesofGeriatricRehabilitation ScreeningforAdmission Selectingappropriatepatientsforinpatientgeriatricrehabilitationinvolves identifyingindividualswithcomplexproblemsbutwhomaypotentiallybenefitfrom rehabilitation.Althoughcarefulpatienttargetinghasbeenadvocatedasamethodof improvingtheoutcomesofservicesforolderpersons,variationsintargetingpracticeshave leadtoinconsistentresultsinstudiesofgeriatricrehabilitation(Rubenstein,Stuck,Siu,& Wieland,1991;Stuck,Siu,Wieland,Adams,&Rubenstein,1993).Whenselectingpatientsfor geriatricrehabilitation,thedimensionsusedtodefinefrailtyshouldbeassessed:functional impairment,medicalcomplexity,psychologicalfunctioning,andsocialsupport(Mosqueda, 1993).Patientswhoaretoomedicallyunstableorwhoaremoreappropriateforpalliative careandthosewhocanremainathomeandbetreatedasoutpatientsshouldbeexcluded (Miller,Applegate,Elam,&Graney,1994;ManSonHing,Power,Byszewski,&Dalziel,1997; Wieland&Rubenstein,1996). Comprehensivegeriatricassessmentconsensusconferenceshavesupportedpatient targetingforrehabilitation.Rubenstein,Josephson,WielandandKane(1986)describedthe categorizationofpatientsintodiagnosticandprognosticgroupstotargetthemost appropriatepatientsforspecializedgeriatricinpatientcare.Patientsoverage65were classifiedintofivecategories:(1)geriatricevaluationunitcandidate(patienthasmedical, functional,orpsychologicalproblemspreventingdischargehome);(2)severelydemented; (3)medical(patientswithasinglemedicaldisease);(4)terminal,orpalliative;and(5) independent.Severalseparatemetaanalyseshavedefinedtargetingbywhetherthetrials excludedtoohealthysubjectsorsubjectswithpoorprognosis(Stuck,etal.,1993; Wieland,Stuck,Siu,Adams,&Rubenstein,1995).Studiesthatusedtargetingweremore likelytoshowimprovedoutcomes(Wieland,etal.,1995).Moreover,targetingpatientsfor geriatricevaluationininpatientunitsmayimprovecosteffectiveness(Wieland& Rubenstein,1996). Medicalassessmentisanimportantcomponentofpreadmissionscreening.Acohort studyof507acutelyhospitalizedmaleveteransaged65yearsandovershowedthat patientswithgreaternumbersoftargetingcriteriaatadmission(e.g.,polypharmacy, confusion,falls)weremorelikelytohavepooroutcomes,includingnursinghome
GeriatricAssessmentandRehabilitation placement,longerhospitalstays,andmortalityat12months(Satish,Winograd,Chavez,& Bloch,1996).Althoughtargetingacutelyill,geriatricinpatientswithpotentiallyremediable geriatricsyndromes(polypharmacy,confusion,falls)forgeriatricservicesmayprevent adverseoutcomes,arecentstudyof110GRUpatientssuggestedthattheremaybea thresholdofseverecomorbidityabovewhichpoorerrehabilitationoutcomemaybe expected(Patrick,Knoefel,Gaskowski,&Rexroth,2001).Furtherresearchisneededto refinethescreeningcriteriaforrehabilitationpotentialingeriatricrehabilitation. Cognitivescreeningisalsoimportantinassessingrehabilitationpotential (Ruchinskas,Singer,&Repetz,2001).Inabilitytounderstandinstructionsorremember informationmayhindertherapy.Nonetheless,recentstudies(Diamond,Felsenthal, Macciocchi,Butler,&LallyCassady,1996;Goldsteinetal.,1997;Heruti,Lusky,Barell,Ohry,& Adunsky,1999;Patrick,Leber,&Johnston,1996;Ruchinskas,Singer,&Repetz,2001) suggestthatsomecognitivelyimpairedpatientsmaybenefitfromgeriatricrehabilitation. Onelongitudinalstudy(Goldsteinetal.,1997)ofpatientswithhipfracturefoundthat althoughcognitivelyintactpatientshadhigherlevelsofmobilityatdischarge,both cognitivelyimpairedandintactpatientsimprovedsimilarlyinsphinctercontrol,locomotion, selfcare,andmotorfunction.Thus,somecognitivelyimpairedgeriatricpatientsshouldbe consideredforrehabilitation. Patientmotivationissometimesusedinassessingpotentialforrehabilitation success.Ithasbeensuggestedthatpatientswithlowmotivationtoparticipateingeriatric rehabilitationhavelowerrehabilitationpotentialthandopatientswithhighmotivation (Mosqueda,1993).Depressioncaninfluenceapatientsmotivationlevel.Depressedpatients maybelessmotivatedtoparticipateintherapy,which,inturn,maydelaydischarge. Treatingdepression,however,shouldimprovemotivationandoutcomes(Teasell,Merskey, &Deshpande,1999).Lowmotivationtoparticipateinrehabilitationshouldnotnecessarily begroundsforexclusion.Itispossible,forexample,thatapatientmaybeperceivedas poorlymotivatedwhenthegoalssetbytheinterdisciplinaryteamarenotpatient focused.Whenthisoccurs,blameistransferredtothepatientwhenthereisnosubstantial functionalimprovement(Resnick,1996;SeeChapterFive). Motivationtoparticipateinrehabilitationmaybefostered.Inastudyof77GRU patients,37participantswererandomlyassignedtoatreatmentgroup(40toacontrol groupofusualgeriatricrehabilitativecare)ofinterventionsconsistingofverbalpersuasion, rolemodeling,andphysiologicfeedback(Resnick,1998).Motivationwasassessedbyfour measuresofselfefficacyandaparticipationindex.Outcomemeasuresincludedafunctional measureandtwopainmeasures.Thetreatmentgroupexperiencedlesspain,hadgreater participationandefficacybeliefsrelatedtoparticipation,andhadimprovedfunctional performancecomparedwiththecontrolgroupatdischarge. Basedontheliteratureevidence,itisrecommendedthat:(1)patientsshouldhave preadmissionscreeningforrehabilitationpotentialbeforeadmissiontoaGRU(level3 evidence;Mosqueda,1993;Patricketal.,2001;Ruchinskasetal.,2001;Wieland& Rubenstein,1996);and(2)thescreeningprocessshouldbeusedtoestablishwelldefined, patientfocusedgoalsforrehabilitation(level3evidence;Mosqueda,1993;Resnick,1996;
GeriatricAssessmentandRehabilitation Wieland&Rubenstein,1996).Table4.2presentsasummaryofalltheevidencebased recommendationsforGRUbestpracticesgeneratedfromthisliteraturereview. Table4.2:SummaryofEvidenceBasedRecommendationsfor GeriatricRehabilitationUnitBestPractices GeriatricRehabilitationBestPractices AdmissionScreening Patientsshouldhavepreadmissionscreeningforrehabilitationpotentialpriorto admissiontoaGRU(level3evidence). o Assess:functionalimpairment,medicalcomplexity,psychological functioning,andsocialsupport. o Exclude:patientswhoaretoomedicallyunstable,moreappropriatefor palliativecare,orcanbetreatedathomeasoutpatients. Thescreeningprocessshouldbeusedtoestablishwelldefined,patientfocused goalsforrehabilitation(level3evidence). ComprehensiveGeriatricAssessment(CGA) CGAisimportantforfrailolderpersonswithrehabilitationneeds(level3 evidence). Closemedicalsupervisionandconcomitanttreatmentforintercurrentand comorbiditiesisimportant(level3evidence). AssessmentTools Assessmenttoolsshouldbeusedtoaidindiagnosisandtomeasureoutcomeof rehabilitation(level3evidence). TeamApproachtoCare Geriatricrehabilitationshouldhaveaninterdisciplinaryteamapproach(level1 evidence). Medicalcareandrehabilitationshouldbemanagedbyaphysicianandteam trainedincareoftheelderly(level1evidence). Therehabilitationteamphysicianandpharmacistshouldcompleteamedication review(level3evidence). Patientswithcomplexmedicationregimeswhoarereturningtocommunityliving maybenefitfromaselfmedicationprogram(level1evidence). HipFracture Frailolderpersonswithhipfractureshouldreceivegeriatricrehabilitation(level1 evidence).
GeriatricAssessmentandRehabilitation Nutrition Frailolderrehabilitationpatientsshouldreceivenutritionalscreening(level3 evidence). Nutritionalsupplementsshouldbeprovidedtoundernourishedfrailolder rehabilitationpatients(level1evidence). Treatmentplananddietaryinterventionsshouldbeprovidedtoforfrailolder patientswithdysphagia(level2evidence). Gastrostomytubefeedingissuperiortonasogastrictubefeedingforolderstroke patientswithseveredysphagia(level1evidence). Thenutritionallyatriskolderpatientwithhipfracturemaybenefitfromnutrition supplementation(level1evidence). Depression Frailolderrehabilitationpatientsshouldbescreenedfordepressionand treatmentplansinitiatedwhenappropriate(level3evidence). Cognitiveimpairment Frailolderpatientsshouldbescreenedforcognitiveimpairment(level2 evidence). Frailolderrehabilitationcandidateswithmildtomoderatedementiashouldnot beexcludedfromrehabilitation(level1evidence). ComprehensiveGeriatricAssessment AsnotedinChapter3,thebestevidencefortheefficacyofCGAhasbeenproduced forinpatientrehabilitation.CGAinvolvesamultidimensionalteamapproachthatdetermines anolderpersonsbiomedical,psychosocial,andenvironmentalneedssothatanappropriate treatmentandfollowupplancanbeinitiated.CGAinvolvesamedicalandrehabilitation approach,aswellasanassessmentofvision,hearing,cognition,depression,andfunctional status.Ithasbeenshownintheinpatientsettingtoimprovecognition,improvefunctional status,preventplacementinanursinghome,reducereadmissionstohospital,andlower mortality(Applegate,etal.,1990b;Rubenstein,etal.,1991;Stuck,etal.,1993;Scott,1999).A metaanalysisofCGA(totalof28RCTs;CGApatientsn=4959;controlgroupn=4912) demonstratedthat,forbothinpatientsandoutpatients,CGAassociatedwithlongterm managementiseffectiveinimprovingsurvivalandfunction(Stucketal.,1993). Theresultsofcosteffectivenessofgeriatricevaluationandcarearemixed.Millerand colleaguesanalysis(1994)ofaRCTbyApplegateandcolleagues(1990b;geriatriccaren= 78;usualcaren=77)showedthattheimprovedoutcomesinthegeriatricgroupwerenot associatedwithdecreasedcostoflatermedicalserviceafteroneyearoffollowup.In contrast,Rubenstein,Josephson,Harper,MillerandWieland(1995)demonstratedreduced costsforinstitutionalcare,fewerhospitalreadmissions,highermoraleandfunctionalstatus, andlowermortalityandnursinghomeplacementinanRCTofgeriatricassessmentpatients
GeriatricAssessmentandRehabilitation comparedwithusualcare(treatmentgroupn=63;controlgroupn=60).Thecostofcarein ageriatricunitwasshowntobenodifferentthanstandardcareoverthreeyearsandcarein thegeriatricunitresultedinlowermortalitywithoutcompromisingqualityoflife.Consistent withthis,Trentini,Semearo,andMotta(2001),inanoutpatientsetting,showedthatfrail elderlypatientsrandomizedtoCGA(n=79)hadimprovedmentalstatus,morale,and function,andreducedhospitalandnursinghomeadmission.CGApatientsreceivedmore homecareandoutpatientservicethanusualcarepatients(n=73),resultinginequivalent totalhealthcareexpenditure. Whileinrehabilitation,frailolderpersonsoftenhaveactivemedicalproblemsand comorbiditiesthatrequireclosemedicalmanagement.Patrickandcolleagues(2001)found that66%ofGRUpatientshad6ormorecoexistingillnesses.Felsenthal,Cohen,Hilton, PanagoesandAiken(1984),documentedinarehabilitationsettingthat3.7medical interventionswererequiredperpatient(N=82;Mage=74years;Mlengthofstay[LOS]= 28days).Wilkinson,BuhrkuhlandSainsbury(1997),reportedthatof200patientsinaGRU (agerange=6098years;Mage=80.5years;MLOS=28days),86%requiredmedical interventionand49%hadtheirrehabilitationcoursecomplicatedbymedicalillnesses. TheCGAapproachtogeriatricrehabilitationassessesthecontributionofmultiple medicalproblemsandhasbeenshowntouncovernewdiagnosesthatwerepreviously unrecognizedanduntreated(Epsteinetal.,1990;Winograd,1987).Despitethemultifactorial natureofdisabilityandtheburdenofcomorbidity,geriatricrehabilitationhasimprovedthe healthandfunctionofmanyfrailolderpersons(Applegate,etal.,1990b;Harris,OHara,& Harper,1995;Liem,etal.,1986;Mason&Bell,1994;Rubenstein,etal.,1984;Straus,etal., 1997).Areviewofmodelsofgeriatriccarefrom1984to1998concludedthatinpatient geriatricunitsprovidingrehabilitationforselectedolderpatientsofferprovenbenefitsand shouldbeavailableinallgeneralhospitals(Scott,1999). Theliteraturesupportsthefollowingconclusionsforfrailolderpersonsreceiving rehabilitation:(1)CGAisimportantforfrailolderpersonswithrehabilitationneeds(level1 evidence;Rubenstein,etal.,1984;1991;Stuck,etal.,1993),and(2)becausemanypatientsin geriatricrehabilitationhaveintercurrentillnessesandcomorbidities,closemedical supervisionandconcomitanttreatmentisimportant(level3evidence;Felsenthal,etal., 1984). StandardizedAssessmentTools Theneedforstandardizedassessmenttoolsingeriatricassessmentand rehabilitationstemsfromthedevelopmentofCGAandtheassessmentofobjective componentsoffrailty.Physiciansoftenunderestimatetheextentofdisabilitythatapatient hasinbasicactivitiesofdailyliving(ADLs).Further,physicianrecordingofthelevelof functioninmedicalnotesispoor(Rodgers,Curless,&James,1993).Impairmentinphysical function,mentalstatus,continence,emotionalstatus,vision,andgaitarenotableexamples thatcanbeunderdocumented.Byusingstandardizedassessmenttools,CGAcanobjectively documentphysical,cognitive,emotional,andfunctionalconditions(Applegate,Blass,& Williams,1990a;Miller,Morley,Rubenstein,Pietruska,&Strome,1990;Pinholt,etal.,1987). Agreementonwhichtoolsshouldbeusedconsistentlywouldhelpfacilitatemulticentre
GeriatricAssessmentandRehabilitation trialsandthedevelopmentofbenchmarksingeriatricrehabilitation.Table4.3presentsthe mostcommonlyusedtoolsinthecontextofCGAandinpatientgeriatricrehabilitation settingsasreportedintheliterature. Table4.3:CommonlyUsedCGAandGeriatricRehabilitationAssessmentTools AssessmentTools IndividualizedAssessment GoalAttainmentScaling(GAS) FunctionalCapability BarthelIndex,ModifiedBarthelIndex FunctionalIndependenceMeasure(FIM) ActivitiesofDailyLiving KatzActivitiesofDailyLivingScale LawtonBrodyassessment GaitandBalance Timedupandgo(TUG)test BergBalanceScale(BBS) CognitiveFunctioning FolsteinMiniMentalStateExamination(MMSE) Clockdrawingtest Depression GeriatricDepressionScale(GDS) EvenBrieferAssessmentScaleforDepression(EBASDEP) CornellScaleforDepressioninDementia MedicalComplexity(comorbidity) CumulativeIllnessRatingScale HealthStatus,QualityofLife RandMOSMeasures(SF36,SF12,SF8) Duke17 QualityofLifeinAlzheimersDisease(QOLAD) QualityofLifeinDementia(QOLID)
GeriatricAssessmentandRehabilitation Assessmentandreassessmentofapatientsindividualfunctionalproblemsmonitor improvementduringrehabilitation.TheBarthelIndexandtheFunctionalIndependence Measure(FIM)instrumentsarecommonlyusedfunctionalmeasures(Pinholtetal.,1987). TheBarthelIndexwasdevelopedforpeoplewithneurologicalormusculoskeletaldisabilities toassessperformancebeforeadmissionandafterdischargefromarehabilitationprogram. AModifiedBarthelIndexcomprises10itemsfocusingonADLs.Itiseasytoadminister; scorescorrelatewellwithlengthofstayanditalsohashighintraandinterraterreliability. However,itisnotparticularlyresponsivetochange,andfallsshortinsensitivityinthehigher andlowerranges(Pinholt,etal.,1987).TheFIMisbasedontheBarthelIndexandisavalid, sensitivemeasureoffunctionalstatusintheelderly.Itrates18functionalactivitiesonscales ofrelativeindependencefrom1to7.Therearesixdomainsincludingselfcare,sphincter control,mobility,locomotion,communication,andsocialcognition(McDowell&Newell, 1996). Inthegeriatricpopulation,thereareoftenmultiplegoalsbasedontheindividual patientscomplexmedical,social,andfunctionalproblems.Oneapproachtoaddressthe complexandindividualizednatureoftheseproblemsforgeriatricpatientsistheuseofan individualizedmeasuresuchasgoalattainmentscaling(GAS).GASaddressescomplexityby identifyingandscalingdisparate,individualizedgoalsforeachpatient(Kiresiuk,Smith,& Cardillo,1994).AlthoughGASwasdevelopedinthe1960sforuseinhumanserviceand mentalhealthprograms,ithasmorerecentlybeenappliedtothegeriatricrehabilitation setting(Stolee,Rockwood,Fox,&Streiner,1992).Ithasbeenshowntobevalid,reliable, responsivetochange,andpracticaltouseinavarietyofsettingsinthecareoftheelderly (Stolee,etal.,1992;Rockwood,Joyce,&Stolee,1997;Rockwood,Stolee,&Fox,1993;Yip,et al.,1998).GASismoreresponsivetochangethanotherstandardizedmeasures,suchasthe BarthelIndex,NottinghamHealthProfile,andMiniMentalStateExamination(MMSE; Stolee,Stadnyk,Myers,&Rockwood,1999). ADLsandinstrumentalactivitiesofdailyliving(IADLs)arecarefullydocumentedin CGAandinthegeriatricrehabilitationsetting.TheKatzADLscaleiswidelyused.Ithasthe advantagethatitcanbecompletedbythepatientorcaregiver.Itisbrief,reliable,andvalid, butitisnotverysensitivetochange(Studenski&Duncan,1993).TheLawtonBrody assessmentisascaleforselfcareADLandIADL(Lawton&Brody,1969).Ithasproventobe validandreliableintheolderpopulation(Israel,Kozarevic,&Sartorius,1984). TestsofspecificfunctionarealsocommonlyusedinCGAandthegeriatric rehabilitationsetting.Assessmentofgaitandbalanceisoneexample.TheTimedUpandGo (TUG)testinvolvestimingapatientashe/sherisesfromachair,walks10feet,turnsaround, walksbacktothechairandsitsdown.TheTUGtesthasbeenshowntobereliable,valid, easytoadminister,anditcorrelateswellwithtestssuchastheBergBalanceScale(BBS)and BarthelIndex.Italsopredictsapatientsabilitytowalksafelyaloneoutside(Podsiadlo& Richardson,1991).TheBergBalanceScale(BBS)isawellknowntoolforassessingbalance thathasbeendevelopedandvalidatedforuseintheelderlypopulation(Berg,Wood Dauphinee,Williams,&Grayton,1989).Itconsistsof14commonmovementsrequiredfor balanceandmobilityineverydaylife.Theitemsaregradedonascaleof0to4,givingatotal of56points,withhigherscoresrepresentingbetterperformance.Thetestissimpleto
GeriatricAssessmentandRehabilitation administer,safetoperform,andtakesabout15minutestocomplete.Intraandinterrater reliabilityarehigh(Berg,etal.,1989). AcognitiveassessmentisanessentialpartofaCGA.LuxenbergandFeigenbaum (1986)havenotedthatinnongeriatricinpatientrehabilitationsettingsphysicianstendtobe unawareofthecognitiveproblemsoftheirpatientsunlesscognitiveimpairmentwas documentedbeforeadmission.Theysuggestthatcognitivetestingbeadministered routinelyforpatientsinarehabilitationward.Thebestknownmeasureofcognitive functioninginolderpersonsistheFolsteinMiniMentalStatusExamination(MMSE;Folstein, Folstein,&McHugh,1975).Ithasbeenextensivelyvalidated,iseasytoadminister,andhas beenstandardized(Molloy,Alemayehu,&Roberts,1991).Theclockdrawingtestisaquick, validcognitivetestofexecutivefunctionandspatialorientationthatcorrelateswellwith generalcognitiveabilityandrehabilitationoutcome(Ruchinskas,etal.,2001). Severalassessmenttoolsarecommonlyusedtoassesssymptomsofdepression.The GeriatricDepressionScale(GDS)isabriefselfadministeredquestionnairethathasbeen proventobevalidandreliableinolderpersonswhoarenotcognitivelyimpaired(Yesavage, etal.,1982).TheEvenBrieferAssessmentScaleforDepression(EBASDEP)isalsovalidand reliableandeasytouseintheelderly(Allen,etal.,1994).Bothofthesetoolsarecommonly usedingeriatricassessmentsettings.Seniorswithdementiausuallylacktheinsightto providereliableresponsestotheGDSandEBASDEP.TheCornellScaleforDepressionin Dementiaismoreappropriatetoassessdepressivesymptomsinthosewithcognitive impairment.TheCornellscalehasbeenvalidatedwithbothcognitivelyintactandimpaired patients.Itisalsoeasytoadministerandmakesuseofbothpatientassessmentand caregiverreports(Alexopoulos,Abrams,Young,&Shamoian,1988a;1988b). TheCumulativeIllnessRatingScale(CIRS)hasbeendesignedspecificallytoassess medicalcomorbiditiesandcomplexity(Linn,Linn&Gurel,1968).TheCIRSmeasures13 bodilysystemstogiveacomorbidityindexandtotalcumulativeillnessratingscore.Thistool hasbeenvalidatedasameasureofmedicalcomplexityforfrailolderpersons(Parmalee, Thuras,Katz,&Lawton,1995).Thecomorbidityindex,inconjunctionwithotherindicesof function(e.g.,FIMorBarthelIndex)cancaptureapatientsleveloffrailty. Basedontheevidence,itisrecommendedthatassessmenttoolsbeusedtoaidin diagnosisandtomeasureoutcomeofrehabilitation(level3evidence;Folstein,etal.,1975; Rockwood,Stolee,&Fox,1993;Stolee,Rockwood,Fox,&Streiner,1992;Stolee,etal.,1999; VanSwearingen&Brach,2001). InterdisciplinaryTeams Thereismuchsupportforaninterdisciplinaryteamapproachtogeriatric rehabilitation(Applegate,etal.,1990b;Hughes&MedinaWalpole,2000;Lokk,1999; Rubensteinetal.,1984;1988;1995;Toseland,etal.,1996;Williams,Williams,Zimmer,Hall,& Podgorski,1987).Apurelymultidisciplinaryapproachmerelyimpliesthattherearemultiple disciplinesworkingonthecareofapatient(Weber,Fleming,&Evans,1995).Keyfeaturesof effectiveinterdisciplinarygeriatricrehabilitationteamsaresummarizedinTable4.4. Nursingstaffhavebeenidentifiedaskeymembersoftherehabilitationteam (Covinsky,etal.,1998).Nursesoftenspendsignificantlymoretimewithpatientsthanother
GeriatricAssessmentandRehabilitation teammembersandcanmoredirectlyassesstheirfunctionalprogressandpsychosocial needs.Nursesingeriatricrehabilitationcanalsopreventmuscledeconditioningby encouragingpatientstostriveforindependenceinactivities(Harrisetal.,1995).Inastudyof 251geriatricrehabilitationpatients,nursinginterventionsaimedatbladderretrainingand selfadministrationofmedicationwerefoundtodecreaseurinaryincontinenceand retentionandtoimproveknowledgeofmedications(Resnick,Slocum,Lynn,&Moffett, 1996).Otherevidencesuggeststhattheempowermentofpatientsbynursesisessentialin clinicalmanagement,andcontributestodecreasedhospitalcosts,lengthofstay,and improvedshorttermfunctionaloutcomes(Covinskyetal.,1998). Table4.4:KeyFeaturesofEffectiveInterdisciplinaryGeriatricRehabilitationTeams KeyFeatures Primaryfunctionsareassessment,treatment,anddischargeplanning Membershipincludesphysicians,nurses,socialworkers,occupationaltherapists, physiotherapists,speechtherapists,psychologists,andpharmacists(SeeTable4.1) Primarygoalistomaximizethepatientsfunctionalindependence Jointdecisionmakingandresponsibilitywithopencommunication,cooperation, andrespectforeachteammembersexpertise Negotiationofrolesandtaskstoaccomplishmutuallydefinedgoals Leadershiptendstobevestedinthedisciplinewiththehigheststatus Nursingstaffplayakeyroleintheclinicalmanagementofpatients,particularly assessmentandfosteringindependenceinactivities Medicationreviewbyphysiciansandpharmaciststoreducedruginteractionsand complicationinfrailolderpersons Selfmedicationprogramsforpatientswithcomplexmedicationregimes Dischargeplanning,includingahomevisit(s)conductedbyateammember Collaborativerelationshipsbetweenteammembers,patients,andfamilymembers, particularlyarounddischargeplanning Pharmacistsplayanimportantroleintheassessmentofthefrailelderly.A medicationreviewbytheteamphysicianandpharmacistisconsideredastandard componentofaCGA.Itsroleistoreducedruginteractionsandcomplicationsinfrailolder persons(Seymour&Routledge,1998).Recommendationsfromapharmacisthavebeen showntohelpwithdischargeplanning,toreducethetotalnumberofmedications,andto reducereadmissiontohospitalbecauseofmedicationcomplications(Romonko&Pereles, 1992).Selfmedicationprogramsassesspatientsabilitytomanagemedications independentlyandinvolveacoordinatedapproachwithinputfrombothnurseand pharmacist.Selfmedicationprogramsinthegeriatricrehabilitationsettinghavebeen showntoimprovemorale,independence,patientknowledgeabouttheircomplex medicationregimens(Platts,1989),andcompliance(Perelesetal.,1996).
GeriatricAssessmentandRehabilitation Theprimarygoalofinterdisciplinaryteamworkistomaximizepatientsfunctional independence.InaRCTcomparingtheeffectivenessofateamorientedgeriatric assessmentandevaluationtotraditionalcarebyaninternist,patientsreceivingtheteam approachhadsignificantlyfewerhospitaldaysandlowerannualhospitalcostsperpatient afteroneyear(Williams,etal.,1987).Anothercontrolledtrialcomparing205olderpatients receivinggeriatricteamcareinanoutpatientgeriatricclinicversusageneralmedicalclinic foundthatpatientsreceivingteamcarehadsignificantlylessdeclineinfunctionalhealthon thetotalSicknessImpactProfileanditsphysicaldimension(Yeo,Ingram,Skurnick,&Crapo, 1987). Interdisciplinaryteamsappeartoincreasepatientsatisfactionwithcare.InaRCT comparingoutpatientgeriatricassessmentandmanagementtousualoutpatientprimary care,frailolderpatientsreceivinggeriatricteamassessmentandmanagementreported highersatisfactionwithgeriatricservices(Toseland,etal.,1996). Inadditiontoassessmentandtreatment,interdisciplinaryteamsarealsoinvolvedin theprocessofearlydischargeplanning.Dischargeplanningshouldinvolvecollaboration betweentheinterdisciplinaryteam,patient,andfamilymembers(Simmons,1986).Bulland Roberts(2001)conductedsemistructuredinterviewswithhealthcareprofessionalsfrom twowardsina78bedgeriatricrehabilitationhospital.Participantsconsistentlynotedthe importanceofgeriatricteamsandcontinuouscommunicationascomponentsofproper discharge.Teamcoordinatedgeriatricdischargeplanningserviceshavebeenfoundto decreasethepercentageofbedsforpatientsawaitinglongtermcareandincreasedthe percentageofpatientsreturningtocommunityliving(Brymer,etal.,1995). Theroleoftheteamapproachingeriatricrehabilitationdischargeplanningis generalizedfromothersettings.Instrokepatients,forexample,earlyhospitaldischarge combinedwithhomebasedrehabilitationhasbeenshowntobeaseffectiveasusualcare (Anderson,etal.,2000;Mayo,etal.,2000;vonKoch,WidenHolmqvist,Kostulas,Almazan, &dePedroCuesta,2000). Dischargeplanningmayinvolveahomevisit(s)fromamemberofthe interdisciplinaryteam.InaRCTof530olderpersonsrecruitedfromselectedhospitalwards, thosepatientsreceivingahomevisitbyanoccupationaltherapisttoassessenvironmental hazardsandtomakenecessaryhomemodificationswerelesslikelytofallthanthecontrol groupatoneyearfollowup(Cumming,etal.,1999).Thisinterventionreducedthenumber offallsinpatientswhohadahistoryoffalls. Theevidencefromtheliteraturesupportsthefollowingrecommendations:(1) geriatricrehabilitationshouldhaveaninterdisciplinaryteamapproach(level1evidence; Applegate,etal.,1990b;Rubensteinetal.,1984;1988;Williams,etal.,1987;Yeo,etal.,1987); (2)medicalcareandrehabilitationshouldbemanagedbyaphysicianandteamtrainedin careoftheelderly(level1;Applegateetal.,1990b;Rubenstein,etal.1984;Scott,1999);(3) therehabilitationteamphysicianandpharmacistshouldcompleteamedicationreview (level3;Romonko&Pereles,1992:Seymour&Routledge,1998);and(4)patientswith complexmedicationregimeswhoarereturningtocommunitylivingmaybenefitfromaself medicationprogram(level1;Pereles,etal.,1996).
GeriatricAssessmentandRehabilitation GeriatricRehabilitationinCanada Asmentionedearlier,thereisnogoldstandardforrehabilitation(Lokk,1999),andit isnotclearwhetherthereisconsistencyinrehabilitationpracticesinGRUsacrosscenters. CanadianacademicGeriatricMedicinecentresweresurveyedtoidentifybestpracticesin geriatricrehabilitation,todeterminewhethertheseareconsistentwiththosedescribedin theliterature,andtodeterminewhetherthereisanyconsistencyintheuseofassessment toolsandoutcomemeasures(Borrie,Stolee,Knoefel,Wells,&Seabrooke,2005).Asurvey toidentifypracticesandcommonlyusedassessmenttoolsandoutcomemeasuresin geriatricrehabilitationwasdevelopedbasedontheliteraturereviewdescribedabove.The rehabilitationprocesswasdividedintothefollowingprocessesofcare:preadmission screening,admission,teamprocessesandinterventions,toolsforassessment,monitoring andoutcomemeasurement,anddischargeplanningandfollowup.Outcomemeasureswere definedasmeasurementtoolsthatarecompletedonadmissionanddischargeandreflect changesinfunctionandcognitionthatmayoccurwhileonarehabilitationservice. ThesurveywasdistributedelectronicallytotheChairorHeadresponsiblefor GeriatricRehabilitationUnits(GRUs),GeriatricDayHospitals(GDHs),ChronicCareUnits (CCUs),andoutpatientfacilities(OFs)ateachofthe17CanadianacademicGeriatric MedicineDivisionsandDepartments.Datafromthe17GeriatricRehabilitationUnitswillbe thefocusofthisdiscussion *.TheaverageageofpatientsintheGRUswas81years,andthe genderdistributionacrosstheGRUswasrelativelyconsistent.Themeannumberof admissionstotheGRUsperyearwas175.TheaveragenumberofbedsacrosstheGRUswas 30,withanoccupancyrateof88%andaveragelengthofstayof44days. Table4.5presentsGRUpreadmissionandadmissionprocessesandpractices.The majorityofGRUs(N=13;76.5%)requireapreadmissionassessmentforpatientsandallof thesearecompletedbyaspecialistingeriatricmedicine.Applicationsforbackuplong termcaredischargeoptionsarenotcommonlyrequiredbyGRUs.Potentialtobenefit, motivationandwillingnesstoparticipate,endurancefortherapyandmedicalstabilitywere commonlyidentifiedadmissioncriteria.Conversely,terminalillness,medicalinstability, cognitiveimpairment,andpoormotivationwerecommonlyidentifiedexclusioncriteria. WhileadmissionpracticesforalmostalloftheGRUs(N=16;94%)requirephysiotherapist completedmobilityassessmentsimmediatelyafteradmission,fewerGRUsrequirean admissionmedicalhistoryandphysicalexaminationcompletedbyaspecialistingeriatric medicine,orprovideinformationpackagespriortooratadmission(N=10;58.8%, respectively).
* Thisdatareflectscareprovidedindesignatedrehabilitationunitsanddoesnotincluderehabilitationcarethat isprovidedoutsideoftheseunits(e.g.,incomplexcontinuingcareunitswhererehabilitationmaybeprovided inbedsthatarenotspecificallydesignatedasrehabilitationbeds) OrganizationDesignforGeriatrics:AnEvidenceBasedApproach 45
GeriatricAssessmentandRehabilitation Table4.5:GeriatricRehabilitationUnit(GRU)Preadmission,Admission,andDischarge ProcessesandPractices ProcessesandPractices GRUs(N=17) Preadmission Requiringpreadmissionassessment 13(76.5%) PreadmissionassessmentscompletedbySpecialistinGeriatric Medicine 13(76.5%) Preadmissionassessmentscompletedbynurses 12(70.6%) RequiringLTC*dischargeoptionsbeforeadmission 4(23.5%) Admissionselectioncommittee 13(76.5%) Admission Providinginformationpackageprior/atadmission 10(58.8%) Completingmobilityassessmentimmediatelyafteradmission 16(94.0%) Physiotherapistcompletingmobilityassessment 16(94.0%) SpecialistinGeriatricMedicinecompletedadmissionmedical history&physicalexamination 10(58.8%) Discharge Earlydischargeplanning 17(100%) st nd Dischargeplanningin1 or2 weekofadmission 13(76.5%) Opportunitiesforselfmedicationprograms 15(88.0%) Patienteducationbypharmacist 15(88.0%) Educationtorelativesbypharmacist 15(88.0%) Dischargeinformationsentattimeofdischarge 13(76.5%) Satisfactionquestionnaires 12(70.5%) *LTCLongTermCare Table4.6presentsthetypesofinterventionsofferedbytheGRUs.Almostallofthe GRUs(N=16;94%)useaninterdisciplinaryteamapproachtogeriatricrehabilitation,and manyoftheseoperateaccordingtoaninterdisciplinarymodelofcarecoordination(N=12; 70.6%).Nurses,physiotherapists,occupationaltherapists,socialworkers,andteam physiciansarethemostcommonhealthdisciplinesthatattendteamroundsandreport progressonpatientgoals.Teamroundscommonlyoccuronceperweek.PrimaryNursingis themostcommonnursingmanagementmodelforGRUs.Thesettingofrehabilitationgoals, whichareinfluencedbyeachpatientsdesiredleveloffunctionanddischargelocation,are usuallyestablishedwithpatientsinconjunctionwithbaselineassessmentinformation. Communicationwithfamilyandcaregiversusuallyoccursthroughtheprimarynurseormost
GeriatricAssessmentandRehabilitation relevantteammemberatscheduledfamilyconferences.Communicationcommonlyoccurs withinthefirstweek,whenthereisachangeinapatientsmedicalconditionorfunctional status,andasrequiredpriortodischarge.AlloftheGRUsconductnutritionalscreening. Usualbodyweight,idealbodyweightandserumalbuminarethethreemostcommonly usedmeasuresofnutritionalstatus.Patientsbelowidealbodyweightarethemostlikelyto receiveoralortubefeedingnutritionalsupplements. Table4.6:GeriatricRehabilitationUnit(GRU)TeamModelsandInterventionPractices TeamModelandInterventionPractices GRUs(N=17) Interdisciplinaryteamapproach 16(94.0%) Regularteamrounds 17(100%) Teamroundsonceperweek 14(14.0%) Reviewintervaldeterminedbyconsistentintervals 16(94.0%) PrimarycarebySpecialistinGeriatricMedicine 10(58.8%) ConsultationprovidedbyGeriatricPsychiatrist 12(70.6%) Interdisciplinarymodelofcarecoordination 12(70.6%) Timingofcommunication:Asnecessarypriortodischarge 14(82.0%) Goalsettinginfirstweek 11(64.7%) Nutritionalscreening 17(100%) Nutritionist/Dieticiancompletionofnutritionalevaluation 17(100%) SwallowingassessmentbySpeechLanguagePathologist 15(88.0%) Nutritionalsupplements 17(100%) Theuseofstandardizedtoolsforassessment,monitoringand/oroutcome measurementbyGRUsispresentedinTable4.7.WhilethemajorityofGRUsusetheMini MentalStatusExaminationatthetimeofadmission(N=13;76.5%),andsomeuseitat discharge(N=8;47%),fewerGRUsareusingstandardizedmeasurescommonlycitedinthe literatureaspartoftheiradmissionordischargepractice.Somescalesareusedonlyas needed,asforexampletheBergBalanceScale,theTimedUpandGo(TUG),andthe GeriatricDepressionScale(usedby53%,47%,and53%oftheGRUs,respectively).Veryfew GRUs(lessthan5;29%)usestandardizedmeasuresoffunctionalautonomy. Dischargeandfollowuppracticesacrosstherehabilitationservicesarepresentedin Table4.5.AlloftheGRUshaveearlydischargeplanning,withmostGRUs(N=13;76.5%) initiatingthiswithinthefirstorsecondweekofadmission.Selfmedicationprogramsand educationtopatientsandfamiliesbypharmacistsarecommoninGRUs.(N=15;88%).Most commonlyphysicianscompletethedischargesummariesforGRUs.Familyphysiciansand CommunityCareAccessCenter(CCAC)casemanagersarethemostlikelytoreceive dischargeinformation.
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GeriatricAssessmentandRehabilitation Table4.7:GeriatricRehabilitationUnit(GRU)UseofCommonAssessmentToolsand OutcomeMeasuresuponAdmission,AtDischarge,andAsNeeded. GRUs(N=17) AssessmentToolsandOutcomeMeasures Admission Discharge Asneeded GoalAttainmentScaling(GAS;Kiresuketal.,1994; 5(29.0%) 4(23.5%) 5(29.0%) Stoleeetal.,1999) FunctionalIndependenceMeasure(FIM;Keithetal., 5(29.0%) 3(17.6%) 2(11.8%) 1987) BarthelIndex(Mahoney&Barthel,1965) 4(23.5%) 3(17.6%) 0 MiniMentalStateExamination(MMSE;Folsteinetal., 13(76.5%) 4(23.5%) 8(47.0%) 1975) GeriatricDepressionScale(GDS;Yesavageetal.,1982 5(29.0%) 2(11.8%) 9(53.0%) 83) CornellScaleforDepressioninDementia 0 0 1(6%) (Alexopoulousetal.,1988a;1988b) LawtonBrody(Lawton&Brody,1969) 1(6.0%) 1(6.0%) 3(17.6%) CanadianOccupationalPerformanceMeasure(COPM; 1(6.0%) 1(6.0%) 1(6.0%) Lawetal.,1990) MinimalDataSystem(MDS;Hirdes&Carpenter,1997; 1(6.0%) 0 2(11.8%) Hirdesetal.,1997) BergBalanceScale(BBS;Bergetal.,1989) 6(35.2%) 3(17.6%) 9(53.0%) TinettiBalanceandMobilityScale (Tinetti,Williams,& 0 0 2(11.8%) Mayewski,1986) FunctionalAutonomyMeasurement(SMAF;Hbert, 2(11.8%) 2(11.8%) 2(11.8%) Carrier,&Bilodeau,1988) TimedUpandGo(TUG;Podsiadlo&Richardson,1991) 3(17.6%) 3(17.6%) 8(47.0%) Std.Levodopa 1(6.0%) 1(6.0%) 3(17.6%) BladderScanner 0 0 9(53.0%) Conclusion Maintainingandrestoringthehealthandindependenceofthegrowingpopulationof olderpersonswillbeanincreasinglyimportantpartofhealthcareprovisioninthecoming years.Geriatricrehabilitationisanemergingareainhealthcare,andsomeissuesofcaring forseniorsinthisrehabilitationsettingarenotwellunderstood.Therearedifferences betweentherehabilitationofyoungadultsandthatoffrailolderadults.Themostsalient differencerelatestothehigherburdenofmedicalcomorbidityexperiencedbyfrailolder persons.Disabilityamongseniorsisoftenmulticausal,requiringinputfromseveral subspecialtiesandprofessionaldisciplinestoinvestigateandmanagethemedicalissuesand rehabilitationneeds. Frailtyistheclinicalstatethatmakesthemedicalmanagementandrehabilitationof theelderlycomplex.Frailtycanbeviewedasamultidimensionalconstructthat
GeriatricAssessmentandRehabilitation encompassesmorethanjustsimpledependenceforactivitiesofdailyliving.Itisacomplex interplayofapersonsassetsanddeficits,includinghealthandillness,attitudes,practices, resources,anddependenceonothers(Rockwood,Fox,Stolee,Robertson,&Beattie,1994; Rockwood,Stolee,&McDowell,1996). Frailtyisalsoseenasthelossoffunctionalhomeostasis.Functionalhomeostasisis theabilityofanindividualtowithstandillnesswithoutlossoffunction(Carlsonetal.,1998; Rozzini,Frisoni,Franzoni,&Trabucchi,2000).Ithasbeenshownthatolderpatientswith poorfunctionalhomeostasisdeclineinfunctionalstatusandhavehigheradverseoutcomes andreadmissiontohospital(Carlson,etal.,1998).Theassessmentoffunctionalhomeostasis mayprovideamethodtoidentifyfrailindividualsformoreintensivemanagementstrategies includingrehabilitation. Diseasepresentationintheelderlyisatypical,andolderpersonsoftenunderreport symptomsandproblems.Thetraditionalmedicalmodelofillnesspresentationhasbeen foundtofitlessthan50%ofseniorspresentingforgeriatricoutpatientassessment(Fried, Storer,King,&Lodder,1991).Forthisreason,modelsthatacknowledgethecumulative burdenofmultipleproblems,aswellasenvironmental,psychosocial,caregiver,and functionalissuesareimportantinassessingandcaringfortheelderly.Whenapersonwith chronicillnessesistreatedinadiseasespecificmodelofcare,unrelateddiseasesaremore likelytobeleftuntreated(Redelmeier,Tan,&Booth,1998). Personswithmultiplemedicalproblemsfaceagreaterdecrementinfunctionthan thosewithonlyasingleproblem.Concomitantcardiac,pulmonary,gastrointestinal,renal, musculoskeletal,andneurologicproblemscoupledwithmuscledeconditioningall contributetoapersonsdeclineinfunction.Thehigherprevalenceofcognitiveimpairment inolderpatientsaddstocomorbidity(Stewart,etal.,1989;Weber,etal.,1995).Geriatric syndromessuchasfalls,delirium,andincontinencearefunctionalproblemsandare consideredmarkersoffrailty(Rockwood,etal.,1994).Geriatricassessmentand rehabilitationacknowledgetheheterogeneityofthefrailolderpopulationandencompass theconceptofprevention,management,andrehabilitationofallaspectsoffrailty,notjust thetreatmentofmedicalillnessesintheacutesetting.ACGAisaprovenmodalityto decreasemortalityandtoincreasethecognitionandfunctionalstatusoffrailolderpatients withcomplexmedicalproblemsandmultiplecomorbidities(Rubenstein,etal.,1991;Scott, 1999). Thischapterhasdescribedcurrentandemergingbestpracticesingeriatric rehabilitation,particularlyasprovidedinwithinGRUs.Basedonourreview,werecommend thatolderpatientsbescreenedforinpatientrehabilitationpotentialandthatstandardized assessmenttoolsbeusedtoaidindiagnosis,assessment,andoutcomemeasurement.The teamapproachforgeriatricrehabilitationshouldbeinterdisciplinaryandshouldinvolve CGA.Theuseofselfmedicationprogramsandamedicationreviewissupported.Medical careandrehabilitationoffrailolderpatientsshouldbemanagedbyaphysicianandteam trainedinthecareoftheelderly.
GeriatricAssessmentandRehabilitation CallforResearch Ongoingclinicalresearchwillincreaseourknowledgeofthisfieldbecausethe rehabilitationneedsoffrailolderpersonswillhaveincreasinglyimportantimplicationsfor thehealthcaresystem.Allphysiciansshouldbeeducatedincareofthefrailelderly.More researchisneededintheareaofscreeningandfrailtytobetteridentifywhicholderpersons willbenefitmostfromCGAandgeriatricrehabilitation.Oneofthechallengesoffuture researchwillbetodeterminethedegreeofcomorbidityandcognitiveimpairmentthatis compatiblewithsuccessfuloutcomesingeriatricrehabilitation.Researchingeriatric rehabilitationshouldaddresswhichselectioncriteriabasedoncognitionarereasonable,and theoptimalperiodforatrialperiodofrehabilitationifinitiated.Althoughsomestudieshave shownthatmoderatelycognitivelyimpairedpatientsshowstatisticalimprovementin rehabilitation,moreresearchisneededtoshowclinicalsignificanceanddurationofeffect. Moreresearchisneededtohelpdefinewhichrehabilitationsettingsaremost appropriateandcosteffective.OnecriticismofCGAistheresourceintensityandthecostof care,particularlyintheinpatientsetting(Cefalu,Kaslow,Mims,&Simpson,1995;Keeler,et al.,1999).Becausethefieldofgeriatricrehabilitationisnew,therearelimitedstudieson costeffectiveness.Rubensteinandcolleagues(1995)werethefirsttodocumentthecost effectivenessofinpatientCGA.Theirstudyshowedthatsurvivalandfunctionalstatuswere improvedinthetreatmentgroupandthatpercapitacostsdidnotdiffersignificantlyfrom usualcare,bothbeforeandaftersurvivaladjustment.Furtherstudyoncosteffectivenessis required. Asidefrominpatientrehabilitationunits,rehabilitationandassessmentoffrailelderly withrehabilitationneedsmayoccurinothersettings.Recentlyithasbeenshowninameta analysisof18RCTsof13,447patientsthatpreventivehomevisitationprogramswitha multidimensionalassessmentandfollowupcanreducenursinghomeplacement,functional decline,andmortality(Stuck,Egger,Hammer,Minder,&Beck,2002).Geriatricdayhospitals haveshownbenefitsinmortalityandfunctionalstatusandmayoffercostbenefitsifthe reductioninlongtermcareplacementisconsidered(Forster,etal.,1999;seeChapter7).In theUnitedStates,rehabilitationservicesareofferedfortheelderlyinskillednursing facilities.VonSternbergandcolleagues(1997),forexample,describesamanagedcare modelofsubacutegeriatricrehabilitationinnursinghomestofacilitateearlydischargefrom hospital.Careunderthismodelresultedinfewercoststhanusualcaresettings. Economicevaluationsareneededcomparingorthopedicrehabilitationunits(GORUs) andmixedgeriatricassessmentandrehabilitationunits(MARUs)forcommunitydwelling hipfracturepatientswhoaretoodisabledforanearlysupporteddischarge.Anotherareain needoffurtherstudyisearlysupporteddischargeandgeriatrichipfractureprograms (GHFPs)toestablishevidenceforbestpracticeguidelines.Researchshouldemphasize functionalstatus,qualityoflife,andcaregiverburden,aswellaseconomicfactorsand societalperspectives(Cameron,etal.,2000).Moreover,researchisneededtoprovide clinicalpracticeguidelinesforspecializedtreatmentingeriatricrehabilitation.Forexample, thereisaneedforresearchtoaddresswhethernondrugand/ormedicationtreatmentof depressionishelpfulinthegeriatricrehabilitationsettingandtodeterminewhichpatients benefitmostfromnutritionalsupplements.
GeriatricAssessmentandRehabilitation Onelimitationofthisreviewisthatsomeoftherecommendationsarederivedfrom level3evidence.Longitudinalcasecontrol,multicenterrandomizedcontroltrials,andwell designedcohortstudiesareneededtoevaluateprognosticfactors,toidentifyriskfactors forcontinueddisability,andtoidentifyfactorsrelatedtosuccessfuloutcomes.More researchaboutCGA,frailty,anddisablementmayhelptoestablishwhichcomponentsof geriatricassessmentandmanagementofrehabilitationpatientsarecritical(Jette,1997). Similarly,researchinoutcomesingeriatricrehabilitationisstronglyencouragedto helpdefinewhichbenefitsareachievedandsustained.Therearemanycommonlyusedtools ingeriatricrehabilitation.GASandtheCIRSlookpromisingasmeasuresthatcanaddressthe complexityofgeriatricrehabilitation.Consensusonassessmentandoutcometoolswould facilitatemulticentercomparisonsofpracticesandpatientoutcomestofurtheradvance bestpracticesingeriatricrehabilitation.Agreementonselectioncriteriafortargeting patientsandcommonoutcomemeasureswillbenecessarytomakemeaningful comparisonsacrosscentresandservices.OursurveyofGRUsacrossCanadafoundthat althoughrehabilitationservicesarelargelyconsistentwiththosefoundintheliterature,in CanadianGRUstherewasnotwidespreaduseofstandardizedassessmenttools.Arecent consensusconferenceongeriatricrehabilitationwithresearchersandcliniciansfromacross Canadaestablishedagreementthatfurtherresearchonassessmenttoolsandprocesseswas apriority,particularlyasrelatedtogoalsettingprocesses,clientneedsandpreferences,the detectionofunmetneeds,andtheidentificationofbestassessmenttools(Stolee,Borrie, Cook,&Hollomby,2004).
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GeriatricAssessmentandRehabilitation References Alexopoulos,G.S.,Abrams,R.C.,Young,R.C.,&Shamoian,C.A.(1988a).CornellScalefor DepressioninDementia.BiologicalPsychiatry,23,27184. Alexopoulos,G.S.,Abrams,R.C.,Young,R.C.,&Shamoian,C.A.(1988b).UseofCornell scaleinnondementedpatients.JournaloftheAmericanGeriatricsSociety,36,230236. Allen,N.,Ames,D.,Ashby,D.,Bennetts,K.,Tuckwell,V.,&West,C.(1994).Abriefsensitive screeninginstrumentfordepressioninlatelife.AgeandAgeing,23,213218. Anderson,C.,Rubenach,S.,Mhurchu,C.N.,Clark,M.,Spencer,C.,&Winsor,A.(2000). Homeorhospitalforstrokerehabilitation?Resultsofarandomizedcontrolledtrial:I: Healthoutcomesat6months.Stroke,31,10241031. Applegate,W.B.,Blass,J.P.,&Williams,T.F.(1990a).Instrumentsforthefunctional assessmentofolderpatients.NewEnglandJournalofMedicine,322,12071214. Applegate,W.B.,Miller,S.T.,Graney,M.J.,Elam,J.T.,Burns,R.,&Akins,D.E.(1990b).A randomized,controlledtrialofageriatricassessmentunitinacommunity rehabilitationhospital.NewEnglandJournalofMedicine,322,15721578. Berg,K.,WoodDauphinee,S.,Williams,J.L.,&Gayton,D.(1989).Measuringbalanceinthe elderly:Preliminarydevelopmentofaninstrument.PhysiotherapyCanada,41,304311. Borrie,M.J.,Stolee,P.,Knoefel,F.,Wells,J.L.,&Seabrooke,J.A.(2005).Currentbest practicesingeriatricrehabilitationinCanada.GeriatricsToday:CanadianJournalof GeriatricMedicineandGeriatricPsychiatry,8,148153. BostonWorkingGrouponImprovingHealthCareOutcomesthroughGeriatric Rehabilitation.(1997).MedicalCare,35(6),420. Brymer,C.D.,Kohm,C.A.,Naglie,G.,ShekterWolfson,L.,Zorzitto,M.L.,ORourke,K.,etal. (1995).Dogeriatricprogramsdecreaselongtermuseofacutecarebeds?Journalof AmericanGeriatricsSociety,43,885889. Bull,M.J.,&Roberts,J.(2001).Componentsofaproperhospitaldischargeforelders. JournalofAdvancedNursing,35,571581. Cameron,L.,Crotty,M.,Currie,C.,Finnegan,T.,Gillespie,W.,Handoll,H.,etal.(2000). Geriatricrehabilitationfollowingfracturesinolderpeople:Asystematicreview. HealthTechnologyAssessment,4,1111. Carlson,J.E.,Zocchi,K.A.,Bettencourt,D.M.,Gambrel,M.L.,Freeman,J.L.,Zhang,D.,et al.(1998).Measuringfrailtyinthehospitalizedelderly:Conceptoffunctional homeostasis.AmericanJournalofPhysicalMedicineandRehabilitation,77,252257. Cefalu,C.A.,Kaslow,L.D.,Mims,B.,&Simpson,S.(1995).Followupofcomprehensive geriatricassessmentinafamilymedicineresidencyclinic.TheJournaloftheAmerican BoardofFamilyPractice,8,263269. Cohen,H.J.,Feussner,J.R.,Weinberger,M.,Carnes,M.,Hamdy,R.C.,Hsieh,F.,etal.(2002). Acontrolledtrialofinpatientandoutpatientgeriatricevaluationandmanagement. NewEnglandJournalofMedicine,346,905912. Covinsky,K.E.,Palmer,R.M.,Kresevic,D.M.,Kahana,E.,Counsell,S.R.,&Forinsky,R.H. (1998).Improvingfunctionaloutcomesinolderpatients:Lessonsfromanacutecare foreldersunit.JournalofQualityImprovement,24,6376.
GeriatricAssessmentandRehabilitation Cumming,R.G.,Thomas,M.,Szonyi,G.,Salkeld,G.,ONeill,E.,Westbury,C.,etal.(1999). Homevisitsbyanoccupationaltherapistforassessmentandmodificationof environmentalhazards:Arandomizedtrialoffallsprevention.Journalofthe AmericanGeriatricsSociety,47,13971402. Diamond,P.T.,Felsenthal,G.,Macciocchi,S.N.,Butler,D.H.,&LallyCassady,D.(1996). Effectofcognitiveimpairmentonrehabilitationoutcome.AmericanJournalof PhysicalMedicineandRehabilitation,75,4043. Epstein,A.M.,Hall,J.A.,Fretwell,M.,Fieldstein,M.,DeCiantis,M.L.,Tognetti,J.,etal. (1990).Consultativegeriatricassessmentforambulatorypatients:Arandomizedtrial inahealthmaintenanceorganization.JournaloftheAmericanMedicalAssociation, 263,538544. Ettinger,W.H.,Jr.,Burns,R.,Messier,S.P.,Applegate,W.,Rejesk,W.J.,Morgan,T.,etal. (1997).Arandomizedtrialcomparingaerobicexerciseandresistanceexercisewitha healtheducationprograminolderadultswithkneeosteoarthritis.TheFitness ArthritisandSeniorsTrial(FAST).JournaloftheAmericanMedicalAssociation,277,25 31. Felsenthal,G.,Cohen,B.S.,Hilton,E.B.,Panagoes,A.V.,&Aiken,B.M.(1984).The physiatristasprimaryphysicianforpatientsonaninpatientrehabilitationunit. ArchivesofPhysicalMedicineandRehabilitation,65,375385. Folstein,M.F.,Folstein,S.E.,&McHugh,P.R.(1975).MiniMentalstate.Apractical methodforgradingthecognitivestateofpatientsfortheclinician.Journalof PsychiatricResearch,12,18998. Forster,A.,Young,J.,&Langhorne,P.(1999).Systematicreviewofdayhospitalcarefor elderlypeople.BritishMedicalJournal,318,837847. Fried,L.P.,Storer,D.J.,King,D.E.,&Lodder,F.(1991).Diagnosisofillnesspresentationin theelderly.JournaloftheAmericanGeriatricSociety,39,117123. Goldstein,F.C.,Strasser,D.C.,Woodard,J.L.,&Roberts,V.J.(1997).Functionaloutcomeof cognitivelyimpairedhipfracturepatientsonageriatricrehabilitationunit.Journalof theAmericanGeriatricsSociety,45,3542. Harris,R.E.,OHara,P.A.,&Harper,D.W.(1995).Functionalstatusofgeriatricrehabilitation patients:Aoneyearfollowupstudy.JournaloftheAmericanGeriatricsSociety,43,51 55. Hbert,R.,Carrier,R.,&Bilodeau,A.(1988).TheFunctionalAutonomyMeasurementSystem (SMAF):Descriptionandvalidationofaninstrumentforthemeasurementof handicaps.AgeandAging,17,293302. Hendriksen,C.,Lund,E.,&Stromgard,E.(1984).Consequencesofassessmentand interventionamongelderlypeople:Athreeyearrandomizedcontroltrial.British MedicalJournal,289,15221524. Heruti,R.J.,Lusky,A.,Barell,V.,Ohry,A.,&Adunsky,A.(1999).Cognitivestatusat admission:Doesitaffecttherehabilitationoutcomeofelderlypatientswithhip fracture?ArchivesofPhysicalMedicineandRehabilitation,80,432436. Hirdes,J.P.,&Carpenter,G.I.(1997).Healthoutcomesamongthefrailelderlyin communitiesandinstitutions:UseoftheMinimumDataSet(MDS)tocreateeffective
GeriatricAssessmentandRehabilitation linkagesbetweenresearchandpolicy.CanadianJournalofAging/CanadianPublic Policy,Supplement,5369. Hirdes,J.P.,Fries,B.E.,Morris,J.,Steel,K.,Mor,V.,Fritjters,D.,etal.(1997).Integrated healthinformationsystemsbasedontheRAI/MDSseriesofinstruments.Healthcare ManagementForum,12,3040. Hoenig,H.,Nusbaum,N.,BrummelSmith,K.(1997).Geriatricrehabilitation:Stateoftheart. JournaloftheAmericanGeriatricsSociety,45,13711381. Hughes,T.L.,&MedinaWalpole,A.M.(2000).Implementationofaninterdisciplinary behaviourmanagementprogram.JournaloftheAmericanGeriatricsSociety,48,581 587. Israel,L.,Kozarevic,D.,&Sartorius,N.(1984).Sourcebookofgeriatricassessment(Vol1.) Basel,Switzerland:Karger. Jette,A.M.(1997).Disablementoutcomesingeriatricrehabilitation.MedicalCare,35,2837. Joseph,C.L.,&Wanlass,W.(1993).Rehabilitationinthenursinghome.ClinicsinGeriatric Medicine,9,859871. Karppi,P.(1995).Effectsofageriatricinpatientunitonelderlyhomecarepatients:A controlledtrial.AgingClinical&ExperimentalResearch,7,207211. Keeler,E.B.,Robalino,D.A.,Frank,J.C.,Hirsch,S.H.,Maly,R.C.,&Reuben,D.B.(1999). Costeffectivenessofoutpatientgeriatricassessmentwithaninterventionto increaseadherence.MedicalCare,37,11991106. Keith,R.A.,Granger,C.V.,&Hamilton,B.B.(1987).Thefunctionalindependencemeasure:A newtoolforrehabilitation.AdvancesinClinicalRehabilitation,1,618. Kiresuk,T.J.,Smith,A.,&Cardillo,J.E.(Eds).(1994).Goalattainmentscaling:Applications, theory,andmeasurement.Hillsdale,NJ:Erlbaum. Law,M.,Baptiste,S.,McColl,M.,Opzoomer,A.,Polatajko,H.,&Pollock,N.(1990).The CanadianOccupationalPerformanceMeasure:Anoutcomemeasureforoccupational therapy.CanadianJournalofOccupationalTherapy,57,8287. Lawton,M.P.,&Brody,E.M.(1969).Assessmentofolderpeople:Selfmaintainingand instrumentalactivitiesofdailyliving.Gerontologist,9,179186. Liem,P.H.,Chernoff,R.,&Carter,W.J.(1986).Geriatricrehabilitationunit:Athreeyear outcomeevaluation.JournalofGerontology,41,4450. Linn,B.S.,Linn,M.W.,&Gurel,L.(1968).Thecumulativeillnessratingscale.Journalofthe AmericanGeriatricSociety,16,622626. Lokk,J.(1999).Geriatricrehabilitationrevisited.AgingClinicalandExperimentalResearch,11, 353361. Luxenberg,J.S.,&Feigenbaum,L.Z.(1986).Cognitiveimpairmentonarehabilitation service.ArchivesofPhysicalMedicineandRehabilitation,67,796798. Mahoney,F.A.,&Barthel,D.W.(1965).Functionalevaluation:TheBarthelIndex.Maryland StateMedicalJournal,14,6165. ManSonHing,M.,Power,B.,Byszewski,A.,&Dalziel,W.B.(1997).Referraltospecialized geriatricservices.Whichelderlypeoplelivinginthecommunityarelikelytobenefit? CanadianFamilyPhysician,43,925930.
GeriatricAssessmentandRehabilitation Mason,M.,&Bell,J.(1994).Functionaloutcomesofrehabilitation,inthefrailelderly:Atwo yearretrospectivereview.Perspectives,18,79. Mayo,N.E.,WoodDauphinee,S.,Cote,R.,Grayton,D.,Carlton,J.,Buttery,J.,etal.(2000). Theresnoplacelikehome:Anevaluationofearlysupporteddischargeforstroke. Stroke,31,10161023. McDowell,I.,&Newell,C.(1996).Measuringhealth(2nded.).NewYork:OxfordUniversity Press. Miller,S.T.,Applegate,W.B.,Elam,J.T.,&Graney,M.J.(1994).Theinfluenceofdiagnostic classificationonoutcomesandchargesingeriatricassessmentandrehabilitation. JournaloftheAmericanGeriatricsSociety,42,115. Miller,D.K.,Morley,J.E.,Rubenstein,L.Z.,Pietruszka,F.M.,&Strome,L.S.(1990).Formal geriatricassessmentinstrumentsandthecareofelderlygeneralmedicaloutpatients. JournaloftheAmericanGeriatricsSociety,38,645651. Molloy,D.W.,Alemayehu,E.,&Roberts,R.(1991).AStandardizedMiniMentalState Examination(SMMSE):ItsreliabilitycomparedtothetraditionalMiniMentalState Examination(MMSE).AmericanJournalofPsychiatry,148,102105. Mosqueda,L.A.(1993).Assessmentofrehabilitationpotential.ClinicsinGeriatricMedicine,9, 689703 Parmalee,P.A.,Thuras,P.D.,Katz,I.R.,&Lawton,M.P.(1995).ValidationoftheCumulative IllnessRatingScaleinageriatricresidentialpopulation.JournaloftheAmerican GeriatricsSociety,43,130137. Patrick,L.,Knoefel,F.,Gaskowski,P.,&Rexroth,D.(2001).Medicalcomorbidityand rehabilitationefficiencyingeriatricinpatients.JournaloftheAmericanGeriatrics Society,49,14711477. Patrick,L.,Leber,M.,&Johnston,S.(1996).Aspectsofcognitivestatusaspredictorsof mobilityfollowinggeriatricrehabilitation.AgingClinicalandExperimentalResearch,8, 328333. Patterson,C.J.,Gauthier,S.,Bergman,H.,Cohen,C.A.,Feighther,J.W.,Feldman,H.,etal. (1999).Therecognition,assessmentandmanagementofdementingdisorders: ConclusionsfortheCanadianConsensusConferenceonDementia.CanadianMedical AssociationJournal,160(12),115. Pereles,L.,Romonko,L.,Murzyn,T.,Hogan,D.,Silvius,J.,Stokes,E.,etal.(1996).Evaluation ofaselfmedicationprogram.JournaloftheAmericanGeriatricsSociety,44,161165. Pinholt,E.M.,Kroenke,K.,Hanley,J.F.,Kussman,M.J.,Twyman,P.L.,&Carpenter,J.L. (1987).Functionalassessmentoftheelderly:Acomparisonofstandardinstruments withclinicaljudgment.ArchivesofInternalMedicine,147,484488. Platts,S.(1989).Aselfmedicationpilotprogram.Dimensions,3335. Podsiadlo,D.,&Richardson,S.(1991).ThetimedUpandGo:Atestofbasicfunctional mobilityforfrailelderlypersons.JournaloftheAmericanGeriatricsSociety,39,142 155. Redelmeier,D.A.,Tan,S.H.,&Booth,G.L.(1998).Thetreatmentofunrelateddisorderin patientswithchronicmedicaldiseases.NewEnglandJournalofMedicine,338,1516 1542.
GeriatricAssessmentandRehabilitation Reid,J.,&Kennie,D.C.(1989).Geriatricrehabilitativecareafterfracturesoftheproximal femur:Oneyearfollowupofarandomizedclinicaltrial.BritishMedicalJournal,299, 2526. Resnick,B.(1996).Motivationingeriatricrehabilitation.JournalofNursingScholarship,24,41 45. Resnick,B.(1998).Efficacybeliefsingeriatricrehabilitation.JournalofGerontological Nursing,24,3444. Resnick,B.,Slocum,D.,Lynn,R.,Moffett,P.(1996).Geriatricrehabilitation:Nursing interventionsandoutcomesfocusingonurinaryfunctionandknowledgeof medications.RehabilitationNursing,21,142147. Reuben,D.B.,Borok,G.M.,WoldeTsadik,G.,Ershoff,D.H.,Fishman,L.K.,Ambrosini,V.L., etal.(1995).Arandomizedtrialofcomprehensivegeriatricassessmentinthecareof hospitalizedpatients.NewEnglandJournalofMedicine,332,23451350. Rockwood,K.,Fox,R.A.,Stolee,P.,Robertson,D.,&Beattie,B.L.(1994).Frailtyinelderly people:Anevolvingconcept.CanadianMedicalAssociationJournal,150,489495. Rockwood,K.,Joyce,B.,&Stolee,P.(1997).Useofgoalattainmentscalinginmeasuring clinicallyimportantchangeincognitiverehabilitationpatients.JournalofClinical Epidemiology,50,581588. Rockwood,K.,Stolee,P.,&Fox,R.A.(1993).Useofgoalattainmentscalinginmeasuring clinicallyimportantchangeinthefrailelderly.JournalofClinicalEpidemiology,46,1113 1118. Rockwood,K.,Stolee,P.,&McDowell,I.(1996).Factorsassociatedwithinstitutionalization ofolderpeopleinCanada:Testingamultifactorialdefinitionoffrailty.Journalofthe AmericanGeriatricsSociety,44,578582. Rodgers,H.,Curless,R.,&James,O.F.(1993).Commentary:Standardizedfunctional assessmentscalesforelderlypatients.AgeandAgeing,22,161163. Romonko,L.,&Pereles,L.(1992).Anevaluationofpharmacyassessmentforgeriatric patients.CanadianJournalofHospitalPharmacy,45,1520. Rozzini,R.,Frisoni,G.B.,Franzoni,S.,&Trabucchi,M.(2000).Changeinfunctionalstatus duringhospitalizationinolderadults:Ageriatricconceptoffrailty.Journalofthe AmericanGeriatricsSociety,48,10241025. Rubenstein,L.Z.,Josephson,K.R.,Harper,J.O.,Miller,D.K.,&Wieland,D.(1995).The SepulvedaGEUstudyrevisited:Longtermoutcomesuseofservicesandcosts.Aging ClinicalandExperimentalResearch,7,212217. Rubenstein,L.Z.,Josephson,K.R.,Wieland,G.D.,English,P.A.,Sayre,J.A.,&Kane,R.L. (1984).Effectivenessofageriatricevaluationunit.Arandomizedclinicaltrial.New EnglandJournalofMedicine,311,16641670. Rubenstein,L.Z.,Josephson,K.R.,Wieland,G.D.,&Kane,R.L.(1986).Differential prognosisandutilizationpatternsamongclinicalsubgroupsofhospitalizedgeriatric patients.HealthServicesResearch,20,881895. Rubenstein,L.Z.,Stuck,A.E.,Siu,A.L.,&Wieland,D.(1991).Impactsofgeriatricevaluation andmanagementprogramsondefinedoutcomes:Overviewoftheevidence.Journal oftheAmericanGeriatricsSociety,39,816.
GeriatricAssessmentandRehabilitation Rubenstein,L.Z.,Wieland,G.D.,Josephson,K.R.,Rosbrook,B.,Sayre,J.,Kane,R.L.(1988). Improvedsurvivalforfrailelderlyinpatientsonageriatricevaluationunit(GEU):Who benefits?JournalofClinicalEpidemiology,41,67782. Ruchinskas,R.A.,Singer,H.K.,&Repetz,N.K.(2001).Clockdrawing,clockcopying,and physicalabilitiesingeriatricrehabilitation.ArchivesofPhysicalMedicineRehabilitation, 82,920924. Satish,S.,Winograd,C.H.,Chavez,C.,&Bloch,D.A.(1996).Geriatrictargetingcriteriaas predictorsofsurvivalandhealthcareutilization.JournaloftheAmericanGeriatrics Society,44,914921. Scott,I.(1999).Optimizingcareofthehospitalizedelderly:Aliteraturereviewand suggestionsforfutureresearch.AustralianandNewZealandJournalofMedicine,29, 254264. Seymour,R.M.,&Routledge,P.A.(1998).Importantdrugdruginteractionsforgeriatric patients.DrugsandAging,12,485495. Simmons,W.J.(1986).Planningfordischargewiththeelderly.QualityReviewBulletin,12, 6871. Stewart,A.L.,Greenfield,S.,Hays,R.D.,Wells,K.,Rogers,W.H.,Berry,S.D.,etal.(1989). Functionalstatusandwellbeingofpatientswithchronicconditions.Journalofthe AmericanGeriatricsSociety,262,907913. Stolee,P.,Borrie,M.J.,Cook,S.,&Hollomby,J.,andtheparticipantsoftheCanadian ConsensusWorkshoponGeriatricRehabilitation.(2004).Aresearchagendafor geriatricrehabilitation:TheCanadianconsensus.GeriatricsToday:Journalofthe CanadianGeriatricsSociety,7,3842. Stolee,P.,Rockwood,K.,Fox,R.A.,&Streiner,D.L.(1992).Theuseofgoalattainment scalinginageriatriccaresetting.JournaloftheAmericanGeriatricsSociety,40,574 578. Stolee,P.,Stadnyk,K.,Myers,A.M.,&Rockwood,K.(1999).Anindividualizedapproachto outcomemeasurementingeriatricrehabilitation.TheJournalofGerontology.SeriesA, BiologicalSciencesandMedicalSciences,54,641647. Straus,S.E.,Kirkland,J.,Verwoerd,F.,Hamilton,L.,Gottfried,M.,&Naglie,G.(1997). Dischargeshomefollowingintensiveinpatientgeriatricrehabilitation.Canadian JournalofRehabilitation,11,8185. Stuck,A.E.,Egger,M.,Hammer,A.,Minder,C.E.,&Beck,J.C.(2002).Homevisitstoprevent nursinghomeadmissionandfunctionaldeclineinelderlypeople:Systematicreview andmetaregressionanalysis.JournaloftheAmericanMedicalAssociation,287,1022 1028. Stuck,A.E.,Siu,A.L.,Wieland,G.D.,Adams,J.,&Rubenstein,L.Z.(1993).Comprehensive geriatricassessment:Ametaanalysisofcontrolledtrials.Lancet,342,10321036. Studenski,S.,&Duncan,P.W.(1993).Measuringrehabilitationoutcomes.ClinicsinGeriatric Medicine,9,823830. Teasell,R.W.,Merskey,H.,&Deshpande,S.(1999).Antidepressantsinrehabilitation. PhysicalMedicineandRehabilitationClinicsinNorthAmerica,10,237253.
GeriatricAssessmentandRehabilitation Tinetti,M.E.,Williams,T.F.,&Mayewski,R.(1986).Fallriskindexforelderlypatientsbased onnumberofchronicdisabilities.AmericanJournalofMedicine,80,42934. Toseland,R.W.,ODonnell,J.C.,Engelhardt,J.B.,Hendler,S.A.,Richie,J.T.,&Jue,D. (1996).Outpatientgeriatricevaluationandmanagement:Resultsofarandomized trial.MedicalCare,34,624640. Trentini,W.,Semeraro,S.,&Motta,M.(2001).Effectivenessofgeriatricevaluationandcare. Oneyearresultsofamulticenterrandomizedclinicaltrial.Aging,13,395405. VanSwearingen,J.M.,&Brach,J.S.(2001).Makinggeriatricassessmentwork:Selecting usefulmeasures.PhysicalTherapy,81,12331252. vonKoch,L.,WidenHolmqvist,L.,Kostulas,V.,Almazan,J.,&dePedroCuesta,J.(2000).A randomizedcontrolledtrialofrehabilitationathomeafterstrokeinsouthwest Stockholm:Outcomesatsixmonths.ScandinavianJournalofRehabilitationMedicine, 32,8086. vonSternberg,T.,HepburnK.,Cibuzar,P.,Convery,L.,Dokken,B.,Haefemeyer,J.,etal. (1997).Posthospitalsubacutecare:Anexampleofamanagedcaremodel.Journalof theAmericanGeriatricsSociety,45,8791. Weber,D.C.,Fleming,K.C.,&Evans,J.M.(1995).Rehabilitationofgeriatricpatients.Mayo ClinicProceedings,70,11981204. Wieland,D.,&Rubenstein,L.Z.(1996).Whatdoweknowaboutpatienttargetingingeriatric evaluationandmanagement(GEM)programs?AgingClinicalandExperimental Research,8,297310. Wieland,D.,Stuck,A.E.,Siu,A.L.,Adams,J.,&Rubenstein,L.Z.(1995).Metaanalytic methodsforhealthservicesresearch:Anexamplefromgeriatrics.Evaluationandthe HealthProfessions,18,252282. Wilkinson,T.J.,Buhrkuhl,D.C.,&Sainsbury,R.(1997).Assessingandrestoringfunctionin elderlypeoplemorethanrehabilitation.ClinicalRehabilitation,11,321328. Williams,M.E.,Williams,T.F.,Zimmer,J.G.,Hall,W.J.,&Podgorski,C.A.,(1987).Howdoes theteamapproachtooutpatientgeriatricevaluationcomparewithtraditionalcare? Areportofarandomizedcontrolledtrial.JournaloftheAmericanGeriatricsSociety, 35,10711078. Winograd,C.H.(1987).Inpatientgeriatricconsultation.ClinicsinGeriatricMedicine,3,193 202. Yeo,G.,Ingram,L.,Skurnick,J.,&Crapo,L.(1987).Effectsofageriatriccliniconfunctional healthandwellbeingofelders.JournalofGerontology,42,252258. Yesavage,J.A.,Brink,T.L.,Rose,T.L.,Lumo,O.,Huang,V.,Adey,M.,etal.(1983). Developmentandvalidationofageriatricdepressionscreeningscale:Apreliminary report.JournalofPsychiatricResearch,17,3749. Yip,A.M.,Gorman,M.C.,Stadnyk,K.,Mills,W.G.,MacPherson,K.M.,&Rockwood,K. (1998).AstandardizedmenuforGoalAttainmentScalinginthecareoffrailelders. Gerontologist,38,735742.
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CommonClinicalProblemsinGeriatricRehabilitation
Chapter5
EvidenceBasedBestPracticesforCommonClinical ProblemsinGeriatricRehabilitation
JennieWells,MichaelBorrie,andPaulStolee
ExecutiveSummary Severalkeydiagnosesfromamongthegeriatricgiantsareparticularlyrelevantto rehabilitation,eitheraspresentingproblemsorasfactorsconfoundingtreatment(or both).Thesearehipfracture,stroke,nutritionissues,dementia,anddepression.The literaturesupportsthefollowingrecommendations:(1)frailolderrehabilitationcandidates withmildtomoderatedementiashouldnotbeexcludedfromrehabilitation(level1 evidence;Huuskoetal.,2000);(2)frailolderpatientsshouldbescreenedforcognitive impairment(level2evidence;Goldsteinetal.,1997;Heruti,Lusky,Barell,Ohry,&Adunsky, 1999);and,(3)treatmentfordepressioncanimproverehabilitationoutcomes.Moreover, basedontheliterature,werecommendthat(4)frailolderpatientswithhipfracture receivegeriatricrehabilitation;(5)thatfrailseniorsreceivenutritional,cognition,and depressionscreening;and(6)thatnutritionalsupplementsbeprovidedtoundernourished frailolderrehabilitationpatients. Introduction AsalreadynotedinChapter4,thebenefitsofgeriatricrehabilitationhavebeen documented,butthepracticesthataccountforenhancedoutcomeshavenotbeen;thereis nogoldstandardforrehabilitationofgeriatricpatients.Therefore,theobjectiveofthis Chapteristoreviewkeyclinicaldiagnosesrelevanttogeriatricrehabilitation(hipfracture, stroke,nutrition,dementia,depression),and,basedonthis,toprovideevidencebased recommendationsforcare. HipFracture Hipfractureisamajorcauseofmortalityandmorbidityinolderpersonsandisa diagnosticcategoryinwhichthelargestproportionofpatientsareaged75andover(White, Fisher,&Laurin,1987).Hipfractureisamajorburdenonthehealthcaresystemprimarily becauseaddedcomorbiditiesofpatientsintheolderagegrouplengthenhospitalstays. Manypatientsdeclineinfunctionafterhipfractureandrequirelongtermcare(Marittiku, Marottoli,Berkman,&Cooney,1992).Itisexpectedthatthedemandforhospitalizationfor hipfracturewillcontinuetoincreasebeyondtheyear2020(Jaglal,Sherry&Schatzker, 1996).Theevidencebasedbestpracticesforhipfracturereviewedinthissectionare presentedinTable5.1.
CommonClinicalProblemsinGeriatricRehabilitation Table5.1:SummaryofEvidenceBasedBestPracticesforHipFractureinOlderPersons EvidencebasedPracticesforHipFracture Comorbidityandclinicalinstabilityshouldnotbeabarriertorehabilitation. Olderpersonswithhipfractureshouldreceiveinterdisciplinarycareincluding orthopedicsurgeonsandgeriatricians.Thesepatientsmaybenefitfromspecialized geriatricorthopedicrehabilitationunitstoreducereadmissiontoacutecare,and geriatrichipfractureprogramstoreducelengthofstayandincreasereturnto community. Olderpersonswithhipfractureshouldreceiveearlyinpatientrehabilitationto reducelengthofstay,totalcostsofcareandhastenfunctioning. Earlysupporteddischargeprogramsaremostsuitableforhighfunctioning patients. AlthoughmosthipfracturepatientsinNorthAmericaaredischargedfromtheacute carehospitaltotheirhomesinthecommunity,about40%requirefurtherrehabilitationor admissiontonursinghome(Papaioannou,2000).Thesepatientsareoftenfrailwithmultiple medicalproblemsorhavesufferedinhospitalcomplications,requiringmoreintensive rehabilitationasinpatients.Bernardiniandcolleagues(1995)investigatedcomorbidityand adverseclinicaleventsinpatientsovertheageof65admittedtoageriatricrehabilitation unitafterproximalhipfracture.Thesepatientshadcomplex,multiple,andinteracting pathologies,with78%havingsignificantcomorbidity.Themeanageofthesepatientswas 82.7yearsand85%werewomen;theiraveragerehabilitationlengthofstay(LOS)was68 days.Themostcommonsystemsaffectedwithcomorbiddiseases(otherthan musculoskeletal)werecardiovascular,gastrointestinal,urinary,respiratory,andneurologic. Eight%ofthesepatientsdied,and6%requiredrehospitalizationfororthopedic complications.Therewasasignificantreductionincomorbidityfromadmissiontodischarge. TheModifiedBarthelIndexadmissionscorewasthekeypredictoroffunctionaloutcome (accountingfor46%ofthevarianceinfunctionaloutcome)withcognitivescores,clinical instability,andCumulativeIllnessRatingScalescoreaddingmorepredictivepower(r2=.61, p<.0001).Theauthorsdescribedtheburdensofcomorbidityandclinicalinstabilityas dynamiccomponentsoffrailty,whicharetreatableusingacomprehensiveapproachsuchas geriatricrehabilitation,andarenotanabsolutebarriertorehabilitation. Modelsofinterdisciplinarycarefororthopedicpatientshavebeendevelopedto shortenhospitalstayandreduceinstitutionalization.Forpatientsovertheageof60, collaborativesupervisionofgeriatricrehabilitationbedsbyanorthopedicsurgeonanda geriatricianhasbeenshowntoreduceLOS(Murphy,Rai,Lowy,&Bielawska,1987).Similarly, astudyofolderwomenwithproximalhipfracturepostoperativelyrandomizedtoeither routineorthopediccareortogeriatriccareshowedthatthegeriatriccarepatientswere
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CommonClinicalProblemsinGeriatricRehabilitation significantlymoreindependentinADLs,hadshorterLOS,andfewerdischargesto institutionalcare(Kennie,Reid,Richardson,Kiamari,&Kelt,1988). Toreducecostsofcare,thereispressuretoshortenLOSinacutecarehospitals. However,ashorterLOSdoesnotnecessarilytranslatetoanimprovedclinicaloutcome.In theUnitedStates,thetrendtowardshorterLOSwasaidedbytheemergenceofprospective paymentsystemsin1983.Followingtheimplementationofthisnewpaymentsystem,the meanacutecarestayforhipfracturepatientsfellfrom21.9daysin1981to12.6daysin1986, theproportionofpatientsdischargedtonursinghomesrosefrom38%to60%,discharge walkingdistancefellfrom27to11m,andphysiotherapysessionsdecreasedfrom7.6to6.3. (Fitzgerald,Moore,&Dittus,1988).Comparedwithpatientswithotherhealthcare providers,83%versus55%weretransferredtonursinghomesandLOSwas7.3daysversus14 days.AsaresultoftheshorterLOSinhospitals,themodelofanursinghomeasaskilled nursingfacilityprovidingrehabilitationhasemerged(Hoenig,etal.,1997). TargetingpatientsforearlyinpatientrehabilitationisonemethodofreducingLOS. Muninandcolleagues(1998)randomizedelectivehipandkneearthroplastypatientsover theageof70wholivealoneorwhohad2ormorecomorbidillnessestousualrehabilitation orearlyrehabilitationonhospitaldaythree.TheearlytreatmentgrouphadshorterLOS, lowertotalcostsofcare,morerapidattainmentoffunctionalgoals,andequivalent4month functionalstatusascomparedtotheusualcaregroup. Earlydischargewithoutpatientrehabilitationmaybeonemethodtomeettheneeds ofsomeolderpatientswithhipfracture.ArecentCanadianpilotstudyfoundthatearly rehabilitationinadayhospitalwasappropriatefortheneedsofwomenaged59to91years whoweredischargedfromacutecare(Papaioannou,Parkinson,Adachi,&Clarke,2001).The authorsofthisstudysuggestedthatthedayhospitalmodelhasadvantagesoverahome basedmodelinthatitmayprovidemoreefficientuseofhealthcareresourcesand therapiststime. Theresultsofasystematicreviewofgeriatricrehabilitationforfracturesofthelower limbs,pelvis,upperlimbs,orspinesuggeststhatthegeriatricprinciplesofcareforfrail elderlypatientswithhipfracturecanbegeneralizedtoincludethefrailelderlywithpelvisor otherlowerlimbfracture(Cameron,etal.,2000).AlthoughtherewasnoevidencethatLOS inageriatricorthopedicrehabilitationunit(GORU) *isshorterthaninconventional orthopedicunits,itispossiblethatgeriatricpatientsmaybenefitfromthisinterventionin otherways.TotalLOSwasreducedbytheuseofgeriatrichipfractureprograms(GHFPs) , earlysupporteddischarge ,andclinicalpathways.OlderpeoplewhoparticipatedinGHFPs andearlysupporteddischargeprogramshadasignificantlyhigherrateofreturntoprevious communityliving.Theincreasedrateofreturntoresidentialstatuswasalsocostsaving.The
* AGORUisaspecializedinpatientorthopedicrehabilitationunitdedicatedtothegeriatricpopulation supervisedbyageriatricianwithamultidisciplinaryteam. AGHFPinvolvesthegeriatricteamsoonafteradmission;carebeginsinthesurgicalunit.Somehigher functioningpatientsstayintheorthopedicuntiltheyarereadytogohome.Othersmaybetransferredtoa rehabilitationunitortoearlysupporteddischargeprograms. Earlysupporteddischargeprogramsprovidesupportandrehabilitationtotheorthopedicpatientathome (Cameronetal.,2000). OrganizationDesignforGeriatrics:AnEvidenceBasedApproach 61
CommonClinicalProblemsinGeriatricRehabilitation resultsofthisreviewprovidedinsufficientevidencetocommentontheimpactofany programonqualityoflife(QOL),mortality,caregiverburden,orleveloffunction. GORUslikelyprovidebenefittofrailolderpersonswhomayotherwiserequire nursinghomeplacement.Theyarealsolikelytoreducereadmissionratestoacutecare.The earlysupporteddischargeisonlysuitableforhighfunctioninghipfracturepatients.Early supporteddischargeshouldbeacomponentofGHFPstomaximizethepossibilityofreturn toresidentialliving.AlternativeprogramssuchasGORUsormixedgeriatricassessmentand rehabilitationunits(MARUs)arenecessarytohelpprovidecareforthemoredisabled.Based ontheresultsoftheirreview,Cameronandcolleagues(2000)suggestedtheneedfor economicevaluationscomparingGORUsandMARUsforcommunitydwellinghipfracture patientswhoaretoodisabledforanearlysupporteddischargeandfurtherstudyofearly supporteddischargeandGHFPstoestablishevidenceforbestpracticeguidelines. Moreover,theysuggestedthatfutureresearchshouldemphasizefunctionalstatus,quality oflife,andcaregiverburden,aswellaseconomicfactorsandsocietalperspectives. Theliteraturesupportsthefollowingrecommendation:frailolderpatientswithhip fractureshouldreceivegeriatricrehabilitation(level1evidence;Cameron,etal.,2000; Kennie,etal.,1988). Stroke Strokeisacommonproblemfortheelderly.Infact,theriskofstrokedoublesfor eachdecadeafterage55(Rosenberg&Popelka,2000).TheStrokeUnitTrialists Collaborationmetaanalysisof19trialswith3249patientshasshownthatorganizedstroke unitcareisassociatedwithlowermortality,dependency,andinstitutionalizationwithoutan increaseinuseofresources(StrokeUnitTrialistCollaboration,1997).Thisbenefithasbeen showntobesustainedforfiveyearsaftertreatment(Indredavik,Slordahl,Bakke,Rokseth, &Haheim,1997). Althoughstrokeunitcarehasbeenshowntobebeneficialacrossarangeofstroke severityandforpatientsunderandovertheageof75(StrokeUnitTrialistCollaboration, 1997),olderpatientshavepoorerrehabilitationoutcomesthanyoungerpatientsdueto otheragerelatedcomorbiditiesandfrailty(Rosenberg&Popelka,2000;Falconer, Naughton,Strasser,&Sinacore,1994).Thepredictorsoffavorableoutcomeingeriatric strokerehabilitationaresimilartothatofyoungerpeople,thoughithasbeenshownthat comorbidcoronaryarterydiseaseisanimportantpredictorofpooreroutcomesinolder persons(Meins,MeierBaumgartner,Neetz,&vonRentelnKruse,2001).Inadditiontoage andmedicalcomorbidity,thenatureandseverityofstroke,disabilityatentryinto rehabilitation,cognitiveimpairment,perceptualdeficits,depression,incontinence,and presenceofasupportivecaregiverallinfluencerehabilitationoutcome(Bagg,1998). Falconerandcolleagues(1994)evaluatedtheperformanceofolderpatientsona strokeunit,comparingtheyoung(under65years),youngold(6574years),andolder patients(75yearsandover).Therewerenosignificantdifferencesincognitivefunctioning betweenthegroups.Thereweresignificantdifferencesinperformanceofmotorfunction skillsatdischarge,withtheoldestgroupperformingleastwell.Theoldergroupalsohad lowermotorfunctionatadmission.Agreaterpercentageoftheoldergrouprequiredpaid
CommonClinicalProblemsinGeriatricRehabilitation caregivers(64%vs.40%and31%,inthe6574andunder65agegroups,respectively).The olderagegroupwasalsomorelikelytorequirenursinghomeplacementondischarge(30% vs.16%and10%,intheotheragegroups,respectively).Theauthorsattributethese differencestodecreasedphysiologicreserve,noavailabilityofahealthyspouse, comorbidities,tenuousfinances,andothersocialsupportfactors.Theoldergroupdidmake significantgainsintherapy,butoverallLOSwasshorterfortheoldestagegroupthaninthe youngeragegroups,thereasonforwhichisnotknown.Falconerandcolleagues(1994) suggestthatfutureresearchinhealthdeliverymodelsmayindicatethatlonger rehabilitationathomeorinlongtermcaremayprovideoptimalbenefitinfunctionalstatus aswellasbeingcosteffective. Poststrokerehabilitationhasalongerhistoryandagreaterdepthofresearchthan doesgeriatricrehabilitation.Basedonthisextensiveresearch,clinicalguidelinesforpost strokerehabilitationwerepublishedin1995(Gresham,etal.,1995).Theseguidelinesoffer discussionandrecommendationsforthefollowingareas:rehabilitationduringacutecarefor stroke,screeningforrehabilitation,andtransitiontocommunityliving.Someofthe guidelinesforscreeningincludemedicalstability,presenceofafunctionaldeficit,andability tolearnandparticipateactively.Considerationsinscreeningincludetheextentofthe neurologicaldeficits,comorbidillnesses,aswellasnutritionandswallowingissues.Other importantconsiderationsarethefunctionalstatusbeforestroke,currentmotivationand endurance,socialsupports,potentialdischargeenvironments,andpreviouslivingsituation. BoultandBrummelSmith(1997)andRosenbergandPopelka(2000)provideageneral summaryanddiscussionofpoststrokeclinicalpracticeguidelines.Althoughgeriatric rehabilitationaddressesagreaterheterogeneityofmedicalcognitiveandfunctional problems,therearemanysimilaritiestothesespecializedtreatments.Futureresearchmay leadtosimilarevidencebasedguidelinesforgeriatricrehabilitation. Nutrition Theolderpopulationisatriskformalnutritionandundernutritionformany physiologicandmedicalreasons.Decreasedphysicalactivityandageassociateddecreased musclemassandincreasedbodyfatresultindecreasednutritionalintake.Community dwellingolderpersonsmayhavenutritionaldeficienciesthatcaninfluenceimmunefunction andincreaseriskofdisease(Gariballa,2000;Chandra,1997).Hospitalizedfrailolderpersons areatanevenhigherriskfornutritionalproblems.Stressassociatedwithillnesscauses catabolismwithnetlossesofproteinfrommusclestores.Whenadequateproteinand caloriesarenotprovidedtomeetthiselevatedenergyexpenditure,malnutritionandfurther muscleweaknessresult(Stahl,1987).Poornutritionalstatuscanleadtohealth complicationsandhospitalreadmissions(Stahl,1987).Ingeneral,undernourishedseniors havelongerhospitalstays,delayedwoundhealing,moremedicalcomplications,andhigher readmissionandmortalityratesthanthewellnourished(Hall,Whiting,&Comfort,2000; Nourhashemi,etal.,1999).Undernutritionisanindependentriskfactorformortalityof patientsdischargedfromgeriatricunits,thoughitisapotentiallycorrectableproblem (Sullivan,Walls,&Bopp,1995).
CommonClinicalProblemsinGeriatricRehabilitation Malnutritioninolderpersonshasbeenalargelyunderrecognizedproblem(Hall,et al.,2000;Nourhashemi,etal.,1999),inpartbecausetherearefewvalidatedtoolsavailable toassessandexplainmalnutritioninthispopulation.TheMiniNutritionalAssessmentfor theElderly,whichwasdevelopedasameasureofnutritionalstatustobeusedinCGA,has beenshowntobevalidandclinicallyuseful(Nourhashemi,etal.).Thistypeoftoolcanbe usedtoidentifypatientsathighrisksothatpromptinterventionscanbeimplementedto preventfurtherdeteriorationinnutritionalstatus.Ithasbeenstronglyrecommendedthata nutritionalassessmentbeincludedinthecomprehensiveassessmentoffrailolderpersons (Hall,etal.;Nourhashemi,etal.). Manygeriatricrehabilitationpatientshavesignificantnutritionalproblems(Keller, 1997).Inastudyofthenutritionalstatusofgeriatricrehabilitationpatients(N=152),Keller foundthat57%hadproteinenergymalnutritionand12%haddysphagia;theaveragenumber ofnutritionalproblemsperpatientwasfour.Moreover,nutritionalproblems,suchas proteinenergymalnutrition,weightloss,feedingimpairment,anddysphagia,were associatedwithincreasedLOS,death,andgreaterlikelihoodofnursinghomeplacement. Withintervention,morethantwothirdsofthesepatientswereabletomeettheirnutritional goals.Gariballa(2000),inareviewoftheliterature,supportedtheconclusionthatan aggressivenutritionalinterventionduringgeriatricrehabilitationcanleadtoimproved nutritionalstatus,betterclinicaloutcomes,reducedreadmissionrates,andmayimprove qualityoflife. Nutritionandswallowingproblemsarecommoninolderpersonsrecoveringfrom stroke.FinestoneandGreeneFinestone(1998)estimatetheprevalenceofmalnutritionin strokerehabilitationunitstobe49%to60%.Theyreportedthat16%to22%ofstrokesurvivors presentwithmalnutritiononadmissionfortheiracutestroke,andthisincreasesto35%by the14thdayofhospitalstay.Aptaker,Roth,Reichardt,DuredenandLevy(1994) documentedthatolderstrokepatientswithlowserumalbuminlevelshavehighermedical complicationsratesandpoorerfunctionaloutcomes.Moreover,dysphagiaisasignificant factorcontributingtothenutritionalstateoftheolderstrokepatient(Finestone&Greene Finestone).Duetoavarietyofreasonsrelatedtonormalagingandunderlyingmedical conditions,seniorsarepredisposedtodysphagia,whichisassociatedwitha13%mortality risk,aswellasariskofaspirationpneumoniaandfurthermuscleandproteinloss(Hudson, Daubert,&Mills,2000). Earlytreatmentandpropermanagementofnutritionandswallowingishighly recommendedtocircumventmanyofthesecomplications.Identificationofswallowing problemsanddietaryinterventionshavebeenshowntoreducetheriskofaspiration pneumoniaandtobeassociatedwithimprovedfunction,reducedLOS,andwerealso showntobecosteffective(Odderson,Keaton,&McKenna,1995).Rehabilitationpatients whoreceivedactiveinterventionfordysphagiawerelesslikelytohaveaspiration pneumoniathanuntreatedpatients(Kasprisin,Clumeck,&NinoMurcia,1989).More aggressivenutritionalinterventionsduringacutecareandrehabilitationmayfavorablyalter thepatientscourse.Nortonandcolleagues(1996)showedthatgastrostomyfedpatients withdysphagiasecondarytostrokehadlowerriskofaspirationpneumonia,earlier dischargefromhospitalandhigheralbuminlevelsthannasogastrictubefedpatients.Early
CommonClinicalProblemsinGeriatricRehabilitation gastrostomyfollowingstrokewasassociatedwithasignificantreductioninmortality.Table 5.2presentsrecommendationsforthenutritionalmanagementofstrokepatientsdeveloped byFinestoneandGreeneFinestone(1998),andconsistentwithevidencebasedpractice guidelinesdescribedbyBoultandBrummelSmith(1997). Table5.2:RecommendationsfortheNutritionalManagementofOlderStrokePatients (FinestoneandGreeneFinestone,1998) NutritionManagement monitornutritionalstatuswithroutineongoingscreensandassessmenttools provideadequatenutrition usetheservicesofaclinicaldietician whendysphasiaissuspected,involveaspeechandlanguagepathologisttoprovide recommendationsforcareandmanagement observeandmonitorpatientsregularlyforsignsofdehydration provideenteralnutritionwhenpatientsareunabletoconsumesufficientfluidor caloriesorforthosewhoareathighriskofaspiration monitorandprovideinterventionforotherstrokerelatedeatingproblemssuchas attention,cognitivechanges,apraxias,visualneglect,paresis discussdietaryinterventionswithpatientandfamily,especiallyduringdischarge planning. Nutritionalsupplementationforhospitalizedolderpersonscanimproveoutcomes.A studyofthenutritionalstatusofpatientshospitalizedinanacutecaregeriatricunit,found thatbetternutritionalstatesofolderpatientsresultedinimprovedthermoregulationand improvedclinicaloutcomes(Allison,Rawlings,Field,Bean,&Stephen,2000).Larssonand colleagues(1990)randomized501geriatricinpatientstoreceiveoralnutritionalsupplements orhospitalmealsonly.Thisstudyshowedthebenefitsofnutritionalsupplementsintermsof mortality,hospitalstay,mobility,andskinbreakdown.Finally,Volkertandcolleagues(1996) showedthatundernourishedolderhospitalizedpatientsrandomizedtonutritional supplementationweremorelikelytogainindependenceduringtheirhospitalstayand remainindependentafter6monthsthanwerethosewhodidnotreceivesupplementation. Micronutrientmalnutrition,inadditiontoproteinenergymalnutrition,hasbeen identifiedasaprobleminolderpeople.Chandra(1997)hasshownthatcommunitydwelling seniorswhotookmultivitaminsupplementshadlowerriskofinfectionandimproved immunitycomparedwithaplacebogroup.Theincidenceofdeficiencyforvarious micronutrientsvariedfrom2.1%to18.7%,buttherewasnosignificantdifferenceinthisrate betweentreatmentandplacebogroups.Glothandcolleagues(1995)showedthatfrail, communitydwellingseniorshaveborderlineorlowvitaminDlevelsandthat supplementationwithvitaminDisassociatedwithanimprovedfunctionalstatus.
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CommonClinicalProblemsinGeriatricRehabilitation Oneoftheearliestreportsofnutritionalsupplementationinrehabilitationisthework ofBastowandcolleagues(1983).Inthisstudy,744olderwomen(agerange,6892years) withafractureoftheneckofthefemurwerescreenedfornutritionalstate.Personsat higherrisk(n=122)wererandomizedtoreceiveovernightnasogastricnutritional supplementation.Thisinterventionwasassociatedwithareductioninmortality,shortened rehabilitationtime,shorteracutecarehospitalstay,andimprovementsinanthropometric measurementandserummarkersofnutrition.Asubsequentstudyshowedthatoral nutritionalsupplementationresultedinlowerdeathandcomplicationrates,shorterhospital stays,andimprovedclinicaloutcomesinpatientswithhipfractures(Delmi,etal.,1990).Ina Cochranemetaanalysisof15randomizedtrialsofhipfracturepatients(n=1054),thefive trialsusingoralsupplementsshowedthatnutritionalinterventionmayreducecomplications ordeath(14/66vs.26/73;Avenell&Handoll,2000).Incontrast,arecentrandomized controlledtrialinwhichhipfracturepatientswererandomizedtoreceiveanutritional supplementorplacebo,foundthatnutritionalsupplementationreducedinhospital complications,butdidnotimprovefunctionalrecoveryorreducemortality(Espaulella,etal., 2000).TheresultsoftheCochranemetaanalysis(Avenell&Handoll,2000)suggestedthat thequalityofthestudiesreviewedwerecompromisedbyinadequatesamplesizeand outcomeassessments,andmethodologicalproblems,andthus,theauthorsconcludedthat moreresearchisneededonthebenefitsofnutritionalsupplementsforhipfracturepatients. Thefollowingrecommendationsaresupportedbytheliterature:(1)nutritional screeningforfrailolderrehabilitationpatients(level3evidence;Gariballa,2000;Chandra, 1997;Stahl,1987);(2)nutritionalsupplementsforundernourishedfrailolderrehabilitation patients(level1evidence;Larssonetal.,1990;Volkertetal.,1996);(3)treatmentplanand dietaryinterventionsforfrailolderpatientswithdysphagia(level2evidence;Aptaker,etal., 1994;Finestone&GreeneFinestone,1998;Kasprisin,etal.,1989;Odderson,etal.,1995);(4) ifdysphagiainolderstrokepatientsissevere,gastrostomytubefeedingissuperiorto nasogastrictubefeeding(level1evidence;Norton,etal.,1996);and(5)thenutritionallyat riskolderpatientwithhipfracturemaybenefitfromnutritionsupplementation(level1 evidence;Avenell&Handoll,2000;Bastow,etal.,1983;Delmi,etal.,1990). Depression Depressionisveryprevalentintheolderpopulation.About15%ofcommunity dwellingeldersand15%to25%ofnursinghomeresidentsexperiencesymptomsof depression(Montano,1999).Similarly,studiesreportratesofdepressionrangingfrom20% to45%inhospitalizedpatients,includingthoseingeriatricrehabilitationunits(Diamond, Holroyd,Macciocchi,&Felsenthal,1995;Harris,Mion,Patterson,&Frengley,1988). Depressionintheelderlycancomplicateillness,maybeobscuredbymultiplecomorbid illnesses,andisoftenundertreated(Wilson,Mottram,Sivanranthan,&Nightingale,2001).In astudyoftherelationshipbetweendepressionandphysicalfunctioninginpatientsina geriatricrehabilitationunit,Harrisandcolleagues(1988)foundthatpatientswhofailedto regainpriorabilitiesfollowingillness,regardlessofdegreeofdisability,experienced persistentdepression.Fewofthesepatientswerediagnosedandtreatedfordepression. Similarly,Diamondandcolleagues(1995)evaluated51patientsenrolledininpatientgeriatric
CommonClinicalProblemsinGeriatricRehabilitation rehabilitationfordepressiontoexaminetherelationshipbetweendepressionandfunctional outcome.AlthoughtherewerenodifferencesinLOS,changeinfunctionalscores,Mini MentalStateExamination(MMSE)scores,ordischargestohomeversusnursinghome betweendepressedandnondepressedgroups,patientswithdepressionhadsignificantly lowerfunctionalscoresatadmissionanddischargethanthenondepressedsubjects. Reducedmotivation,asaresultofdepressivesymptoms,maydelayrecoveryanddischarge (Teasell,Merskey,&Deshpande,1999).Ithasbeenrecommendedthatearlydiagnosisand treatmentofdepressivesymptomsisessentialforrecoveryandshouldinvolveboth pharmacologicandnonpharmacologictherapies(Harris,etal.,1988). Treatmentfordepressionhasbeenassociatedwithbetterrehabilitationoutcomes (Teaselletal.,1999).Harrisandcolleagues(1988)foundthatimprovementinmoodin geriatricrehabilitationpatientswasassociatedwithimprovementinphysicalandcognitive functioning.Slaetsandcolleagues(1997)randomizedmedicallyfrailhospitalizedpatients overage75topsychogeriatricteamcareversususualmedicalcare.Patientsreceiving psychogeriatricteamcare(n=140)hadashorterLOS,becamemoreindependentinphysical function,hadfewerreadmissionstohospitals,andwerelesslikelytobeadmittedtonursing homes.Psychiatriccomorbiditywasanimportantriskfactorforpoorerclinicaloutcome. Similarly,LopezandMermelstein(1995)foundthatdepressedgeriatricrehabilitation patientswhoparticipatedinacognitivebehavioraltreatmentprogrammadesimilargainsin rehabilitationasnondepressedpatients. Theliteraturesupportsthefollowingrecommendation:frailolderrehabilitation patientsshouldbescreenedfordepressionandtreatmentplansinitiatedwhenappropriate (level3evidence;Diamond,etal.,1995;Harris,etal.,1988). CognitiveImpairment Cognitiveimpairmentisamajorchallengeinthecareofolderpersons.Thirtyoneto 45%ofpatientsinGORUsarereportedtohavecognitiveimpairment(Goldstein,etal.,1997; Heruti,etal.,1999;Seidel,Millis,Lichtenberg,&Dijkers,1994).Althoughithasbeena commonstereotypethatpatientswithlowerlevelsofcognitionarelesslikelytoachieve independenceinADLsandambulation,recentresearchhasfoundthatimprovementin functionalscoresareindependentofbothageandcognition(Diamond,etal.,1996; Goldstein,etal.,1997). Astudyof52geriatricrehabilitationpatients(Diamond,etal.,1996)foundthat cognitivelyimpairedpatientstendedtoentertheprogramwithlowerfunctionalscoresand weremorelikelytobeplacedinanursinghomethancognitivelyintactpatients,buta significantportion(38%)oftheseverelyimpairedandalmostall(92%)ofthosewithmildto moderateimpairmentwereabletoreturnhomeafterrehabilitation.Similarly,Huuskoand colleagues(2000)showedthathipfracturepatientswithmildandmoderatedementiawill bemorelikelytoreturntocommunitylivingiftheyreceivegeriatricrehabilitation. Goldsteinandcolleagues(1997)foundthatalthoughcognitivelyintactolderpersons madegreatergainsinmobilitythancognitivelyimpairedolderpersonsfollowinginpatient rehabilitationforhipfracture,thecognitivelyimpaired,whoweremostlymildlyto moderatelyimpaired,werejustaslikelyasthecognitivelyintacttoreturntocommunity
CommonClinicalProblemsinGeriatricRehabilitation living.Giventhatgeriatricpatientswithcognitiveimpairmentbenefitfromrehabilitation theyshouldnotberoutinelyexcludedfromrehabilitation(Diamond,etal.,1996;Goldstein etal.,1997).Patrickandcolleagues(1996)suggestthat,althoughcognitivelyimpaired patientsimprove,theymaynotbeabletomaintaintheirimprovementovertimein comparisontothecognitivelyintact.Itispossiblethatthismayalsoberelatedtoother comorbidities. Herutiandcolleagues(1999)evaluatedrehabilitationoutcomesofcognitively impaired(Mage=82.6years;MMMSEscore=16)andcognitivelyintact(Mage=75.6years; MMMSEscore=28.7)olderpatientswithhipfeature.Althoughallpatientsimprovedin functionalabilities,thecognitivelyintactpatientshadbetterresults.Motorfunction improvedsimilarlyinthetwogroups,buttherelativefunctionalgain(motorefficacyand efficiency)waslowerforthecognitivelyimpairedgroup.LOSwassignificantlylongerforthe cognitivelyimpairedgroup.Theanalysiswasadjustedforthesignificantdifferenceinage betweenthe2groups,butmedicalmorbidityandcomplexitywerenotexamined.Herutiand colleaguesconcludedthat,giventhesedifferences,screeningiscrucialinordertoselect appropriatecandidates. Conclusion Theliteratureevidencesupportsthefollowingrecommendations:(1)frailolder rehabilitationcandidateswithmildtomoderatedementiashouldnotbeexcludedfrom rehabilitation(level1evidence;Huusko,etal.,2000);(2)frailolderpatientsshouldbe screenedforcognitiveimpairment(level2evidence;Goldstein,etal.,1997;Heruti,etal., 1999);(3)treatmentfordepressioncanimproverehabilitationoutcomes.Moreover,based ontheliterature,werecommendthat(4)frailolderpatientswithhipfracturereceive geriatricrehabilitation;(5)thatfrailseniorsreceivenutritional,cognition,anddepression screening;and(6)thatnutritionalsupplementsbeprovidedtoundernourishedfrailolder rehabilitationpatients.
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CommonClinicalProblemsinGeriatricRehabilitation References Allison,S.P.,Rawlings,J.,Field,J.,Bean,N.,&Stephan,A.D.(2000).Nutritionintheelderly hospitalpatientNottinghamstudies.JournalofNutrition,HealthandAging,4,5457. Aptaker,R.L.,Roth,E.J.,Reichhardt,G.,Duerden,M.E.,&Levy,C.E.(1994).Serumalbumin levelasapredictorofgeriatricstrokerehabilitationoutcome.ArchivesofPhysical MedicineandRehabilitation,75,8084. Avenell,A.,&Handoll,H.H.(2000).Nutritionalsupplementationforhipfractureaftercarein theelderly.CochraneDatabaseSystematicReview,4,CD001880. Bagg,S.D.(1998).Outcomepredictorsandtheeffectivenessofstrokerehabilitation. PhysicalMedicineandRehabilitation,12,581592. Bastow,M.D.,Rawlings,J.,&Allison,S.P.(1983).Benefitsofsupplementarytubefeeding afterfracturedneckoffemur:Arandomizedcontrolledtrial.BritishMedicalJournal,287, 15891592. Bernardini,B.,Meinecke,C.,Pagani,M.,Grillo,A.,Fabbrini,S.,Zaccarini,C.,etal.(1995) Comorbidityandadverseclinicaleventsintherehabilitationofolderadultsafterhip fracture.JournaloftheAmericanGeriatricsSociety,43,894898. Boult,C.,&BrummelSmithK.(1997).Poststrokerehabilitationguidelines.Journalofthe AmericanGeriatricsSociety,45,881887. Cameron,L.,Crotty,M.,Currie,C.,Finnegan,T.,Gillespie,W.,Handoll,H.,etal.(2000). Geriatricrehabilitationfollowingfracturesinolderpeople:Asystematicreview.Health TechnologyAssessment,4,1111. Chandra,R.K.(1997).Nutritionandtheimmunesystem:Anintroduction.AmericanJournal ofClinicalNutrition,66,460S463S. Delmi,M.,Rapin,C.H.,Bengoa,J.M.,Delmas,P.D.,Vasey,H.,&Bonjour,J.P.(1990).Clinical practice:Dietarysupplementationinelderlypatientswithfracturedneckofthefemur. Lancet,335,10131016. Diamond,P.T.,Holroyd,S.,Macciocchi,S.N.,&Felsenthal,G.(1995).Prevalenceof depressionandoutcomeonthegeriatricrehabilitationunit.AmericanJournalofPhysical MedicineandRehabilitation,74,214217. Espaulella,J.,Guyer,H.,DiazEscriu,F.,MelladoNavas,J.A.,Castells,M.&Pladevall,M. (2000).Nutritionalsupplementationofelderlyhipfracturepatients:Arandomized, doubleblind,placebocontrolledtrial.AgeandAgeing,29,425431. Falconer,J.A.,Naughton,B.J.,Strasser,D.C.,&Sinacore,J.M.(1994).Strokerehabilitation: Acomparisonacrossagegroups.JournaloftheAmericanGeriatricsSociety,42,3944. Finestone,H.M.,&GreeneFinestone,L.S.(1998).Nutritionanddietpoststroke.Physical MedicineandRehabilitation,12,437458. Fitzgerald,J.F.,Moore,P.S.,&Dittus,R.S.(1988).Thecareofelderlypatientswithhip fracture.NewEnglandJournalofMedicine,319,13921397. Gariballa,S.E.(2000).Nutritionalsupportinelderlypatients.JournalofNutrition,Healthand Aging,4,2527.
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CommonClinicalProblemsinGeriatricRehabilitation Goldstein,F.C.,Strasser,D.C.,Woodard,J.L.,&Roberts,V.J.(1997).Functionaloutcomeof cognitivelyimpairedhipfracturepatientsonageriatricrehabilitationunit.Journalofthe AmericanGeriatricsSociety,45,3542. Gresham,G.E.,Duncan,P.W.,Adams,H.P.Jr.,Adelman,A.M.,&Alexander,D.N.(1995). Poststrokerehabilitation.ClinicalPracticeGuidelineNo.16.(AHCPRReportNo.95 0662).Rockville,MD:USDepartmentofHealthandHumanServices,PublicService, AgencyforHealthCarePolicyandResearch. Hall,K.,Whiting,S.J.,&Comfort,B.(2000).Lownutrientintakecontributestoadverse clinicaloutcomesinhospitalizedelderlypatients.NutritionReview,58,214217. Harris,R.E.,Mion,L.C.,Patterson,M.B.,&Frengley,J.D.(1988).Severeillnessinolder patients:Theassociationbetweendepressivedisordersandfunctionaldependency duringtherecoveryphase.JournaloftheAmericanGeriatricsSociety,36,890896. Heruti,R.J.,Lusky,A.,Barell,V.,Ohry,A.,&Adunsky,A.(1999).Cognitivestatusat admission:Doesitaffecttherehabilitationoutcomeofelderlypatientswithhipfracture? ArchivesofPhysicalMedicineandRehabilitation,80,432436. Hoenig,H.,Nusbaum,N.,BrummelSmith,K.(1997).Geriatricrehabilitation:Stateoftheart. JournaloftheAmericanGeriatricsSociety,45,13711381. Hudson,H.M.,Daubert,C.R.,&Mills,R.H.(2000).Theinterdependencyofproteinenergy malnutrition,aginganddysphagia.Dysphagia,15,3138. Huusko,T.M.,Karppi,P.,Avikainen,B.,Kautiainen,H.,&Sulkava,R.(2000).Randomized clinicallycontrolledtrialofintensivegeriatricrehabilitationinpatientswithhipfracture: Subgroupanalysisofpatientswithdementia.BritishMedicalJournal,321,11071111. Indredavik,B.,Slordahl,S.A.,Bakke,F.,Rokseth,R.,&Haheim,L.L.(1997).Strokeunit treatment:Longtermeffects.Stroke,28,18611866. Jaglal,S.B.,Sherry,P.G.,&Schatzker,J.(1996).Theimpactandconsequencesofhip fractureinOntario.CanadianJournalofSurgery,39,105111 Kasprisin,A.T.,Clumeck,H.,&NinoMurcia,M.(1989).Theefficacyofrehabilitative managementofdysphagia.Dysphagia,4,4852. Keller,H.H.(1997).Nutritionproblemsandtheirassociationwithpatientoutcomesina geriatricrehabilitationsetting.JournalofNutritionfortheElderly,17,113. Kennie,D.C.,Reid,J.,Richardson,I.R.,Kiamari,A.A.,&Kelt,C.(1988).Effectivenessof geriatricrehabilitativecareafterfracturesoftheproximalfemurinelderlywomen:A randomizedclinicaltrial.BritishMedicalJournal,297,10831086. Larsson,J.,Unosson,M.,Ek,A.C.,Nilsson,L.,Thorslund,S.,&Jurulf,P.(1990).Effectof dietarysupplementonnutritionalstatusandclinicaloutcomein501geriatricpatients. ClinicalNutrition,9,179184 Lopez,M.A.,&Mermelstein,R.J.(1995).Acognitivebehavioralprogramtoimprove geriatricrehabilitationoutcome.Gerontologist,35,696700. Marittiku,R.A.,Marottoli,R.A.,Berkman,L.F.,&Cooney,L.M.,Jr.(1992).Declinein physicalfunctionfollowinghipfracture.JournaloftheAmericanGeriatricsSociety,40, 861866.
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CommonClinicalProblemsinGeriatricRehabilitation Meins,W.,MeierBaumgartner,H.P.,Neetz,D.,&vonRentelnKruse,W.(2001).Predictors offavorableoutcomeinelderlystrokepatientstwoyearsafterdischargefromgeriatric rehabilitation.ZeitschriftfurGerontologieundGeriatrie,34,395400. Montano,C.B.(1999).Primarycareissuesrelatedtothetreatmentofdepressioninelderly patients.JournalofClinicalPsychiatry,60Suppl20,4551. Munin,M.C.,Rudy,T.E.,Glynn,N.W.,Crossett,L.S.,&Rubash,H.E.,(1998).Earlyinpatient rehabilitationafterelectivehipandkneearthroplasty.JournaloftheAmericanGeriatrics Society,279,847852. Murphy,P.C.,Rai,G.S.,Lowy,M.,Bielawska,C.(1987).Thebeneficialeffectsofjoint orthopedicgeriatricrehabilitation.AgeandAgeing,16,273278. Norton,B.,HomerWard,M.,Donnelly,M.T.,Long,R.G.,&Holmes,G.K.(1996).A randomizedprospectivecomparisonofpercutaneousendoscopicgastrostomyand nasogastrictubefeedingafteracutedysphagicstroke.BritishMedicalJournal,312,1316. Nourhashemi,F.,Andrieu,S.,Rauzey,O.,Ghisolfi,A.,Vellas,B.,Chumlea,W.C.,etal.,(1999). Nutritionalsupportandaginginpreoperativenutrition.CurrentOpinioninClinical NutritionandMetabolicCare,2,8792. Odderson,I.R.,Keaton,J.C.,&McKenna,B.S.(1995).Swallowmanagementinpatientson anacutestrokepathway:Qualityiscosteffective.ArchivesofPhysicalMedicineand Rehabilitation,76,11301133. Papaioannou,A.,(2000).Mortality,independenceinlivingandrefracture:1yearfollowing hipfractureinCanadians.SocietyofObstetriciansandGynaecologistsofCanada,22,1924. Patrick,L.,Lever,M.,&Johnston,S.(1996).Aspectsofcognitivestatusaspredictorsof mobilityfollowinggeriatricrehabilitation.AgingClinicalandExperimentalResearch,8, 328333. Rosenberg,C.H.,&Popelka,G.M.(2000).Poststrokerehabilitation:Areviewofthe guidelinesforpatientmanagement.Geriatrics,55,7581. Seidel,G.K.,Millis,S.R.,Lichtenberg,P.A.,&Dijkers,M.(1994).Predictingboweland bladdercontinencefromcognitivestatusingeriatricrehabilitationpatients.Archivesof PhysicalMedicineandRehabilitation,80,432436. Slaets,J.P.,Kauffmann,R.H.,Duivenvoorden,H.J.,Pelemans,W.,&Schudel,W.J.(1997).A randomizedtrialofgeriatricliaisoninterventioninelderlymedicalinpatients. PsychosomaticMedicine,59,585591. Stahl,W.M.(1987).Acutephaseproteinresponsetotissueinjury.CriticalCareMedicine,15, 545550. StrokeUnitTrialistsCollaboration(1997).Collaborativesystematicreviewofthe randomizedtrialsoforganizedinpatient(strokeunit)careafterstroke.BritishMedical Journal,314,11511159. Sullivan,D.H.,Walls,R.C.,&Bopp,M.M.(1995).Proteinenergyundernutritionandtherisk ofmortalitywithin1yearofhospitaldischarge:Afollowupstudy.Journalofthe AmericanGeriatricsSociety,43,504512. Teasell,R.W.,Merskey,H.,&Deshpande,S.(1999).Antidepressantsinrehabilitation. PhysicalMedicineandRehabilitationClinicsinNorthAmerica,10,237253.
CommonClinicalProblemsinGeriatricRehabilitation Volkert,D.,Hubsch,S.,Oster,P.,&Schlierf,G.(1996).Nutritionalsupportandfunctional statusinundernourishedgeriatricpatientsduringhospitalizationand6monthfollowup. Aging(Milano),8,386395. White,B.L.,Fisher,W.D.,&Laurin,C.A.,(1987).Rateofmortalityforelderlypatientsafter fractureofthehipinthe1980s.JournalofBoneandJointSurgeryAmericanVolume,69, 13351340. Wilson,K.,Mottram,P.,Sivanranthan,A.,Nightingale,A.(2001).Antidepressantsversus placeboforthedepressedelderly.CochraneDatabaseSystematicReview,2,CD000561.

PartB:OutpatientServices
Inthissection,wereviewoutpatientSGS.Thereisawidevarietyofoutpatient services,butwefocusongeriatricdayhospital(Chapter6),GeriatricPrimaryCarewhich includesoutpatientcomprehensivegeriatricassessment(CGA)andgeriatricevaluationand managementinChapter7,andOutreachinChapter8. Geriatricdayhospitalsarecontroversial.Theyhavenotshownbenefitsinmortality andfunctionalstatusandmayormaynotoffercostbenefits Geriatricprimarycare,bycontrast,hasshownsomeencouragingresults:outpatient comprehensivegeriatricassessmentiseffectiveandcomparedtoinpatientversions reducesriskandburdentopatients,andprobablycosttothesystem.Multidisciplinary geriatricsprimarycarewithfollowupcalledGEMintheUSisalsoeffective,anditmaybe thatthefollowuprequiredisnotlabourintensive. Outreachcarehasbeenthesubjectoffewstudies,yetitisstillapparentthatpositive outcomesarelesslikelyusingasolopractitionerandmorelikelywithamultidisciplinary approach,particularlywhenoneofthedisciplinesinvolvedisgeriatricmedicine.Outreach servicesplayanimportantroleinidentifyingpatientsappropriateforspecializedgeriatric services.
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GeriatricPrimaryCare
Chapter6
DavidLewis
CliniciansPerspective:PatriciaWoo,MD
Thegoalofgeriatricprimarycareistomaintainhealthandfunctionalabilityinthe elderlypopulation.Olderadultshavemultiplecomorbidconditionswhichrequireamore comprehensiveapproach.Therehavebeenpersistentquestionsonthebestapproachto providingthiscarewithinthecontextofabusyoutpatientpracticewhereresourcesare usuallyquitelimited.Fewphysiciansarechoosingcareersthatarefocusedonthecareof olderadults,andthesamephenomenonisseeninotherdisciplines,suchasnursingand physiotherapy.Variousmodelsofoutpatientgeriatricprimarycarehavebeenproposedand studiedandthesearereviewedinthischapter.Ofparticularinterestisthestaffmixthat commonlyincludesagerontologicalnurseornursepractitioner.Costminimization strategiessuchtelephonesfollowupsmaybebeneficialinprovidingcontinuityofcare.A naturalnextstepistounderstandwhetherourclinicalpracticecontainscomponentsof serviceswhichhavebeendemonstratedtobeeffectiveand,ifnot,whynot?Andwhatcan wedoaboutit?Thischapterprovidesaguidetoaddressingthesequestions,anditis tailoredspecificallytotheneedsofstudents,andofthecliniciansandmanagerswho providebehavioralhealthservicestoolderadults.
ExecutiveSummary Therearefewstudiesofgeriatriccliniccare,butseveralongeriatricevaluationand management,whichcombinesaclinicassessmentwithfollowup.Inaddition,most outcomesmeasuredarethoseavailablefromroutinereviewofdatabases:mortality,place ofresidence/institutionalization,dependency,globalpooroutcome(combiningdeath, institutionalizationordependency)andresourceuse.Afewstudieshavemeasured activitiesofdailyliving(ADL)scores,subjectivehealthstatus,patientsatisfaction,and resourceuse.Recommendationsinclude: Targetingandscreeningofpatientswhoarelikelytobenefit. Afocusonclientswithtreatablechronicconditionsthaterodequalityoflifeand thatmayrequireinstitutionalcare(Boult,Boult,Morishita,Smith,&Kane,1998; Burns,Nichols,&Marshall,&Cloar,1995;Silverman,etal.,1995).
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Combiningcarewithotherspecialprogramsforolderadultsatrisk,includingcase management,homecare,subacuteunits,geriatrichospitalunits,advance directives,andwellorganized,guidelinedrivenprimarycare.OutpatientSGSis,at best,onlymarginallycosteffective,soitmustbedesignedtomaximizeefficiency. Combiningassessmentwithsustainedtreatmentinaninterdisciplinaryteam approach.Thismeansthatclinicswithlargenumbersofnewclientsmaybeless effective.Specificprotocolsforfollowup,possiblyincludingtelephonefollowup, and/ortoincreaseadherenceareneeded.Programsmayneedtoretain responsibilityforcomplexoutpatientsindefinitely.
Inhealthservicesresearch,therehavebeensystematicreviewsofcomprehensive geriatricassessment,geriatricdayhospital,inpatientgeriatricconsultationservice,and recentlyofinpatientgeriatricrehabilitation(Forster,Young,&Langhorne,2003;Scott,1999; Stuck,Siu,Whieland,Adams,&Rubenstein,1993;Wells,Seabrook,Stolee,Borrie,&Knoefel, 2003a,2003b).However,noreviewoftheliteratureonhowtoorganizegeriatricoutpatient carehasbeencompleted.Itisnotclearifthereareoptimalscreening,assessment,staffing, treatmentand/orfollowupprocessesthatmaximizeoutcomes,effectivenessandefficiency intheoutpatientsetting. Theobjectiveofthischapteristoidentifycomponentsofoutpatientgeriatric servicesthathavebeendemonstratedtobeeffective,butthathavenotbeenreviewedin earlierchapters.(Notethatthischapterfocusesonoutpatientservices;community(home) basedcareofferedthroughoutreachservicesisdiscussedinChapter8).Basedonthis information,weintendtoprovideadministratorsandclinicianswithevidencebased recommendationsregardingprotocols,screeningcriteria,assessment,treatment,followup strategies,andteammakeup.Isolatingthoseactivitiesthathavebeendemonstratedto enhancethequalityofgeriatricoutpatientcarewillhaveparticularvalueforthosewhoneed tochooseandoperationalizemodelsofservice. DESIGN Toachievetheobjectivesofthischapter,aMedlinesearchwasperformed.Selection criteriafocusedonrandomizedtrialsorotherhighqualityresearchcomparingspecialized geriatricoutpatientserviceswithalternativeformsofcareandexcludinggeriatricmedical dayhospitals.Somereviewers,notablythoseintheCochraneCollaboration,explicitlylimit articlesabstractedtorandomizedcontrolledtrials(RCT);Oxman,1994.However,this approachmaynotbeasusefulinhealthservicesresearch(Chalmers,Celano,Sacks,&Smith, 1983;Sacks,Berrier,Reitman,AnconaBerk,&Chalmers,1987),sootherformsofresearch wereincluded,butstillreservedprideofplacetoRCTs.Inaddition,theweightofthe evidencewasconsidered,thatis,thenumberofresearcharticleswhichconsistentlysupport agivenapproach.
GeriatricPrimaryCare Medlinewassearchedusingtwostrategies.Inthefirstsearch,thetermgeriatric clinicwasselectedandtheresultslimitedtoanyformofclinicaltrialincludingRCTs, consensusdevelopmentconferences,evaluationstudies,metaanalyses,anyoftheseveral formsofreviewpermitted,orevidencebasedpractice.Finally,theresultswerelimitedto articleswithabstracts,intheEnglishlanguage,andusinghumansubjectsaged65orolder. Inthesecondsearch,weusedthekeywordsgeriatric(andvariants)orgerontology(or variants).Theresultswerecombinedwiththekeywordoutpatient,thenlimitedasdescribed above.SimilarsearchesoftheCochraneRegisterandBestEvidence(theACPJournalClub) wereconducted. Eacharticlewasretrieved,scoredforclinicalquality,andsummarizedintermsofthe substantivefindings.Inordertoassessclinicalquality,studysizeandduration,completion rates,exclusioncriteria,andoutcomeswereconsidered(Mulrow,1994;Oxman,1994). Whereavailable,numbersofsubjectsperarm,timespanofthestudy,completionrates, admission/exclusioncriteria,mainoutcomes,changesreported,andstatisticalsignificance andclinicalsignificancewererecorded.Thisinformationwasusedtodevelopaqualityscore, intheformofanordinalscale.Thevalidityoftheclinicalqualityscorewasassessedby havingarandomsampleof13articlesscoredindependentlybyblindedassessorsand, despitetheordinalnatureofthescores,averageintraclasscorrelationcoefficientvalueswas calculated.ThequalityscoresupplementedJadadscores(Moher,etal.1995),whichwealso calculated.TheJadadscaleisawidelyusedmethodtoquantifyastudysquality;thatis,to assesswhetherreportedmethodologyandresultsarefreeofbias.However,itsuseis confinedtorandomizedcontrolledtrials. Participantswereconfinedtomedicalpatientsaged65orolder,andtoincludeonly thosesourcesreportingspecificoutcomes:deaths,placeofresidence/institutionalization, dependency,globalpooroutcome(asinglescorecombiningdeath,institutionalizationor dependency),activitiesofdailyliving(ADL)scores,subjectivehealthstatus,patient satisfaction,andresourceuse. TheMedlinesearchusingthekeywordsgeriatricclinicyielded16articles,ofwhich 7wererejectedbyhandsearching.Thesecondsearch,usinggeriatric(andvariants)or gerontology(orvariants)andoutpatientretrievedover2,232articles.Handsearching wasusedtoreducethenumberofarticlesto27,includingallfromthefirstsearch.Similar searchesoftheCochraneRegisterandBestEvidence(theACPJournalClub)yieldedtwo additionalarticles,foratotalof29.Eightofthesewereexcludedbecausetheydidnotdeal withspecializedgeriatricoutpatientcare,becausetheyincludednomeasuresof effectiveness,orbecausetheyrepeatedinformationfoundelsewhere. Basedonrelevanceandquality,21articleswereretained,dealingwith10sites.Table 6.1containsasummaryofthesearticles.Asampleof13articlesratedforquality independentlybytworatersachievedaverageintraclasscorrelationcoefficientvaluesof 0.85(p<.001),indicatinghighreliability(notshown). Ofthe21articlesretrieved,16dealtwithoutpatientassessmentorconsultation,or withgeriatricevaluationandmanagement,whiletheremainderdealtwithsomeother aspectofoutpatientcare,suchastelephonefollowup.
GeriatricPrimaryCare Table6.1:StudyResults
LifeSatisfaction AcuteCare Utilization NursingHome Utilization Other Utilization Mentalhealth QualityScore Comparison JadadScore Satisfaction
2 0 3 3 2 2 0 3 2 0
175
Alessi,etal.,1997
215/ 199
inhomeNP,CGA vsTAU None(CGA) TAUvsOutpt TAUvsOutpt TAUvsOutpt TAUvsOutpt TAUvsOutpt teleconsults vsTAUf/up TAUvsOutpt TAUvsOutpt teleconsults vsTAUf/up
+* +
+ + +
+ + + + + +
87 Aminzadehetal.,2002 116/0 274/ Boultetal.,1998 112 248 294/ Boult,etal.,1994 199 274 60/ Burns,etal.,1995 187 68 696/ 176 Cohen,etal.,2002 692 80/ 186 Engelhardt,etal.,1996 80 46/ 171 Jaatinen,etal.,2002 48 180/ 186 183 Keeler,etal.,1999 274/ 178 Morishita,etal.,1998 294 10/ 177 Noel,&Vogel,2002 9
+** +
+ + *** + ****
77
Diagnosis
Mortality
Function
Author
Burden
HRQOL
Social
Cost
LifeSatisfaction
AcuteCare Utilization NursingHome Utilization Other Utilization
Mentalhealth
QualityScore
Comparison
JadadScore
Satisfaction
3 3 3 1 2 1 3 2 3 0
186 192 120
Reuben,etal.,1999 Rubin,etal.,1993 Schmader,etal.,2004 Shah,1997
180/ 183 97/ 97 834 n/a 239/ 203 215/ 199 80/ 80 294/ 274 117
TAUvsOutpt TAUvsOutpt TAUvsOutpt outptvs homegerpsych TAUvsOutpt annualf/up vsTAU TAUvsOutpt TAUvsOutpt TAUvsOutpt TAUvsOutpt
+ +
+ +
+ + +
+ +
194 Silverman,etal.,1995 185 170 187 143 188

Stuck,etal.,1995 Toseland,etal.,1996 Toseland,etal.,1997 Weuve,etal.,2000
Williams,etal.,1987 +resultssupportintervention resultsdonotsupportintervention f/up:followup NP:NursePractitioner TAU:Treatmentasusual Outpt:Outpatient
*mayrequireinitialsubsidy **Homecare ***Depression ****Mentalhealth Jadadscore:lowerscoresindicatehigherqualityQualityscore:higherscoresindicatehigherquality
78
Diagnosis
Mortality
Function
Author
Burden
HRQOL
Social
Cost
GeriatricPrimaryCare Ofthosearticlesdealingwithgeriatricevaluationandmanagement,sixreported greatersatisfactionamongthosereceivinggeriatricevaluationandmanagementand/or stakeholders,fourfoundreducedinformalcaregiverburden,twoindicatedimprovedmental health,twoshowedimprovedsocialfunctioning,onedescribedimprovedcasefinding,and onefoundfeweradversedrugreactionsandfewerinstancesofsuboptimalprescribing. Incontrast,twofoundreducedmortalitywithgeriatricevaluationandmanagement, whiletwoshowednodifference.Similarly,threereportedimprovedqualityoflifeandtwo foundnodifference;fivereportedimprovedfunctionbutthreedescribednodifference;one showedimprovedlifesatisfactionandoneindicatednodifference. Intermsofcostsandserviceutilization,fourfoundcostsavingswithgeriatric evaluationandmanagementwhilethreedidnot(afourthshowinggreatercostforthiswas supersededbyapositivestudy).Inaddition,onestudyshowedreducedhomecare utilizationamonggeriatricevaluationandmanagementpatients.Theremainingstudies foundgreaterutilization,ornodifference,inacuteserviceutilization(fourstudies),nursing homeplacement(fivestudies),andotherutilizationforgeriatricevaluationand managementpatients(onestudy). Ofthosedealingwithotheroutpatientinterventions,twostudiesexamined telephonefollowupaftertreatmentversustreatmentasusualandfoundnodifferencein costorpatientfunction(averysmallstudy)orinanyformofhealthserviceutilization(a somewhatlargerstudy).Thelatterstudydidfindgreaterreferralsourceandclient satisfactionamongthosereceivingtelephonefollowup.Ahigherqualitystudyofannualin personfollowupfoundimprovedfunctionbutnochangeinutilizationintheintervention arm.Arelatedstudyalsofoundimprovedcasefindingintheinterventionarm. ProcessRecommendations Althoughfurtherstudyiscertainlyneeded,asnotedinseveralarticles,wecan concludeeachofthefollowingwithsomeconfidence. Targetingandscreeningofpatientswhoarelikelytobenefitfromgeriatric outpatientcareiscrucialtosuccess(Boult,etal.,1998;Boult,etal.,1994;Burns,et al.,1995;Cohen,etal.,2002;Silverman,etal.,1995;Williams,Williams,Zimmer,Hall, &Podgorski,1987). Geriatricoutpatientcareismostlikelytobenefitthosewithtreatablechronic conditionsthaterodequalityoflifeandthatmayrequireinstitutionalcare(Boult,et al.,1998;Burns,etal.,1995;Silverman,etal.,1995). Geriatricevaluationandmanagementismosteffectiveinconcertwithotherspecial programsforolderadultsatrisk,includingcasemanagement,homecare,subacute units,geriatrichospitalunits,advancedirectives,andwellorganized,guidelinedriven primarycare(Boult,etal.1998;Reuben,Frank,Hirsch,McGuigan,&Marley,1999; Touseland,etal.,1997). Inordertobeeffective,geriatricoutpatientcaremustcombineassessmentwith sustainedtreatment(Alessietal.,1997;Aminzadeh,Amos,Byszewski,&Dalziel,2002; Boult,etal.,1994,1998;Burnsetal.,1995;Silverman,etal.,1995).
GeriatricPrimaryCare o Specificprotocolsforfollowupand/ortoincreaseadherenceareneeded (Aminzadeh,etal.,2002;Boult,etal.,1994;Reuben,etal.,1999;Touseland,et al.,1997).Thesemayinvolvetelephoneconsultationorfollowup(Boult,etal., 1998;Jaatinen,Aarnio,Remes,Hannukainen,&KoymariSeilonen,2002;Noel, &Vogel,2000). Betteroutcomesmaybeachievedbygeriatricevaluationandmanagementprograms thatretainresponsibilityforcomplexpatientsindefinitely(Alessi,etal.1997;Boult,et al.,1994,1998;Burns,etal.,1995;Silverman,etal.,1995). Becausegeriatricevaluationandmanagementprogramsare,atbest,marginallycost effective(Boult,etal.,1994,1998;Burns,etal.1995;Engelhardt,Toseland,ODonnell, Richie,Jue,&Banks,1996)theymustbedesignedtomaximizeefficiency(Engelhardt etal.;Keeler,etal.,1999;Toseland,etal.,1996,1997).Thiscanbeachievedby: o Coordinationofcarewithprimaryproviders,alongwithuseofwell coordinatedservicesthatminimizeredundancies(Aminzadeh,etal.2002; Boult,etal.,1994,1998;Cohen,etal.,2002;Morishita,Boult,Boult,Smith,& Pacala,1998;Reuben,etal.,1999;Williams,etal.,1987).Inparticular,geriatric outpatientshouldnotassumeprimarycareresponsibilities.Ifgeriatric outpatientprogramsaredesignedtocollaboratewithprimarycare,theywill belessresourceintensive,andwillnotsetupaparallelsystemofhealthcare delivery(Keeler,etal.,1999;Morishitaetal.,1998;Reuben,etal.,1999; Williams,etal.,1987). o Emphasizingriskreductionstrategies(e.g.fallsprevention)(Englehardt,etal., 1996). o Seekingtodivertpatientsawayfromemergencyorinpatientcare (Englehardt,etal.,1996;Rubin,Sizemore,Loftis,&deMola,1993). o Reducingthenumberofvisitswithoutcompromisingqualityofcare (Aminzadeh,etal.,2002).Thisismademorelikelywithmoreeffective communicationamongthevariousdisciplinesinvolvedintheassessmentand treatmentprocess,alongwithfamilyconferencing(Aminzadeh,etal.,2002; Boult,etal.1998;Williamsetal.,1987). o Efficientstandardizedtechniquesforassessmentareneeded,asareclinical guidelines(Aminzadeh,etal.,2002;Boult,etal.1998). Aninterdisciplinaryteamapproachprovidingcontinuityofcareiskey(Aminzadeh,et al.,2002;Rubin,etal.,1993;Williamsetal.,1987).
ThesefindingsaresummarizedinTable6.2,whichshowsthenumberofRCTssupporting eachfinding,alongwiththenumberofotherstudiesreportingthefinding.

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GeriatricPrimaryCare Table6.2:KeyRecommendations Numberof Studies RCT Other 4 1
Strategy
Enrollment Targetingandscreeningofpatientswhoarelikelytobenefit Selectthosewithtreatablechronicconditionsthaterodequalityof 2 2 lifeandthatmayrequireinstitutionalcare Combineassessmentwithsustainedtreatment 0 2 Introduceefficientstandardizedtechniquesforassessment,clinical 0 1 guidelines Treatment Workwithotherspecialprogramsforolderadultsatrisk 0 1 Interdisciplinaryteamapproachprovidingcontinuityofcare 2 1 BecauseGEM*programsare,atbest,marginallycosteffective,they 4 1 mustbedesignedtomaximizeefficiency Coordinationofcarewithprimaryproviders,alongwith 4 1 developmentofwellcoordinatedservicesthatminimizeredundancies Emphasizingriskreductionstrategies(e.g.fallsprevention) 1 0 Seekingtodivertpatientsawayfromemergencyorinpatientcare 4 2 Reducingthenumberofvisitswithoutcompromisingqualityofcare. 1 2 Moreeffectivecommunicationamongthevariousdisciplinesinvolved 1 0 intheassessmentandtreatmentprocess Familyconferencing 0 2 Followup 6 3 Specificprotocolsforfollowupand/orincreaseadherence Telephonefollowup 2** 1 BetteroutcomesmaybeachievedbyGEM*programsthatretain 1 responsibilityforcomplexpatientsindefinitely
*GEM=geriatricevaluationandmanagement
**SmallNs
Staffing Therewerebasiclevelsandmixturesofstaffassociatedwithinterventionsthatwere foundtobeeffective;inthe20articlesreviewed,18describedstafftypes(SeeTable6.3): Foroutpatientassessmentsorclinics(Silverman,etal.,1995;Stuck,etal.,1993,1995; Williamsetal.,1987),alleffectiveinterventionsincludedaconsultinggeriatriciananda gerontologicalnurseorgerontologicalnursepractitioner.Twoalsoincludedasocial

GeriatricPrimaryCare Table6.3:StaffingAssociatedwithSuccessfulInterventions Author Alessi,etal.,1997 Boultetal.,1998 Boultetal.,1994 Burns,Nichols,Marshall,&Cloar, 1995 Cohen,etal.,2002 Engelhardt,etal.,1996 Jaatinen,etal.,2002 Keeler,etal.,2002 Morishita,etal.,1998 Noel,&Vogel,2002 Reuben,Frank,Hirsch,McGuigan,& Malay,1999 Rubin,Seizmore,Loftis,&deMola, 1993 Shah,1997 Silverman,etal.,1995 Stuck,etal.,1995 Toseland,etal.,12996 Toselandetal.,1997 Williams,Williams,Zimmer,Hall,& Podgorski,1987 Staffing Geriatrician(consult),NP(Gerontological) Geriatrician,RN(Gerontological),NP,SW Geriatrician;NP(Gerontological),SW Physicians(geriatrician),NP,SW,psychologist, clinicalpharmacist Geriatrician,RN,SW Geriatrician,NP(lead),SW Physicians(othersunstated) Geriatrician,NP(Gerontological),SW,PT Geriatrician,NP(Gerontological),RN,SW RN,Physician(consult) Geriatrician,NP(Gerontological),SW,PT Geriatrician,CNS(Gerontological),SW (Gerontological) Geriatricpsychiatryclinicprimaryphysicians (othersunstated) Geriatrician,RN(Gerontological),SW Geriatrician(consult),NP(Gerontological) Geriatrician,NP,SW Geriatrician,NP,SW Geriatrician,familyphysicians(interestingeriatric), psychiatrists,RN,SW,Nutritionists Intervention InhomeCGA SGSClinic(GEM) SGSClinic(GEM) SGSClinic(GEM) SGSClinic(GEM) SGSClinic(GEM) Teleconsults SGSClinic(GEM) SGSClinic(GEM) Telemedicine SGSClinic(GEM) SGSClinic(GEM) PsychiatryClinic CGA CGA SGSClinic(GEM) SGSClinic(GEM) CGA Favors Intervention Yes No Yes Yes Yes No Yes Yes Yes No Yes Yes Yes Yes Yes Yes Yes Yes
CGA=ComprehensiveGeriatricAssessment;SGS=SpecializedGeriatricServices;GEM=GeriatricEvaluation&Management;NP=NursePractitioner;SW =SocialWorker;RN=RegisteredNurse;PT=Physiotherapist;
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GeriatricPrimaryCare worker,andoneaddedfamilyphysicianswithaninterestingeriatrics,psychiatristsand nutritionists.Aninhomeassessmentunit(Alessi,etal.,1997)wasstaffedbyaconsulting geriatricianandagerontologicalnursepractitioner. Thesinglearticleonapsychiatryclinic(Shah,1997)mentionedgeriatricpsychiatryand primaryphysicians;otherstaff,ifany,werenotdescribed. Onearticleonteleconsultationsmentionsphysiciansonly(Jaatinen,2002).Oneon telemedicinereportedresultsthatdidnotfavortheintervention;itwasstaffedbya nursewithaphysicianavailableforconsults(Noel&Vogel,2000). Theremainingarticlesdescribegeriatricevaluationandmanagement.Ofthese,one describedasatisfactionstudyonly(Morishita,etal.,1998),andtworeportedresultsthat didnotfavortheintervention(Boult,etal.,1998;Englehardt,1996).Oftheremaining eight,allspecifiedasocialworkerasastaffmember(Boult,etal.,1994;Burns,etal., 1995;Cohen,etal.,2002;Keeler,etal.,1999;Reuben,etal.,1999;Rubin,1993;Touseland, etal.,1996,1997).Sevenincludedageriatrician(Boult,etal.,1994;Cohen,etal.;Keeler, etal.,1999;Reuben,etal.,1999;Rubin,etal.,1993;Touseland,etal.,1996,1997)while theeighthmentionedaphysicianonly(Burns,etal.,1995).Fourspecifieda gerontologicalnursepractitionerorgerontologicalclinicalnursespecialist(Boult,1998; Keeler,etal.;Reuben,1999;Rubin,1993)whilefourmentionedanursepractitoner withoutspecifyingagerontologicalfocus(Burns,etal.,1995;Cohen,etal.;Touseland,et al.,1996,1997).Twoincludedphysiotherapy(Keeler,etal.,1999;Reuben,etal.,1999), andoneapsychologistandaclinicalpharmacist(Burns,etal.,1995). Onearticlewithresultsthatdidnotfavourtheintervention,wasledbyanurse practitioner(Englehardt,etal.,1996),anotherwithunfavourableresultsincludedbotha nurseandanursepractitioner(Boult,etal.,1998). Conclusions Thisresearchdescribedthetypesofoutpatientinterventionsingeriatriccarefor whichthereissupportingevidence.Itprovidesstrategiestoenhancecare,someofwhich arefairlyeasytoimplement. Forexample,researchshowsthatseniorswithcomplexhealthneedsrequirestaff whohavespecifictrainingingeriatrics.However,thosewithoutcomplexneedsmaynot.For thosewithcomplexneeds,astaffmixthatcomplementsexpertiseingeriatricsmakesgood sense.Thedatasuggestthattheessentialbuildingblockforstaffingbeginswitha geriatricianandagerontologicalnurseor,morecommonly,agerontologicalnurse practitioner.Manysuccessfulprogramshaveotherstaffaswell,andstudyauthorssupport aninterdisciplinaryorteamapproachtocare.However,dataonstaffingmustbeinterpreted withcaution,sincethestudyauthorswerenottestingpersonnelmodelsintheirstudies. Inordertomaximizesuccess,teammembersneedtohaveclearroledescriptions andeffectivecommunicationstrategieswithintheteam.Theyalsoneedtocommunicate outsidetheteam,tocoordinatecareplanningwithfamilyandcommunitypartners,andto operatewithawellcommunicatedhandingoffplantohealthcareproviders.Treatment plansmustbeunderstoodandfollowedbypatientsandtheirsignificantothers;strategiesto
GeriatricPrimaryCare ensurethatthishappensshouldbeinplace.Specificprotocolsandstrategiestoincreasethe likelihoodthatpatientswilladheretothetreatmentregimenshouldbeputinplace. Likeanyotherliteraturereview,thisonesuffersfromtwomajorsourcesoferror:the limitationsinstudyscope,inwhathasbeenstudied,intheresearchreviewed;andthe possibilitythatthesampleextractedisbiased.Therearesubstantialgapsintheavailable evidencesurroundingtheorganizationofspecializedgeriatricservices.Thesegapscanbe filledwithnewhealthservicesresearch.Ontheotherhand,thisstudyexcludesliterature thatwasnotcitedinMedline,(e.g.,greyliterature).Inaddition,literatureinbusinessand socialsciencejournalswhichmightbearontheissueathandwasnotexamined. Theresultsdescribedhereindicatethatgeriatricoutpatientservicesmustcarefully targetonlythosepatientswhoarelikelytobenefit,combineassessmentwithsustained treatmentandfollowup,andpaycloseattentiontocostminimizationstrategies,perhaps includingtelephonefollowup.
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GeriatricPrimaryCare References Alessi,C.A.,Stuck,A.E.,Aronow,H.U.,Yuhas,K.E.Bula,C.J.,Madison,R.,etal.(1997). Theprocessofcareinpreventiveinhomecomprehensivegeriatricassessment. JournaloftheAmericanGeriatricsSociety,45(9),10441050. Aminzadeh,F.,Amos,S.,Byszewski,A.,&Dalziel,W.B.(2002).Comprehensivegeriatric assessment:Exploringclients'andcaregivers'perceptionsoftheassessmentprocess andoutcomes.JournalofGerontologicalNursing,28(6),613. Boult,C.,Boult,L.,Morishita,L.,Smith,S.L.,&Kane,R.L.(1998).Outpatientgeriatric evaluationandmanagement.JournaloftheAmericanGeriatricsSociety,46(3),296 302. Boult,C.,Boult,L.,Murphy,C.,Ebbitt,B.,Luptak,M.,&Kane,R.L.(1994).Acontrolled trialofoutpatientgeriatricevaluationandmanagement.JournaloftheAmerican GeriatricsSociety,42(5),46570. Burns,R.,Nichols,L.O.,Marshall,J.G.,&Cloar,F.T.(1995).Impactofcontinuedgeriatric outpatientmanagementonhealthoutcomesofolderveterans.ArchivesofInternal Medicine,155,13131318. Chalmers,T.C.,Celano,P.,Sacks,H.S.,&Smith,H.J.(1983).Biasintreatmentassignmentin controlledclinicaltrials.NewEnglandJournalofMedicine,309,13581361. Cohen,H.J.,Feussner,J.R.,Weinberger,M.,Carnes,M.,Hamdy,R.C.,Hsieh,F.,etal. (2002).Acontrolledtrialofinpatientandoutpatientgeriatricevaluationand management.NewEnglandJournalofMedicine,346(12),905912, Engelhardt,J.B.,Toseland,R.W.,O'Donnell,J.C.,Richie,J.T.,Jue,D.,&Banks,S.(1996). Theeffectivenessandefficiencyofoutpatientgeriatricevaluationandmanagement. JournaloftheAmericanGeriatricsSociety,44(7),847856. Forster,A.,Young,J.,&Langhorne,P.(2003).Medicaldayhospitalcarefortheelderly versusalternativeformsofcare.In:TheCochraneLibrary[DatabaseonDiscand CDROM,Issue2].Oxford,UK:UpdateSoftware. Jaatinen,P.T.,Aarnio,P.,Remes,J.,Hannukainen,J.,&KoymariSeilonen,T.(2002). Teleconsultationasareplacementforreferraltoanoutpatientclinic.Journalof TelemedicineandTelecare,8(2),102106. Keeler,E.B.,Robalino,D.A.,Frank,J.C.,Hirsch,S.H.,Maly,R.C.,&Reuben,D.B.(1999). Costeffectivenessofoutpatientgeriatricassessmentwithaninterventionto increaseadherence.MedicalCare,37(12),11991206. Moher,D.,Jadad,A.R.,Nichol,G.,Penman,M.,Tugwell,P.,&Walsh,S.(1995).Assessingthe qualityofrandomizedcontrolledtrials:Anannotatedbibliographyofscalesand checklists.ControlledClinicalTrials,16(1),6273. Morishita,L.,Boult,C.,Boult,L.,Smith,S.,&Pacala,J.T.(1998).Satisfactionwith outpatientgeriatricevaluationandmanagement(GEM).Gerontologist,38(3),303 308. Mulrow,C.D.(1994).Rationaleforsystematicreviews.BritishMedicalJournal,309,597599.
GeriatricPrimaryCare Noel,H.C.,&Vogel,D.C.(2000).Resourcecostsandqualityoflifeoutcomesfor homeboundelderlyusingtelemedicineintegratedwithnursecasemanagement. CareManagement,6(5),2231. Oxman,A.D.(Ed.)(1987).Preparingandmaintainingsystematicreviews.InTheCochrane CollaborationHandbook.Oxford,UK:CochraneCollaboration. Reuben,D.B.,Frank,J.C.,Hirsch,S.H.,McGuigan,K.A.,&Maly,R.C.(1999).A randomizedclinicaltrialofoutpatientcomprehensivegeriatricassessmentcoupled withaninterventiontoincreaseadherencetorecommendations.Journalofthe AmericanGeriatricsSociety,47(3),269276. Rubin,C.D.,Sizemore,M.T.,Loftis,P.A.&deMola,N.L.(1993).Arandomized,controlled trialofoutpatientgeriatricevaluationandmanagementinalargepublichospital. JournaloftheAmericanGeriatricsSociety,41(10),10231028. Sacks,H.S.,Berrier,J.,Reitman,D.,AnconaBerk,V.A.,&Chalmers,T.C.(1987).Meta analysisofrandomizedcontrolledtrials.NewEnglandJournalofMedicine,316(8),450 455. Schmader,K.E.,Hanlon,J.T.,Pieper,C.F.,Sloane,R.,Ruby,C.M.&TwerskyJ.(2004). Effectsofgeriatricevaluationandmanagementonadversedrugreactionsand suboptimalprescribinginthefrailelderly.AmericanJournalofMedicine,116(6),394 401. Scott,I.(1999).Optimisingcareofthehospitalizedelderly:Aliteraturereviewand suggestionsforfutureresearch.AustralianandNewZealandJournalofMedicine, 29(2),254264. Shah,A.(1997).Costcomparisonofoutpatientandhomebasedgeriatricpsychiatry consultationsinoneservice.AgingandMentalHealth,1(4),372376. Silverman,M.,Musa,D.,Martin,D.C.,Lave,J.R.,Adams,J.,&Ricci,E.M.(1995).Evaluation ofoutpatientgeriatricassessment:Arandomizedmultisitetrial.Journalofthe AmericanGeriatricsSociety,3(7),733740. Stuck,A.E.,Aronow,H.U.,Steiner,A.,Alessi,C.A.,Bula,C.J.,GoldMN.,etal.(1995).Atrial ofannualinhomecomprehensivegeriatricassessmentsforelderlypeoplelivingin thecommunity.NewEnglandJournalofMedicine,333(18),11841189. Stuck,A.E.,Siu,A.L.,Whieland,G.D.,Adams,J.,&Rubenstein,L.Z.(1993).Comprehensive geriatricassessment:Ametaanalysisofcontrolledtrials.Lancet,342,10321036. Toseland,R.W.,O'Donnell,J.C.,Engelhardt.J.B.,Hendler,S.A.,Richie,J.T.,&Jue,D. (1996).Outpatientgeriatricevaluationandmanagement.Resultsofarandomized trial.MedicalCare,34(6),624640. Toseland,R.W.,O'Donnell,J.C.,Engelhardt,J.B.,Richie,J.,Jue,D.,&Banks,S.M.(1997). Outpatientgeriatricevaluationandmanagement:Isthereaninvestmenteffect? Gerontologist,37(3),324332. Wells,J.L.,Seabrook,J.A.,Stolee,P.,Borrie,M.J.,&Knoefel,F.(2003).Stateoftheartin geriatricrehabilitation.PartI:reviewoffrailtyandcomprehensivegeriatric assessment.ArchivesofPhysicalMedicine&Rehabilitation,84(6):8907.
GeriatricPrimaryCare Wells,J.L.,Seabrook,J.A.,Stolee,P.,Borrie,M.J.,&Knoefel,F.(2003).Stateoftheartin geriatricrehabilitation.PartII:clinicalchallenges.ArchivesofPhysicalMedicine& Rehabilitation,84(6),898903. Weuve,J.L.,Boult,C.,&Morishita,L.(2000).Theeffectsofoutpatientgeriatricevaluation andmanagementoncaregiverburden.Gerontologist,40(4),429436. Williams,M.E.,Williams,T.F.,Zimmer,J.G.,Hall,J.,&PodgorskiCA.(1987).Howdoesthe teamapproachtooutpatientgeriatricevaluationcomparewithtraditionalcare?A reportofarandomizedcontrolledtrial.JournaloftheAmericanGeriatricsSociety, 35(12),10711078.
GeriatricDayHospital
Chapter7
DavidLewisandMarleneAwad
CliniciansPerspective:IreneTurpie
ThisisausefulreviewoftheGeriatricDayHospital.DayHospitalshavebecomean integralandacceptedpartofgeriatriccaredespitethelackofcompellingsupportive evidenceforthem.InOntariotheyhavechangedlittleincompositionandpurposeinthe20 yearssincetheirinceptiondespitegreatchangesinhealthcaredelivery.Theyaredesigned toproviderehabilitativeservicestothosepersonswhowouldbenefitfromthemandwho arewellenoughtogettothem.DayHospitalselsewherehaveevolvedtofulfilladditional andmorefocusedpurposes. TheproblemswithevaluatingDayHospitals,astheauthorshavedescribed,isthe greatdiversityofservicesofferedandpatientsadmitted.Thesecanincludehomecare services,withwhichtheyareproperlycontrastedinsomestudies. Thisreviewwillformausefulguideforanyoneinterestedinestablishingor evaluatingaDayHospital.ItisawelcomeadditiontotheliteratureonDayHospitalsandwill alsoserveasausefulguideandperhapsastimulustoprovidemorestandardizedand shortenedassessmentsforthefrailelderlypersonswhoattendthem.Withthedecreasing numbersofhospitalbedsandtheincreasingnumbersofelderlypersons,DayHospitalsplay animportantroleinprovidinganefficientandusefulbridgebetweencommunityand hospitalanditisuptothoseofuswhoworkinthemtoworktothisgoal.
ExecutiveSummary GeriatricDayHospital(GDH)isahospitalbasedambulatoryprogramthatprovides diagnostic,rehabilitativeortherapeuticservicestoseniorslivinginthecommunity.The intentisforGDHtoserveasabridgebetweenacutecareandcommunitycare.Thecore servicesarerehabilitativetherapy,intendedtoimprovefunctionandqualityoflife, maintainindependence,andalleviatecaregiverburden. GDHwasintroducedinOxfordinthe1950sandwasrapidlyreplicatedelsewhere. Thereissomeevidence,howeverincompleteandheterogeneous,thatGDHcanhavea positiveimpactonmortality,healthstatusandfunction,and(atleast)balancedcost.
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MoreresearchisneededtoidentifythewaysinwhichGDHarebeneficialandwhich eligibilitycriteriatooptimizetheuseofhealthcaresystemresources.
patientsbenefitmost.Thisinformationwillassistinthedevelopmentofappropriate
SuggestionsforGDHs 1. EnsurethatGDHsusescreeningandenrolmentmeasurestotargetfrailpatientsto helpavoidinpatientadmissionsand/orinstitutionalization. 2. Controlcosts:maintainshortermeanlengthsofstay,avoidredundantquestions andtests,streamlineassessmenttime,andreduceclericalactivities(e.g.,charting) byspecializedstaff. 3. Controlheterogeneityandinappropriateenrolments:standardsfordetermininga treatmentplanshouldbedevelopedandusedconsistently,withmeasurablegoals. Enrolmentcriteriashouldbeusedtoincludeonlycomplexelderlypatientswithat leasttwohealthissues,oneofwhichmustbeamenabletorehabilitation. 4. Enhanceeducationopportunities;forexample,thetreatmentplanshouldbe reviewedwithpatientsandtheircaregivers. 5. Eachdisciplineshouldprioritizecareplanissuesandtreatmentssoastofocuson theessentials(i.e.thosewithahighburdenofillnessandareasonableprospectof change).
Introduction Itiscriticalthatthenecessarydataandinformationbemadeavailabletoallthose whoneedit(policymakers,healthcareprovidersandmanagers,patientsandconsumers)at atimewhendecisionsarebeingmade(NationalForumonHealth,1996).Despitethefact thatmedicalgeriatricdayhospitalshaveexistedsince1952(Anonymous,1994),thereisno clearevidencetoindicatewhethertheywork,orwhethertheyaremoreeffectivethan alternativeformsofservicedelivery.Thismaybebecausetherearenoconsistentstandards forassessingwhatconstitutessuccessinthiscontext(Bach,Bach,Bhmer,Frhwald,& Grilc,1995).Thischapterprovidesanoverviewofgeriatricdayhospitalsandareviewofthe evidencesurroundingthem. ProfileoftheGeriatricDayHospital GeriatricDayHospital(GDH)isahospitalbasedambulatoryprogramthatprovides diagnostic,rehabilitativeortherapeuticservicestoseniorslivinginthecommunity.The intentisforGDHtoserveasabridgebetweenacutecareandcommunitycare(Benson, 1992). Typically,GDHsarelargeusersofoutpatientspecializedgeriatricservices(SGS) resources. *Assessmentandtreatmentmayincludehightechequipmentasneeded,but
* However,thisisarelativeterm:aGDHsresourceusepalesincomparisontoanyacutecareunit,andevento someoutpatientunits. OrganizationDesignforGeriatrics:AnEvidenceBasedApproach 89
GeriatricDayHospital oftentheydonot,eitherbecausetheyareunnecessaryorbecausethepatienthasalready receivedsuchassessmentspriortoreferraltoGDH.Instead,GDHreliesoncomparatively largeamountsofspace(tohouseexerciseandotherrehabilitationequipment)andlabour intensiveactivities.Staffingincludesmedicalandadministrativefunctions,alongwith physiotherapy,occupationaltherapy,rehabilitationassistants,therapeuticrecreation,and clerical.Manyhavesocialworkersaswell.Nursingisalwaysinvolvedandsometimes includesadvancedpracticenursingifavailable.Someuseamultidisciplinarycase managementapproach,whileothersconfinecasemanagementtothenursingrole.Geriatric medicineandperhapsgeriatricpsychiatryarealsoinvolved. Ourreviewof6localdayhospitalsstaffing(Table7.1)andutilizationindicatedhigh variability,butonaverageGDHsoperatedwith1.2patienthoursforevery1.0staffhour. Table7.1:GeriatricDayHospital(GDH)Staffing Spaces Admissions* Visits* ALOS(admissiontodischarge) Averagedailycensus MeanFTEsforGDH Meanstaffhoursperpatient

Means 22 120 2273 108 11 7.19 840.5
ALOS=Averagelengthofstay;FTE=FulltimeEquivalent *peryear
Adayhospitalprovidesanorganizeddayprogramforthesickandelderlyrequiring rehabilitationandinsomeinstances,diagnosticinvestigation/assessment(Black,2005). Althoughdayhospitalsalsoprovidesomerecreational/socialactivities,thesearesecondary. Theprimaryservicesareusuallyrehabilitativetherapy,notablyoccupationaltherapyand physiotherapy,withotherspecialties,likespeech/languagepathology,broughtinasneeded. Therefore,exceptforthepsychiatricGDH,whichisnotafocusofthisreview,aGDHs orientationislikelytobephysicalandtherapeutic,to: reducetheburdenofillnessordisability improvefunctionalability treatancillarybehaviouralandaffectiveproblems reducetheriskofmoreseriousconditions(anddivertpatientsfrommoreintensive treatmentarrangementslikeacutecareorlongtermcare)whereverpossible alleviatecaregiverburdenasanancillarygoal(Eagle,etal.,1991). maintaincommunitylivingaslongasfeasible(Bach,etal.,1995;Goeree,etal.,2005). improvequalityoflife Usually,patientsattendforatleasttwodaysperweek,withthefirstfewvisits dedicatedtoassessment.Onaverage,anassessmentforGDHtakes6hoursplusmedical time.InHamilton,timeinprogramaverages136daysorabout18visits.Astaffmember
GeriatricDayHospital spends3hoursinhandsonpatientcareper7hourday,withtheremainderbeingdevoted tofamilyconferences,caseconferences,charting,andthelike. LiteratureSearchStrategy AsearchwasconductedusingtheAgeline,CINAHL,OvidMEDLINE,andPsycINFO databaseswiththesearchtermGeriatricDayHospital.Thesearchwaslimitedtojournal articlesinEnglish,focusedonthoseaged65orolder,withabstractsandpublishedbetween 1985and2006.ThemostfruitfulofthesesearcheswasMEDLINE,whichyielded97articles. Limitingthesearchtoresearchworks(i.e.,anyclinicaltrialincludingrandomisedcontrolled trials,evaluationstudies,metaanalysesorreviews)inMedlinereducedthatnumberto14. Therearealsoafewstudieswhicharenotdirectlycitedinthischapter,buthavebeen includedinForster,Young,andLanghornes(2004)systematicreview. AReviewofEvidence Evidencefortheeffectivenessofdayhospitalsismixed(Anonymous,1994;Bach,et al.,1995;Benson,1992,Black,2005).Manystudiesfindlittlebenefit(Cranswick,1997;Eagle, etal.,1991;Goeree,etal.,2005)andthosethatdoshowbenefitalsoshowthatpatient inclusioncriteriamustbequiterestrictive(Black,2000;Guyatt,etal.,1993;Hui,Lum,Woo, Or,&Kay,1995;Naylor,Anderson,&Goal,1994).Seetable7.2forasummaryofselected dayhospitalliterature. Lewis,Turpie,Cowan,Diachun,&MacLeod(2000)forexample,foundthatGDHwas effectiveinimprovingthehealthstatus(asindicatedbytheSF12)ofasubsetofpatients who:a)attendedonafairlyregularbasis,andb)werebelowtheagespecificpopulation averageinhealthstatusonenrolment.TheGDHinquestionthensoughttoreformulate inclusioncriteriatorestrictenrolmenttothosewithtwoormorehealthorfunctional problems,atleastoneofwhichwasanameliorablecondition,whichwastypicallydealtwith byaphysiotherapistoroccupationaltherapist. ACanadianpilotstudyin2001(ascitedinWebberetal.,2003),suggestedthatGDH hasadvantagesoverahomebasedmodelforwomendischargedfromacutecareforhip fracture,inthatitmayprovidemoreefficientuseofhealthcareresourcesandtherapists time.Likewise,Tousignant,Hebert,DerosiersandHollander(2003),foundthatGDHnotonly improvedpatientoutcomes,butforeverydollarinvestedinthegeriatricdayhospital programme,thebenefitforthehealthsystemwas$2.14.(p.57). Bycontrast,Forsterandcolleagues(1999)systematicreviewof12randomisedtrials foundnooveralladvantagefordayhospitalcare,whencomparedtoarangeofalternative services.Therewas,however,atrendtoimprovementcomparedtonocomprehensivecare atall,intermsofdeathorpooroutcome,disability,anduseofresources.Therewasalsoa trendtowardsreduceduseofhospitalbedsandinstitutionalcare,butinsufficienttooffset thecostofGDHitself.
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GeriatricDayHospital Table7.2:SummaryofSelectedDayHospitalLiterature
Inclusion criteria
Nodysphasia;did notrequire nursingor medicalcare, morethantwice aweekcare,or focusedOT Patientswith deteriorating functionalstatus believedtohave rehabilitation potential RCTscomparing geriatricday hospitalswith alternativeforms ofcareforelderly medicalpatients
Study Type
RCT
Author
Population
N
50/55
Outcome Measure/ Tool(s)

Secondary outcomes: WHOMobility subscale; Nottinghmam ExtendedADL Scale;NHP BarthelIndex;Rand Questionnaire; GlobalHealth Questionnaire; GQLQ
Intervention Outcome (studyduration) Measures

GDHvsSocial servicedaycentre withrehab;data collectedatstart, 6weeks, 3months GDHvsTAU WHOMobility NHFMobility NHPADL Mobility NHPADLLeisure
Result
ns ns ns ns
Burch,etal., Referred 2000 elderly patients
RCT
Eagle,etal., Referred 1991 elderly patients
55/58
Mortality Functional status GQLQ ADL GQLQemotion 5GDHvs Comprehensive geriatriccare 4GDHvs Domiciliarycare 3GDHvsusual
ns ns ns p<.009
Review
Forster, Young& Langhorne, 2000
Cochrane Library; MEDLINE; Sigle;Bids; Cinahl; Index Medicus; Inter national Dissertation Abstracts
12studies were included involving22 day hospitals and2867 patients
Death;placeof residence; dependency; globalpoor outcome;ADL; subjectivehealth status;patient satisfaction;and resourceuse
3independent reviewers assessedstudy quality
Deathns;Disability ns; useofresourcesns. Deathorpoor outcome,oddsratio =.72(p<.005); functional deterioration,odds ration=.61(p<0.05). Trendstowards lowerhospitalbed useandplacementin institutionalcare. Treatmentcosts higher.
92
Study Type
Before and after RCT
Author
Harwood, &Ebrahim, 2000 Hui,etal., 1995
Population
GDHpatients inanurban setting Elderly stroke patients
Inclusion criteria
37

BarthelIndex;LHS

Effectivenessof2 scalesinGDH3 months rehab GDHv Conventional medical managementby neurologists; followupat3and6 months Barthel LHS
Result
ns ns
Diagnosisof cerebrovascular accident
60/60
BarthelIndex; Hospital, community,and GPservices; Admissions; Satisfaction;Mood
Pro Lewis,etal., GDHpatients ina spective 2000 community cohort healthcentre study
Allpatients admittedand dischargedin 1998
68
SF12; CBI
SFmeasuredat adm&3months postd/c;CBIat admandd/c
Pro Malone,et spective; al.,2002 before and after
Community dwelling patientsd/c fromGDH
Atleast5visits duringGDHstay
41
BarthelIndex;TUG Adm,D/C, Test;BergBalance; 3months MMSE;GDS
p=.04 ns p=.03 ns ns ns ns ns ns Caregiverburden wasreduced;SF12 physicaldomain scoresimprovedfor somepatients. ADMD/C: TUG p<.002 Berg p<.002 GDS p<.002 D/C3months: ns Barthel ns GDS ADM3mos: GDS p<.007 Barthelat 3months Barthelat6 months Feweroutpt visitsat 6months Costs Wellbeing Commservices Satisfaction SF12 CBI
93
Study Type
RCT
Author
Roderick, etal.,2001
Population
Elderly stroke patientsin Poolearea, EastDorset
Inclusion criteria

BarthelIndex; Rivermead MobilityIndex; Philadelphia GeriatricCentre MoraleScale; FrenchayActivities Index;SF36 Servicesreceived; hospitalization;ED visits;placement; death,healthstatus measures EMS; BarthelIndex; FAC

GDHv Domiciliary rehabilitation service; 6monthfollow up Mortality Physicalfunction Socialactivity Costs
Result
ns ns ns ns
Retro Cohort
Siu,etal., 1994
GDHand Geriatric Clinics
Aged55+who 74/66 requiredfurther rehabilitation afterhospital dischargeorafter referralto geriatricianfrom thecommunity 468
GDHvClinicsites (12months)
MortalityED orhospitaluse Placement Healthstatus Barthel EMS FAC
ns ns ns ns p<.001;42% p<.001;83% p<.001;35%
Matched Spilg,etal., pairs 2001 Compar ison QED/ Tousignant, historical etal.,2003 cohort
GDH patients
Patients completinga courseof physiotherapy (meanage=79)
83
Effectiveness of3scalesin aGDH followingPT intervention SMAFmeasureat enrollandD/C
GDHpatients Consecutive atatertiary patients carefacility
151GDH
Functional Autonomy Measurement Systemchange
System cost benefit
SystemsavingsCdn $2.14perGDHdollar
OT=Occupationaltherapy;NHP=NottinghamHealthProfile;GDH=GeriatricDayHospital;ADL=ActivitiesofDailyLiving;GQLQ=GeriatricQualityofLife Questionnaire;TAU=TreatmentAsUsual;RCTs=RandomizedControlledTrials;LHS=LondonHandicapScale;CBI=CaregiverBurdenIndex;TUG=Timed AndGo;MMSE=MiniMentalStatusExamination;Adm=Admission;D/C=discharge;ED=EmergencyDepartment;EMS=ElderlyMobilityScale;FAC= FunctionalAmbulationCategor
94
GeriatricDayHospital Spilg,Martin,MitchellandAitchison(2001)assessedthesensitivityoftheElderly MobilityScale(EMS)todetectimprovementsinmobilityafterphysiotherapyincomparison withtheBarthelIndex(BI)andFunctionalAmbulationCategory(FAC)inroutineclinicalday hospitalpractice.Usingamatchedpairscomparison,theyfoundthatEMSwassignificantly morelikelytodetectanimprovementinmobilityfollowingphysiotherapywithinthestudy groupthantheBI(P<.001)ortheFAC(p<.001;Splig,etal.). Oneoftheweaknessescitedbyseveralresearchersisthechoiceofoutcome measures.Roberts,KheeandPhilp(1994)andRobertsandPhilp(1996)usedDelphianalysis ofBritishpurchasers(referralsources),providers(clinicalserviceandnursing, physiotherapyandoccupationaltherapymanagers),geriatriciansandcognitivelyintact patientsofdayhospitalstoestablishexactlywhattheyviewedasprioritiesforevaluation. Theyfoundstrikingagreementonmeasuringqualityoflifeandreducingdisabilityaboveall. Patientssoughtreducedcaregiverburdenandavoidinginstitutionalizationmorethandid othersstudied;providersandgeriatricianslookedforefficiencyandeffectivenessmorethan others,andgeriatricianslookedmoreforpatientsatisfaction.Nogroup,explicitlyincluding administrators(ChiefExecutiveOfficersofHealthCommissions,andbusiness managers),foundthemostcommonmeasures(mortality,andindicatorsofactivitysuchas numberofvisits)tobeuseful.ThemeasuresadvocatedintheBritishstudiesagreequite wellwiththosecontainedinmoreacademicworks(e.g.Goeree,1994)whichadvancea modelforevaluationthatincludesfactorsrangingfromcostthroughsatisfactiontoquality oflife.Inaddition,thecomplexityofcasesbroughtbeforeGDHmakesgoaldisplacement possible.Forexample,onestudyshowedthatbetweenathirdandaquarterofpatients whoareadmitteddonotshowbenefitfromrehabilitation(Lewis,etal.,2000).Thisraises thepossibilitythatmanyGDHpatientscouldbedivertedawayfromGDHandintomore focusedinterventionssuchasmedicalinterventions,geriatricmooddisordersprograms, seniorsdaycentersforrespite. AlthoughtherehasbeenlimitedhighqualityresearchontheeffectivenessofGDH, thereissomeevidencethatspecializedgeriatricsservicescanhaveapositiveimpacton mortality,healthstatusandfunction,and(atleast)balancedcost(Fowler,Congdon,& Hamilton,2000;Gladman,Lincoln,&Barer,1993;Guyatt,etal.,1993;Harwood&Ebrahim, 2000;Roderick,etal.,2001;Siu,Morishita,&Blaustein,1994),providedthatrestrictive inclusioncriteriaaremet(Gladman,etal.;Harwood&Ebrahim,2000;Guyatt,etal.).More rigorousresearchisneededoneffectivenessofGDH.Methodologicalissuesrelatedtolack ofappropriatetargetingofpatientsandinconsistentuseofstandardizedassessmenttools limitsourunderstandingofthepotentialbenefitsofGDH.Programevaluation,both formativeandsummative,isneededtoidentifythewaysinwhichGDHarebest implementedandbeneficialandtoidentifywhichpatientsbenefitmost.Evidencebased eligibilitycriteriathatarestrictlyadheredto,withcarefullyprescribedassessmentand treatmentplanningwilloptimizetheuseofhealthcaresystemresources. Recommendations Largescale,highqualitycomparativestudieswithappropriatemeasuresofboththe effectivenessandcosteffectivenessofGDHcomparedtootherformsofcareareneeded.
GeriatricDayHospital Basedonexistingevidencetodate,thefollowingrecommendationsregardingGDHcanbe made: 1. TheBritishGeriatricSociety(2006),amongothers,notesthatGDHoccupyamidpoint betweenprimaryandsecondarycare.Theyprolongindependentlivingbythespecialist assessmentandtreatmentoffrailanddisabledolderpeopleenablingthemtoremainin theirownhomesaswellashavingafavourableimpactonimpairment,disabilityand handicap.Inordertoachievetheseaims,itisnecessarythatGDHservicesbetargeted tothosemostlikelytobenefit.Sinceothersmaybedirectedelsewhere,itmaybeuseful to: a. Purchaseservicesatorestablishaseniorsdaycenterinordertomaintainor improvecurrentlevelsofburdenreduction. b. Directsomepatientcaretooutpatientoccupationaltherapy/physiotherapy, and/ortoothertargetedprogramssuchasamooddisordersprogram. 2. Costcontainment:TheForsterandcolleagues(1999)reviewfindshighercostsforGDH, andfindsthatoutcomesaresignificantlydifferentthannoSGStreatmentatall;itis possiblethatthesecanbeachievedwithalessintensiveintervention.TheBritish GeriatricSociety(1996)recommendsthatGDHaiminpartatpreventinghospital admissionorpromotingsubsequentearlydischarge,andrapidaccessadmission avoidanceclinics,.Inaddition,Hebertandcolleaguesdidfindanimpactonsystem utilizationhasyetbeendetected.Thusitisnecessarytoreducelabourcosts,forinstance bymaintainingshortermeanlengthsofstay,potentiallyto90daysorless.Thiscouldbe accomplishedinpartbyreducingtheupwardstraggleofpatientswhoareenrolledfor verylongperiods.Otheroptionsaretostreamlineassessmenttime(e.g.,byusing electronicchartingsoastoavoidredundantquestionsandtests)andusingself administeredassessmenttoolswhereverfeasible.Thisisespeciallytrueofscreening. 3. ComprehensivegeriatricassessmentsaredeliveredviaGDH,butasnotedelsewherein thiswork,theycanbeprovidedinothervenues.Thereisalsoevidence(Lewis,etal., 1999)thatatleastsomeofthedifficultyindemonstratingefficacyisduetoa heterogeneouspatientpopulation:ifthefrailaretargeted,thenimprovementisclearer. Clearstandardsfordeterminingatreatmentplanshouldbedevelopedandused consistently;treatmentgoalsmustbemeasurable. 4. TheBritishGeriatricSociety(1996)recommendshealtheducationforthethirdage. Careplansshouldbesharedwithpatientsandtheircaregiversastheyareintegralto successfulimplementation. 5. TheBritishGeriatricsSociety(1996)alsosuggeststhatGDHshouldfocusontreatment andrehabilitation,inparticularforcomplexmultifacetedproblems,aspartof communitybasedrehabilitationandintermediatecare.Enrolmentcriteriashould includeonlycomplexelders:patientswithatleasttwohealthissues,atleastoneof whichmustbeamenabletorehabilitation(i.e.treatmentbyphysiotherapyand/or occupationaltherapy).Therefore,eachdisciplineshouldprioritizecareplanissuesand treatmentssoastofocusontheessentials(i.e.,thosewithahighburdenofillnessanda reasonableprospectofchange).
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GeriatricDayHospital References Anonymous.(1994).Canadianstudyofhealthandaging:Studymethodsandprevalenceof dementia.CanadianMedicalAssociationJournal,150(6),899913 Bach,D.,Bach,M.,Bhmer,F.,Frhwald,T.,&Grilc,B.(1995).Reactivatingoccupational therapy:AMethodtoimprovecognitiveperformanceingeriatricpatients.Age& Ageing,24(3),222226. Benson,D.(1992).Measuringoutcomesinambulatorycare.Chicago,IL:AmericanHospital Publishing,Inc. Black,D.A.(2000).Themoderngeriatricdayhospital.HospitalMedicine,61(8),539543. Black,D.A.(2005).Thegeriatricdayhospital.Age&Ageing,34(5),427429. Burch,S.,Longbottom,J.,McKay,M.,Borland,C.,&Prevost,T.(2000).TheHuntingdonDay HospitalTrial:Secondaryoutcomemeasures.ClinicalRehabilitation,14(4),447453. Cranswick,K.(1997).CanadasCaregivers.CanadianSocialTrends,47,26. Eagle,D.J.,Guyatt,G.H.,Patterson,C.,Turpie,I.,Sackett,B.,&SingerJ.(1991). Effectivenessofageriatricdayhospital.CanadianMedicalAssociationJournal,144(6), 699704. Malone,M.,Hill,A.,&Smith,G.(2002).Threemonthfollowupofpatientsdischargedfroma geriatricdayhospital.Age&Ageing,31(6),471475. Forster,A.,Young,J.,&Langhorne,P.(1999).Systematicreviewofdayhospitalcarefor elderlypeople.BritishMedicalJournal,318,837847. Fowler,R.W.,CongdonP.,&Hamilton,S.(2000).Assessinghealthstatusandoutcomesina geriatricdayhospital.PublicHealth,114(6),440445. Gladman,J.R.,Lincoln,N.B.,&Barer,D.H.(1993).Arandomisedcontrolledtrialof domiciliaryandhospitalbasedrehabilitationforstrokepatientsafterdischargefrom hospital.JournalofNeurology,NeurosurgeryandPsychiatry,56(9),960966. Goeree,R.,Farahati,F.,Burke,N.,Blackhouse,G.,O'Reilly,D.,Pyne,J.,etal.(2005).The economicburdenofschizophreniainCanadain2004.CurrentMedicalResearchand Opinion,21(12),20172028. Guyatt,G.H.,Eagle,D.J.,Sackett,B.,Willan,A.,Griffith,L.,McIlroy,W.,etal.(1993). Measuringqualityoflifeinthefrailelderly.JournalofClinicalEpidemiology,46(12), 14331444. Harwood,R.H.,&Ebrahim,S.(2000).Measuringtheoutcomesofdayhospitalattendance: AcomparisonoftheBarthelIndexandLondonHandicapScale.ClinicalRehabilitation, 14(5),527531. Hui,E.,Lum,C.M.,Woo,J.,Or,K.H.,&Kay,R.L.(1995).Outcomesofelderlystrokepatients. Dayhospitalversusconventionalmedicalmanagement.Stroke,26(9),16161619. Lewis,D.,Turpie,I.,Cowan,D.,Diachun,L.,&MacLeod,J.(2000).Aprospectiveevaluation ofgeriatricdayhospital.AnnalsoftheRoyalCollegeofPhysiciansandSurgeonsof Canada,33(6),348352. Malone,M.,Hill,A.,&Smith,G.(2002).Threemonthfollowupofpatientsdischargefroma geriatricdayhospital.Age&Ageing,31(6),471475.
GeriatricDayHospital Naylor,C.D.,Anderson,G.M.,&Goal,V.(Eds.).(1994).PatternsofhealthcareinOntario. TheInstituteforClinicalEvaluativeSciencesinOntario,PracticeAlas(1sted.,pp.1,3032, 62,108).Ottawa,ON:CanadianMedicalAssociation. Roberts,H.,Khee,T.S.,&Philp,I.(1994).Prioritisingmeasuresofperformanceofgeriatric medicalservices.Age&Ageing,23,154157. Roberts,H.,&Philp,I.(1996).Prioritisingperformancemeasuresforgeriatricmedical services:Whatdothepurchasersandprovidersthink?Age&Ageing,25,326328. Roderick,P.,Low,J.,Day,R.,Peasgood,T.,Mullee,M.A.,Turnbull,J.C.,etal.(2001).Stroke rehabilitationafterhospitaldischarge:Arandomizedtrialcomparingdomiciliaryand dayhospitalcare.Age&Ageing,30(4),303310. Siu,A.L.,Morishita,L.,&Blaustein,J.(1994).Comprehensivegeriatricassessmentinaday hospital.JournaloftheAmericanGeriatricsSociety,42(10),10941099. Spilg,E.G.,Martin,B.J.,Mitchell,S.L.,&Aitchison,T.C.(2001).Acomparisonofmobility assessmentsinageriatricdayhospital.ClinicalRehabilitation,15(3),296300. Tousignant,M.,Hebert,R.,Desrosiers,J.,&Hollander,M.J.(2003).Economicevaluationof ageriatricdayhospital:Costbenefitanalysisbasedonfunctionalautonomychanges. Age&Ageing,32(1),5359. Webber,C.E.,Papaioannou,A.,Winegard,K.J.,Adachi,J.D.Parkinson,W.,Ferko,N.C.,et al.(2003).A6monthhomebasedexerciseprogrammayslowvertebralheightloss. JournalofClinicalDensitometry,6(4),391400.
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GeriatricOutreachServices
Chapter8
SpecializedGeriatricOutreachServices:AnOverview oftheRandomizedControlledTrials
DavidRyanandJacquelinEsbaugh
CliniciansPerspective:BarbaraLiu,MD
Thegeriatricoutreachteamisauniqueservicewithrootsinthelongtraditionof physicianhousecalls.Asthenumberofphysicianperformedhousecallshasdeclined, outreachteamshaveincreasinglysteppedin,literallyandfiguratively,bridgingthegap betweenthehospital,primaryandcommunitycare. Maximizingfunctionandenablingseniorstoremainintheirownhomesisthe cornerstoneofspecializedgeriatricservices.Inhomeassessmentisanimportantadjunctto comprehensivegeriatricassessmentandforhomeboundseniorsmaybethesoleavenuefor interactionwithhealthcareprofessions.Outreachteamshavemanysupporters,aswellas critics.Thischapterprovidessomevaluableinsightsintotheevidencethatsupports outreachteams,aswellasthelimitationsofthatevidence. Evidencedoessuggestthatmultidisciplinaryoutreachservicesaremoreeffective thanoutreachbysolopractitioners.Targetedmultidisciplinaryservicemodelsarealso effective,althoughtherelevantoutcomesfordifferenttypesoftargetedservicesmustbe weighedcarefullywhencomparingstudies.Geriatricianinvolvementaddsvaluetooutreach teams,andwhileeachteammembermakesspecificcontributionstotheskillmix,the relativecontributionofeachteammembertothecosteffectivenessoftheserviceisnot clear.Theidealteammodelandthedefinitionofthefunctionalrolesofmembersisstill evolvingandfurtherdevelopmentandevaluationofservicemodelsisneeded. Researchonthecosteffectivenessofoutreachteamsisalsoneeded.Ithasbeen pointedoutthatoutreachservicesshouldbeevaluatedwithinaspectrumofservicesrather thanasastandaloneservice.Similarly,costeffectivenessevaluationsofresourceintensive teamsshouldbesystemicratherthanfocusedonasingleepisodeofcare. Thebalanceofevidencesupportsthevalueofoutreachteamsinreducingratesof institutionalizationandpreservingtheabilitytoperformactivitiesofdailyliving.Asinother formsofgeriatricservices,identifyingtheappropriatetargetpopulationiscritical.Despite advancesinthedefinitionoffrailty,westillneedtorefinetheselectionprocessof appropriatepatients.Operationalizingfrailtysothatothers,whoarenotexpertingeriatric care,caneasilyidentifytheappropriatecandidateforgeriatricoutreachservicesisapriority hereasitisforallcomprehensivegeriatricservices.
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GeriatricOutreachServices Consumersaredemandingastrongeremphasisonprevention,wellnesspromotionandthe inclusionofthebroaderdeterminantsofhealthinserviceplanning.Shiftingexpectationsas wellasthechangingdemographicmaymaketheassessmentofpatientsintheirhome environmentamorefrequentnecessity.Evaluationoftheseservicesprovidessome answersbutfutureresearchandevaluationneednotfocusonwhetherweshoulddeliver outreachservices,butratheronhowshouldwedeliverthoseservicesandtowhom.
ExecutiveSummary Outreachservicesareconsideredanimportantlinkbetweenhospitalandcommunity basedcareandanessentialcomponentinthecontinuumofservicesprovidedtofrailseniors byspecializedgeriatricserviceproviders.Theevidencefromrandomized,controlledtrialsof outreachservicesiscompromised,however,bydiverseservicemodels,selectioncriteriaand outcomevariables.Thesemethodologicalissuesareexploredandseveralsuggestionsare providedtoimproveourunderstandingofserviceeffectiveness.
Introduction Specializedgeriatricoutreachservicesareoneofacontinuumofservicesfocusedon thehealthcareneedsoffrailseniors.Ideally,thecontinuumprovidesaseamlesscontinuum ofservicesthatbridgehomeandhospitalbasedcareandpreservesthequalityoflifeand communitylivingstatusoffrailseniorsthreatenedbycomplexbiopsychosocialand functionalchallenges.Inthischapterweconsideroutreachserviceasthatpartofthe continuumofservicesthatareprovidedintheseniorshome. Outreachserviceswouldthenbedistinguishedfromtheotherelementsofthe continuumincludingambulatorycareclinicsthatprovidecomprehensivegeriatric assessmentandclinicsinsuchareasascontinence,cognitionandfalls,acutegeriatricunits forshortterminpatientassessmentandtreatment,internalconsultationservicesproviding geriatricsexpertiseacrossallhospitalinpatientwards,slowstreamgeriatricrehabilitation orreactivationunits,geriatricdayhospitalsandgeriatricemergencymanagementservices. Despitetheidealofaseamlesscontinuumofservice,withfewexceptions, researchontheeffectivenessofspecializedgeriatricserviceshasfocusedonexaminingthe valueofeachservicecomponentratherthanthecontinuumitself.Asaresult,thepresent chapterwillexaminetherandomizedcontroltrials(RCT)oftheeffectivenessofprimarily standalonehomebased,outreachservicesforseniorsratherthanoutreachembeddedin andaddingvaluetoacontinuumofservicesbecausetheresearchdoesnotpresentlyallow ustoexaminethisissue. TheRCTswereselectedfromtheEnglishlanguageliteratureidentifiedbyasearchof Medlinewiththefollowingkeywords:geriatricoutreach,homevisit,homeANDvariantsof geriatricsuchasagedorseniorsorfrailANDRCT.TheCochraneRegisterof trialsandreviewswasalsosearched. Thesearchprocessidentifiedtwometaanalyses.OnebyWardandcolleagues (2003)soughttocomparetheeffectivenessofnursinghome,hospitalandownhome environmentsbutwasdiscontinuedbecausetherewereinsufficientnumbersofstudies
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GeriatricOutreachServices Table8.1:CharacteristicsoftheTrials
Authors, date Style* (location) Dalby,etal. 1. 2000 (Canada)
Sourceof population HSOfamily practice roster
1.
Hbert,et al.,2001 (Canada) Stevens,et al.,2001 (Australia)
Health insurance roster Seniorsliving independently onelectoral role
Inclusion N Criteriaand intervention Intervention (meanage) /control personnel >70yrs, 73/69 Primarycare functional nurse decline,hospital admission (79.1yrs) >75yrs 250/253 Nurse (80.3)
1b
>70 (76)
570/1,167
ResearchNurse
Intervention (studyduration) Assessment,careplan, MDliaison, casemanagement, Followupphoneorvisit (14months) Assessment, careplan, casemanagement (12months) Homehazard assessment,hazard reductioneducation, safetydevicesinstalled CGA,geriatrician consult,Quarterlyvisits (12months)
Followup Byphone orvisit asnecessary
12telephone calls
2.
Fabacher,et Regional al.,1994 veterans (USA) register Stuck,etal. 1995 (USA) Voter registration lists
>70yrs (72.7)
131/123
2.
>75yrs (81.2)
215/199
2.
Stuck,etal. Health 2000 insurance (Switzerland) rosterBerne
>75yrs (81.7)
264/527
MDAsst/nurse geriatrician consult,trained volunteers Geriatricnurse practitioner, consulting geriatrician Geriatricnurse, team consultation
1visit, mailed followup surveyat 11months 4visits
CGA,careplan, 12visits teachingquarterlyvisits (36months) CGA,careplan, 12visits communications quarterlyvisits(36mos)

101
GeriatricOutreachServices Authors, date Style* (location) 2. Byles,etal. 2004 (Australia) Inclusion N Criteriaand intervention Intervention (meanage) /control personnel >70years 942/627 GNPSGSteam, geriatrician consult
Sourceof population Veterans Affairsroster
3.
Rockwood, etal.2000 (Canada) Caplan, Williams, Daly,& Abraham 2004 (Australia) van Haastregt, etal.2000* (Netherlands)
3.
Frailseniors referredby family physician Seniors discharged homefroman Emergency Department
Frailty (81years)
95/87
Intervention (studyduration) CGA, annualvisit&phone followupor6monthly visitandfollowupboth withandwithoutletter toGP(36months) Fullspecialized Mobilegeriatric geriatricservices assessment team team(3months) Geriatricnurse, CGAand4weeksof accesstoa multidisciplinary multidisciplinary intervention geriatricsteam
Followup 3or6 followup visits
>75years (82.2)
369/369
Median2 (range127) 3,6,12month followup Mean2.29 3,,6,12&18 month followup telephone calls 5visits
4.
4.
Seniorswith historyof falls,mobility problems referredby GPs Tinetti,etal. HMO 1994 enrolleeswith (USA)* andatleast onefallsrisk factor
>70 (77.2)
159/157
Community Nurse
Structuredgeriatric assessmentprotocol andhomesafety checklist(12months)
>70 (78)
153/148
Nurse practitionerand physiotherapy
Comprehensive fallsriskassessment. Weeklyphysiotherapy homevisitsfor3 monthsand3monthly maintenancevisits
15
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GeriatricOutreachServices Authors, Inclusion N date Sourceof Criteriaand intervention Intervention Style* (location) population (meanage) /control personnel 4. Hogan,etal. Seniorswitha >65 77/75 Oneassessor 2001 historyoffalls Fallwithin3 froma (Canada) months multidisciplinary (77years) geriatricsteam
Intervention (studyduration) Fallsassessment. Recommendations3 exercisetrainingsessions homeexercise prescription
5.
Gagnon,et al.,1999 (Canada)
frailseniors discharged homefrom emergency departments
>70andatriskof 202/215 hospital readmission (81years)
Nurse
5.
Nikolaus,et al.,1999 (UK)
Seniors admittedto hospitalbut livingathome
livingathome, atrisk,multiple chronicor functional decline (81.4)
181/179/185 Multidisciplinary geriatricsteam
Nursecase management, structuredassessment protocol.Monthly phone,homevisitevery 6weeks.Geriatric consultationteam available(10months) 1.CGA+home Mean7.6 Interventionteam. visits 2.CGAandusual Followup homecare. assessment 3.Usualcare 12months. (3months)
Followup 2visitsand 3exercise training sessions mail followup 6&12 months 10phone contacts 7homevisits
*Where1=Preventivenursingoutreach**IndicatesstudiesincludedintheStuck,Egger,Hammer,Minder,andBeck(2002)metaanalysisthatwehave assignedtodifferentstylesofoutreachthanindicatedbyStucketal. 1b=targetedpreventivenursingoutreach 2=preventivemultidisciplinaryoutreach 3=multidisciplinaryoutreach 4=targetedmultidisciplinaryoutreach 5=casemanagementoutreachservice OrganizationDesignforGeriatrics:AnEvidenceBasedApproach 103
GeriatricOutreachServices meetingselectioncriteria.AsecondmetaanalysisbyStuckandcolleagues(2002)identified 18RCTsexaminingtheextenttowhichhomevisitingpreventednursinghomeadmission andfunctionaldeclineforpeopleaged70yearsorolder.Eightadditionalstudiesmetthe searchcriterionforthepresentreviewthatwerenotincludedintheStuckandcolleagues metaanalysis.Thesestudieswereeitherpublishedafter2001,ordidnotmeetStuckand colleaguesdefinitionofpreventivehomebasedservice.Thecharacteristicsofthese14RCTs areoutlineinTable8.1. Stuckandcolleagues(2000)concludedthatpreventivehomevisitationprograms appeareffectivewhentheyarebasedonmultidimensionalgeriatricassessmentand multiplefollowupvisits.Theyreportthatmorepronouncedbenefitsarefoundforyoung oldthanoldoldpopulationsofseniors. DiverseStylesofOutreachService Thedifferencesinoutreachservicedefinitionspromptedareviewofthe8additional studiesandthoseusedbyStuckandcolleagues(2000)fromadefinitionalperspective.In thisinitialreviewweidentifiedfivestylesofoutreachservice.Twostylesofoutreachare preventiveinnature.Inpreventiveoutreach,patientsarerecruitedwithoutpreidentified problemsfromagestratifiedpopulationssuchascountycensusareasorHMOregistrants. Onestyleofpreventiveoutreachprovidesonlynursingservicewhilethesecondprovides multidisciplinaryservice.Twoadditionalstylesofoutreachareproblemtriggered.Patients arereferredforoutreachservicebyfamilyphysiciansorupondischargefromemergencyor otherhospitaldepartments.Avariantofthisproblemtriggeredoutreachistargetedin whichpatientsarereferredforveryspecifichomebasedservices,primarilyfallsrelated (Note:onestudythatfitbothtargetedandpreventativenursingoutreachstyleswas includedinthelattercategory).Casemanagementisthefinalstyleofoutreachweidentify inwhichreferredpatientsarereferredforcontinuingmanagementofhomebasedhealth care.ThefiveoutreachstylesareoutlinedinTable8.2. Thesedistinctstylesofoutreachprovidetheframeworkforthepresentreview.The reviewfocusesonthe8RCTsthatarenewornotpreviouslyincludedintheStuckand colleagues(2000)metaanalysisand6studiesthatwereincludedinthatanalysiswhichwe haveassignedtoournewcategoriesofoutreach. Table8.2:TheStylesofOutreachServicesandTheirDefinitions Outreachformat Preventivehomevisiting. (3studies) Definition Participantsareselectedonthebasisofagefromvoters lists,HMOorinsurancecompanyregistries,ratherthan throughthepresenceofproblems.Theinterventionis typicallyeducationalnursingvisits Participantsarerecruitedasabovebuttheinterventionis multidisciplinaryandofteninvolvesacomprehensive geriatricassessment
Preventivemultidisciplinary homevisiting (3studies)
GeriatricOutreachServices Outreachformat Definition Problemtriggeredmulti Participantsareselectedbyreferralfromafamily disciplinaryoutreach(2studies) physician,dischargefromanacutecarehospitalof EmergencyDepartment.Interventionistypicallya comprehensivegeriatricassessmentandmultidisciplinary treatment Targetedproblemtriggered Participantsarereferredbyfamilyphysiciansorhospital multidisciplinaryoutreach dischargelistsforspecifichomebasedservicesusuallyfalls (5studies) related.Interventioniscomprehensivegeriatric assessmentandtargetedinhometreatment Casemanagementoutreach Participantsareselectedfromphysiciancaseloadsor services hospitaldischargelistsandhomebasedcareis (2studies) coordinatedbyacasemanagerwithaccesstoa multidisciplinaryteam Servicestyleandoutcomes Isthereevidencethatonestyleofoutreachismoreeffectivethananother? FromTable8.3itseemsevidentthatthereislesslikelihoodofachievingpositiveoutcomes usingthepreventive,solepractitionerstyleofoutreach.Multidisciplinarystylesofoutreach aremorelikelytohavepositiveeffectsandthisseemsmostlikelytobethecasewhena geriatricianispartofthemultidisciplinarymix. Thisobservationofbetteroutcomesarisingfromoutreachinterventiondeliveredby multidisciplinaryteamsratherthansingledisciplineservicesisconsistentwiththe conclusionarisingfromStuckandcolleagues(2002)metaregressionanalysisofprimarily preventivehomevisitingservice. Fromtheavailableevidenceitseemsimpossibletodeterminewhether multidisciplinarypreventiveoutreachismoresuccessfulthantheothermultidisciplinary servicestyles. Table8.3:StylesofOutreach,OutcomeMeasuresandOutcomesofHomeBased Intervention
Styleof out Author,date reach* (location) 1 Dalby,etal. 2000 (Canada) 1 Hbert,etal., 2001(Canada)
Outcomemeasures Deathrates Institutionaladmission Healthservicesutilization Death SMAFdisabilityscore Hospitaladmission Useofhealthservices GeneralWellBeingScale PerceivedSocialSupport(SocialProvisionsScale)
Outcomes ns ns ns ns RR=1(0.821.23) ns ns ns
105
GeriatricOutreachServices Styleof out Author,date reach* (location) 1b Stevens,etal., 2001 (Australia) 2 Fabacher,et al.,1994 (USA) Outcomemeasures Fallscalendar/frequencyoffalls Outcomes ns
Deathrate Immunizationrates Prescriptionusage Overthecounterdrugusage ActivitiesofDailyLiving InstrumentalActivitiesofDailyLiving nursinghomeadmission hospitalusage Stuck,etal. ActivitiesofDailyLiving 1995 InstrumentalActivitiesofDailyLiving (USA) NursingHomeadmissions Stuck,etal. ActivitiesofDailyLiving 2000 InstrumentalActivitiesofDailyLiving (Switzerland) NursingHomeadmissions Byles,etal. Healthrelatedqualityoflife 2004 AdmissiontoHospital (Australia) AdmissiontoNursingHome Deathrate Rockwood,et GoalAttainmentScaling al.2000 ActivitiesofDailyLivingBarthel (Canada) InstrumentalActivitiesofDailyLiving Cognition(MMSE) QualityofLife(SpitzerWolfindex) DeathRate TimetoInstitutionalization Caplan,etal., Hospitaladmissions 2004 RateofEDadmission (Australia) Timetofirstadmission NursingHomeAdmissions DeathRate ActivitiesofDailyLiving(BarthelIndex) vanHaastregt, Fallsfrequency etal.2000* MobilityControlScale (Netherlands) SicknessImpactProfile(shortform) No.ofphysicalcomplaints(RAND36) Perceivedgaitproblems(aLikertscale) FrenchayActivitiesIndex
ns p<.05 ns p<.05 ns p<.05 ns ns p<.05 ns p<.05 ns increased ns p<.05 ns negativep<.05 ns p<.05 ns ns ns ns ns ns p<.05 p<.05 p<.05 ns ns p<.05 ns ns ns ns ns ns
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GeriatricOutreachServices Styleof out Author,date reach* (location) Outcomes ns ns ns p<.05 p<.05 p<.05 p<.05 ns ns p<.05 ns ns ns ns ns ns ns p<.05 p<.05 p<.05 ns p<.05 p<.05 ns
Outcomemeasures FallsEfficacyScale Items4/5ofSocialActivitiesBattery A6pointLonelinessScale Tinetti,etal., FallsCalendar 1994 Lengthoftimetofirstfall (USA)* FallsFrequency FallsefficacyScale TinnettiRiskFactorScreen Hoganetal., Frequencyoffalls 2001(Canada) Rateoffallsinfollowingyear Timebetweenfalls EDvisits Hospitaladmissions Gagnon,etal., MedicalStudyShortForm(SF36) 1999(Canada) ClientSatisfactionQuestionnaire OASMultidimensionalFunctionalAssessment Questionnaire(OARS) HospitalAdmissions LengthofHospitalStay EDadmission Nikolaus,et BarthelIndex al.,1999 LawtonBrodyScale (UK) HospitalAdmission LengthofAdmission NursingHomeAdmission DeathRate
MMSE=MiniMentalStatusExamination;Ed=EmergencyDepartment *1=Preventivenursingoutreach 1b=targetedpreventivenursingoutreach 2=preventivemultidisciplinaryoutreach 3=multidisciplinaryoutreach 4=targetedmultidisciplinaryoutreach 5=casemanagementoutreachservice
Theoutcomesofoutreachservices Table8.3revealsthewidespanofoutcomevariablesexaminedinstudiesof outreach.Thesecanbesortedintothefollowingcategories:healthservicesdatasuchas death,hospital/EmergencyDepartmentadmissions,andlongtermcareadmissionor nom0theticmeasuressuchasActivitiesofDailyLiving/InstrumentalActivitiesofDailyLiving, fallsfrequency/efficacy,andavarietyofmeasuresofwellbeing.Nonewerefoundtobe reliableoutcomesofoutreachinterventionsthoughreductionsininstitutionaladmissions andimprovementsinADLwerethemostfrequentlypositiveoutcomes.

GeriatricOutreachServices
Incontrast,Rockwoodandcolleagues(2000)usedhealthsystemsdataand nomotheticmeasurestogetherwiththemoreidiopathicmeasurementtechniqueofgoal attainmentscaling.Positiveoutcomeswerenotobservedontheformermethodsbut significantpositiveoutcomeswereobtainedusinggoalattainmentscalinginwhich participantsowngoalsarescaledintomeasuresthatarerelevanttothem. Ageandfrailtyasinclusioncriteria AnexaminationofTable8.1revealsthatagewasaninclusioncriterioninallbutone RCT.Inthesetwoinstances,Rockwoodandcolleagues(2000)andNickolausandcolleagues (1999)focusedonfrailtyratherthanageitself.Frailty,whichhasvariousdefinitions,might bestbeunderstoodasthecooccurrenceofcomplexbiopsychosocialandfunctional difficultiessufficienttocompromisequalityoflifeandthreatenthecapacityforindependent living. Forgeriatricserviceproviders,frailtyratherthanageitselfisthecorecharacteristic ofthepatientsthattheybestserve.Typically,frailseniorstendtobeolderpatients.Inthe Rockwoodandcolleagues(2000)study,forexample,theaverageageofthesamplewas81 years.Geriatricserviceprovidersoftenfeelthattheirspecializedskillsarenotneededby seniorsinthe65to75yearagerange.Thus,includingtheyoungoldinresearchexamining theeffectivenessofgeriatricserviceswillleadtoanunderestimationofgeriatrics effectiveness,becauseseniorsintheyoungoldagegroupusuallydonotneedandwillnot benefitfromthespecializedservicesdesignedforolderandfrailseniors.Acrossthe14 studiesinthisreview,age65wasaninclusioncriteriain2studies,age70wasthecriteria in7studies,in4studiestheageinclusioncriteriawas75,oneusedfrailtyasthe inclusioncriteriaandonecombinedbothage>65yearsandfrailtyasinclusioncriteria.This latercombinationofageandfrailtyaccommodatesthepossibilityofyoungerseniors becomingfrailbyvirtueoftheircomplexcomorbidities. Whentheagerelatedinclusioncriteriaisscaled(65=1,70=2,75=3,frailty=4) acorrelationof.64(p<.05)isobtainedbetweenthisscaleandanoutcomescalecomprising theproportionofsignificantoutcomesunderstudy.Thissuggeststheimportanceof advancedageandfrailtyasinclusioncriteriainstudies. Interestinglythough,itisnottheageofparticipantsthemselvesthatseemsof primaryimportance.Whilethemeanageofstudyparticipantsiscorrelatedsignificantlywith ourage/frailtyrelatedinclusioncriteria(r=.59p<.05),meanageofparticipantsisnotitself correlatedwiththeproportionofsignificantprimaryoutcomesachieved.Perhapsthis coincideswithourexpectationthatthefrailtystatusofservicerecipients,ratherthanage itselfisaprimarydeterminantofwhobenefitsfromoutreachservices. Teambasedoutreachandoutreacheffectiveness Theproportionofsuccessfuloutcomesisalsosignificantlycorrelatedwiththestyle ofservicedelivery.Acorrelationof0.59(p<.05)wasobservedintherelationshipbetween ouroutcomeproxyvariableandwhetherornottheservicewasdeliveredbyateamorbya sole,typicallynursing,practitioner. Thisfindingofbetteroutcomesarisingfromoutreachinterventiondeliveredbymulti disciplinaryteamsratherthansingledisciplineservicesisconsistentwiththeconclusion
GeriatricOutreachServices arisingfromStuckandcolleagues(2002)metaanalysisofprimarilypreventivehomevisiting service. Outcomesandthenumberofvisits Thenumberofoutreachvisitsseemstobeunrelatedtooutreachoutcomes.Stuck andcolleaguesfoundintheirmetaanalysisanORofessentially1inoutreachfortrialswith 4orfewervisits,andnotedtheimportanceoffollowup.Ontheotherhand,theaverage2.9 homeoutreachservicevisitsofCaplanandcolleagues(2004)andthe15visitsofTinettiand colleagues(1994)appearequivalentintermsoftheproportionofsignificantoutcomes. However,itmustbepointedoutthattheoutcomeswerequitedifferentinthesetwo studies.InTinettiandcolleaguesstudyoutcomesfocusedonfalls(frequency,selfefficacy), whileCaplanandcolleaguesfocusedonsystemsoutcomes(e.g.,hospitaladmissions,rateof EmergencyDepartmentadmissionsandtimetofirstadmission) Insummary Usingtheapproachofconductingresearchonoutreachserviceindependentofthe continuumofspecializedgeriatricservicesinwhichitisembedded,theresultsarisingfrom theRCTsarebothinconsistentandcompelling.Insomeinstancesoutreachhasbeenfound toreducefalls,hospitalandEDadmissions,andlongtermcareadmissionswhileimproving ADLs.Butthereareasmanyinstancesinwhichoutreachfailedtoachievethesesame outcomes.Insomeinstances,interventionsrequiringamodestnumberofvisitshavehad positiveoutcomes.Atthesametimehowever,themostconsistentlypositiveoutcomes wereachievedbytheservicethatprovidedthegreatestnumberofpatientvisits. Giventhisvariability,researchersandhealthservicedecisionmakerswillneedto examinethoseoutreachservicecharacteristicswhichmoderatetherelationshipbetween serviceprovisionandserviceoutcomes.Twoimportantmoderatingvariablesareevident. Thefirstisthestyleofoutreachserviceprovided.Preventiveoutreachdeliveredbysole practitionersislesseffectivethanmultidisciplinarystylesofservice.Patientcharacteristics areasecondimportantmoderator.Serviceeffectivenessseemsmorepositivewhen patientsaredefinedbythepresenceoffrailtyratherthanbyagealone. Finally,thereisgreatdiversityinthepresumedoutcomesofoutreachservices.From amongtherangeofindicatorsthathavebeenused,institutionaladmissionsseemthemost significantoutcome.Infact,theuseoftargetedoutcomesisessential,thoughperhapsonly incombinationwithratesofadmission.Fromamongsttherangeofnomotheticmeasures thatcanbetakendirectlybyanoutsideobserver,activitiesofdailylivingisthemost reliable,butitmaybethatthebestoutcomemeasuresforoutreach,asforotherspecialized geriatricservices,isanidiopathicapproachusingindividualizedpatientfocusedscalessuch asthosegeneratedbythegoalattainmentscalingmethod.

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GeriatricDayHospital References Byles,J.E.,Tavener,M.,O'Connell,R.L.,Nair,B.R.,Higginbotham,N.H.,Jackson,C.L.,etal. (2004).RandomizedcontrolledtrialofhealthassessmentsforolderAustralian veteransandwarwidows.MedicalJournalofAustralia,181(4),186190. Caplan,G.A.,Williams,A.J.,Daly,B.,&Abraham,K.(2004).Arandomized,controlledtrialof comprehensivegeriatricassessmentandmultidisciplinaryinterventionafter dischargeofelderlyfromtheemergencydepartmentTheDEEDIIStudy.Journalof theAmericanGeriatricsSociety,52(9),14171423. Dalby,D.M.,Sellors,J.W.,Fraser,F.D.,Fraser,C.,vanIneveld,C.,HowardM.(2000) Effectofpreventivehomevisitsbyanurseontheoutcomesoffrailelderly peopleinthecommunity:Arandomizedcontrolledtrial.CanadianMedicalAssociation Journal,162(4),497500. Hbert,R.,Robichaud.L.,Roy,P.M.,Bravo,G.,&Voyer,L.(2001).Efficacyofanurseled multidimensionalpreventiveprogrammeforolderpeopleatriskoffunctional decline.Arandomizedcontrolledtrial.AgeandAgeing,30(2),147153. Hogan,D.B.,MacDonald,F.A.,Betts,J.,Bricker,S.,Ebly,E.M.,Delarue,B.,etal.(2001).A randomizedcontrolledtrialofacommunitybasedconsultationservicetoprevent falls.CanadianMedicalAssociationJournal,165(5),537543. Fabacher,D.,Josephson,K.,Pietruska,F.,Linderborn,K.,Morley,J.E.,&Rubenstein,L.Z. (1994).Aninhomepreventiveassessmentprogramforindependentolderadults:A randomizedcontrolledtrial.JournaloftheAmericanGeriatricsSociety,42(6),630638. Gagnon,A.J.,Schein,C.,McVey,L.,&Bergman,H.(1999).Randomizedcontrolledtrialof nursecasemanagementoffrailolderpeople.JournaloftheAmericanGeriatrics Society,47(9),11181124. Nikolaus,T.,SpechtLeible,N.,Bach,M.,Oster,P.,&Schlier,G.(1999).Arandomizedtrialof comprehensivegeriatricassessmentandhomeinterventioninthecareof hospitalizedpatients.AgeandAgeing,28,543550. Rockwood,K.,Stadnyk.K.,Carver,D.,MacPherson,K.M.,Beanlands,H.E.,Powell,C.,etal. (2000).Aclinimetricevaluationofspecializedgeriatriccareforruraldwelling,frail olderpeople.JournaloftheAmericanGeriatricsSociety,48(9),10801085. Stevens,M.,Holman,C.D.J.,Bennett,N.&deKlerk,N.(2001).Preventingfallsinolder people:Outcomeevaluationofarandomizedcontrolledtrial.JournaloftheAmerican GeriatricsSociety,49(11),14481455. Stuck,A.E.,Aronow,H.U.,Steiner,A.,Alessi,C.A.,Bula,C.J.,Gold,M.N.,etal.(1995).Atrial ofannualinhomecomprehensivegeriatricassessmentsforelderlypeoplelivingin thecommunity.NewEnglandJournalofMedicine,333(18),11849. Stuck,A.E.,Egger,M.,Hammer,A.,Minder,C.E.,&Beck,J.C.(2002).Homevisitstoprevent nursinghomeadmissionandfunctionaldeclineinelderlypeople:Systematicreview andmetaregressionanalysis.JournaloftheAmericanMedicalAssociation,27(8),1022 1030. Stuck,A.E.,Minder,C.E.,PeterWuest,I.,Gillmann,G.,Egli,C.,Kesselring,A.,etal.(2000).A randomizedtrialofinhomevisitsfordisabilitypreventionincommunitydwelling
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GeriatricOutreachServices olderpeopleatlowandhighriskfornursinghomeadmission.ArchivesofInternal Medicine,160(7),977986. Tinetti,M.E.,Baker,D.I.,McAvay,G.,Claus,E.B.,Garrett,P.,Gottschalk,M.,etal.(1994).A multifactorialinterventiontoreducetheriskoffallingamongelderlypeoplelivingin thecommunity.NewEnglandJournalofMedicine,29,331(13),821827. vanHaastregt,J.C.M.,Diederiks,J.P.M.,vanRossum,E.,deWitte,L.P.,Voorhoeve,P.M., Crebolder,H.F.J.M.(2000).Effectsofaprogrammeofmultifactorialhomevisitson fallsandmobilityimpairmentsinelderlypeopleatrisk:Randomisedcontrolledtrial. BritishMedicalJournal,321,994998. Ward,D.,Severs,M.,Dean,T.,Brooks,N.(2003).Carehomeversushospitalandownhome environmentsforrehabilitationofolderpeople.CochraneDatabaseofSystematic Reviews,Issue2.Art.No.:CD003164.DOI:10.1002/14651858.CD003164.

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SettinganAgendaforFutureResearch
Chapter9
SettinganAgendaforFutureResearchinDeliveryof SpecializedGeriatricMedicineServices
WilliamMolloyandDavidLewis
Introduction Inhealthcare,thereisongoingemphasisonevidencebasedpractice,definedbythe CentreforEvidenceBasedMedicineattheUniversityofTorontoas: theintegrationofbestresearchevidencewithclinicalexpertiseandpatientvalues. Bybestresearchevidencewemeanclinicallyrelevantresearchespeciallyfrom patientcenteredclinicalresearchintotheefficacyandsafetyoftherapeutic, rehabilitative,andpreventiveregimens.(2004,para.1). ThishandbookreviewedtheresearchthathasbeendoneindeliveryofSpecializedGeriatric Services(SGS).Thestudieswerereviewedandtheevidenceinsupportoforagainst differentdeliverymodelswasassessed.Insummary, 1. ThereisgoodevidencetosupportcomprehensiveGeriatricAssessments (CGA)withfollowupofolderadultstargetedforconditionsamenableto Geriatricinterventions. 2. Theseassessmentscanbedoneeffectivelyinavarietyofdifferentsettings suchasininpatientandoutpatients. 3. ThereisgoodevidencesupportingtheuseofinpatientGeriatricRehabilitation Units(GRU)orGeriatricAssessmentsUnits(GAU). Theevidencesupportingdayhospitalsandinhospitalgeriatricconsultationservices islessconsistent.Tobeeffective, Patientsmustbescreenedtoassesstheireligibility. CGAhastobecarriedoutbyatrainedinterdisciplinaryteam,whichisspecialized. Patientswithspecificcomplaintsorriskfactorsmustbetargeted. Amedicalassessmentisessential. Theremustbeadequatefollowup. Theassessmentmustbestandardized(coveringcognition,ADL,motivation, depression,nutritionandrehabilitationpotential). Theassessmentmusttrytomatchcareneedswiththeappropriateresources(e.g., physicaltherapywithaphysiotherapist).
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SettinganAgendaforFutureResearch TheGRUandGeriatricAssessmentandRehabilitationUnits(GARU)havethemost evidencesupportingtheiruse,perhapsbecausetheyhavereceivedthemostattentionin termsofclinicaltrialsandbecausetheyhavethegreatestcontroloverpatientselection. Consultationservices,outreachservicesanddayhospitalsaremoreheterogeneousin organizationandintheirpatientpopulation,sothedatasupportingtheuseoftheseservices ismixed.Theseservicesmayalsobemoreheterogeneousintheirgoals,targetingand outcomes.InthecaseofInpatientGRUsandOutpatientGeriatricClinics,thereissome evidencesupportingtheconclusionthatleadershipoftheinterdisciplinaryteamsshouldbe aphysician,althoughnotnecessarilyaGeriatrician.IntheConsultationServices,thereis someevidencesupportingtheeffectivenessofanadvancepracticenurseoperatingunder thesupervisionofaphysician.Inoutpatientservices,telephonefollowupmaybeadequate insomecases. Itislessclearwhatstaffingisoptimalinthesedifferentservices,themodeandlines ofcommunicationandpersonnelmixandvolumes.Itislessclearwhoshouldbetargeted andwhatoutcomesshouldbeparamount.Thecostbenefitratiosandtherapymixisnotso clear.Havingsaidthis,itisnotclearspecificallywhatpatientsshouldbetargetedforeach service,howlongtheassessmentsshouldtakeandwhatinstrumentsshouldbeusedto evaluatechangeovertime. Sogiventhislevelofuncertaintyandheterogeneity,wheredoesonestarttoinitiate researchnowtoclarifytheseissuesandmovethefieldforward? Wecansayafewthingswithcertainty. 1. First,healthservicesingeneraltendtobeunderresearched. 2. Second,specializedgeriatricmedicinehasalsoreceivedevenlessattention,sothere isapaucityofconvincingresearch. 3. Together,thesetwoaccentuatethedeficitsinknowledgeabouttheprovisionof servicesinthisarea. 4. Giventheamountofresourcesthispopulationconsumesandtheincreasingnumber ofolderadults,itisimportanttostudythisareatolookbackandseewherewehave comefrom,andjustifnotmoreimportantlytolookaheadandseewhereweare going. Wehavereviewedthisdatatotrytodevelopablueprintforfutureresearchinthisarea. Itseemstousthatonebigissuehereistheassessmentoffrailtyinthispopulation. FrailtyisakeyconceptinSGSandyetremainspoorlyunderstoodandvaguely conceptualized.Weneedcleardefinitionsandassessmentinstrumentstoassessandweigh frailtyforanumberofreasons. FrailtyIndex Weneedashortsimple,validandreliableinstrumentthatscreensandmeasures frailty.Althoughseveraltoolsarecurrentlyavailable(e.g.,Hbert,Durand,&Tourigny,2003; Rockwood,etal.,2005),generallythereislittleresearchinthisarea.Moreresearchis neededtodeterminehowsimplereliableandvalidinstrumentstomeasurefrailtycanbe usedtoweighindividualfrailtyandpossiblymoreimportantlytoscreentheolderadultsin differentsettingstodeterminetheprevalenceoffrailolderadults,thetypeoffrailtyandthe needforclinicalservicestotargetthesedeficitsandprovideadequateandappropriatecare
SettinganAgendaforFutureResearch tothispopulation.Similarly,moreresearchisneededtodeterminetheeffectivenessof thesetypesoftoolsforquantifyingfrailty,determiningwhoqualifiesfordifferentservices, settingandevaluatingtreatmentgoals,measuringthenaturalhistoryandtheeffectsof treatmentonfrailtyandcostsassociatedwithfrailtyratherthanonproxymeasurelikegrip strength.Moreover,moreknowledgeisneededaboutthesetoolscanbeusedtocompare differenttypesofservicestocomparetheircosteffectivenessandtheireffectsonthe burdenofillnessinthispopulation. ProperlyControlledTrialsinHealthServicesResearchinOlderAdults AnexpertpanelinOntarionoted,Theagingofthepopulationanditsimpacton healthandsocialservicesisthesinglemostimportantissueofthenextdecade. Demographicshiftswillleadtoarapidexpansionintheelderlyasaproportionofthe population.Asbabyboomersexperiencetransitionsfrommiddletoolderageandfrom oldagetoadvancedoldage,theywillencountertransitionsinworkandfamilylife,inhealth status,inphysicalfunctionandsoon.Evenso,littleisknownabouttheimpactofagingorof oldageonpopulationhealth,onhealthsystemcosts,oronoutcomesofcare.Thereisa dearthofhealthservicesresearchinCanada,andaparticularshortageingeriatrics. Understandingtheincidenceandprevalenceofhealthconditionsisanessentialfirst steptohealthservicesresearch.Prevalenceisameasureoftheproportionofindividuals withinapopulationwhohaveaspecifichealthproblemataparticularpointintime. Incidenceisasubcategoryofprevalence,inthatitisthenumberofnewcasesina populationatriskduringaspecifiedtimeperiod(Neutens&Rubinson,2002:241;Rosner, 1990).Inmostcases,estimatesofincidenceandprevalencearesparse,oruseinconsistent definitions,orboth.Diagnosticcriteriaandthresholdpointsaretailoredtoindividual authorspurposes,makingcomparisonsdifficult.Forexample,theabsenceofaconsistent definitionoffrailtyhasoftenbeennoted.Thisabsencemeansthatitisimpossibleto determinetheextentofthephenomenon,orwhetherincidenceisincreasingordeclining. Asaresult,planningmustusethedatathatdoesexist,suchasstatisticsonpopulation aging. SomeOntarioadministrativedataarederivedfromtheregistriesforspecific conditions,thosewithmoreconsensusarounddefinitions,suchascancerordiabetes. Registriesmaywellunderstateincidenceandprevalence,sincetheymustrelyondiagnosis andreporting;thustheactualprevalenceofdiabetesisoftenthoughttobeaboutdouble theofficialrate.Wesuspectthisbecausethereareresearchstudieswhichreporthigher rates.Thatisobviouslyimpossibleforfrailty.Inaddition,theyfailtoconsiderthewhole person;thisisofparticularconcerninhealthresearchontheelderly,whomaybesubjectto avarietyofconditions. TherearealsodatafromtheInstituteforClinicalEvaluativeSciences(ICES),andthe CanadianInstituteforHealthInformation(CIHI).ICEShasaccesstohealthinsurance,drug benefitandsimilardata;however,codessurroundactivitiesbypractitionersratherthan healthconditions.Forexample,therearecodesforgeriatricassessmentbutnotfor diagnoses.CIHIdatabasesdoincludediagnosticcodes.Outcomesofhospitalizationdeath, readmission,anddischargeresidencetypearealsoincluded(Lewisetal.,).
SettinganAgendaforFutureResearch CIHIdatarefertopostillnessinformation,whichisclearlylessusefulforidentifying trendsandearlystagesofaphenomenon.Thesedatamaycountthesamepersontwoor threetimes,andmisseveryonewhoisnothospitalized.Theymaycapturemanyinfectious diseasesandinjuries,suchashipfractureorheartattack,whichcommonlyresultinacute care,buttheyarelesseffectiveatidentifyingchronicconditionsthatarediagnosedinan outpatientsetting,orwhichareaggravatingorcontributingfactors,orofcoursethosethat areundiagnosed.Similarly,registriesofpatients,suchasthediabetesregistry,donot capturetheundiagnosed.Itisthereforeatruismthatepidemiologicalconclusions(onrisk) cannotbedrawnfrompurelyclinicaldata(onthenumberofsickpeopleseen)(Coggon, Rose,&Barker,1997).Inotherwords,onlypopulationstudiescanbeusedtoderive incidenceandprevalenceestimates. InCanada,relativelyfewpopulationstudieshavebeenconducted.Thereare exceptions,includingtheRiskFactorSurveillanceSurveys(RFSS)conductedbysome OntarioPublicHealthdistricts,theCanadianCommunityHealthSurvey(CCHS)andits predecessorsandvariantslikeCTUMSusuallyconductedbyStatisticsCanada.TheCCHS surveys130,000peoplebienniallyabouthealthdeterminants,healthstatusandhealth systemutilization.InOntario,somePublicHealthdistrictsalsoconductRiskFactor SurveillanceSurveys(RFSS). Unfortunately,alloftheseinformationsourceshaveproventobeinadequate:the RFSSisverybriefandrarelyaccessible;thepublicsurveysaresporadicandresultsare availablelongaftertheycouldbeusefulforplanning.Forexample,theCCHStakesplace everytwoyears;themostrecentCCHSdataavailablearefrom2004andareahospitalsoften planonthebasisof1996data.Inaddition,ittakes45minutestocomplete,soitmustgloss overseveralhealthissues,anditaddressesonlythecommunitydwellingpopulation. IntheUS,theCentresforDiseaseControl(CDC),theBureauoftheCensus,andthe AgencyforHealthcareResearchandQuality(AHRQ)collecthugeamountsofpopulation healthsurveillancedataincludinganannualSF36forfivemillionMedicare/Medicaid beneficiaries.TheAHRQalsoconductsanannualMedicalExpenditurePanelSurvey(MEPS) whichcontainsindividualdataonhealthinsurance,disability,illness,riskfactorssuchas smokingandbodymassindex,andaccess,utilization,demographicandsocioeconomic data.TheCDCscollecttheBriefRiskFactorSurveillanceSurvey(BRFSS),andthelistgoes on. DataforongoinghealthconditionsamongtheelderlyinOntarioarebasedon insufficientinformation.Individualstudiesemploycategoriesthatmaynotmatch medicalizeddiagnoses.Forinstance,therearenoquestionsinCCHSonmultiplesclerosisor Parkinsondisease.Thesectionondepressionbeginsasfollows: Duringthepast12months,wasthereeveratimewhenyoufeltsad,blue,or depressedfor2weeksormoreinarow?(Yes,No). 8 Dementiahasbeenidentifiedasamajorhealththreattotheelderly,withahigh burdenofillnessandsubstantialassociatedcosts(Fillit,&Hill,2005).OneCanadianreview assertedthatdementiahasreachedepidemicproportions.(Molnar&Dalziel,1997).A literaturereview(Loneyetal.1998)foundprevalenceratesfordementiarangingfrom2%to
8 Availableat:(http://www.statcan.ca/english/concepts/health/pdf/depression.pdf) OrganizationDesignforGeriatrics:AnEvidenceBasedApproach 115
SettinganAgendaforFutureResearch 9%.Onlyoneofthese,theCanadianStudyofHealthandAgingwasfromCanada,andonlyit wasratedassufficientlyrigorousforthepurpose.Thatstudyestimatedtheprevalenceat8% ormore,rangingfrom2.4%amongpersonsaged6574years,to34.5%amongthoseaged85 andover.Studyauthorsestimated60,150newcasesofdementiaperyearinCanada (CanadianStudyofHealthandAgingWorkingGroup,2002).Byextrapolation,ratesof cognitiveimpairmentwillincrease,asthepercentageofpeopleaged85oroldergrows;that groupisthefastestgrowinginCanada. Thisestimatewouldcertainlyjustifythewordepidemic.However,itisbasedona singlestudynowalmosttenyearsold.Theproblemistwofold:pointprevalenceestimates aregenerallyflawedindesignandbiasedinexecution,andtrendsestimatesuse extrapolation,oftenfromsuchasinglepoint. Similarly,inthecaseofhipfracture,predictionswereofexponentialgrowthrates ofnewhipfracturesinthefuture.Morerecentfindingssuggestthatfractureratesareon thedecline,despitetheagingofthepopulation,perhapsbecauseofincreasedpatternsof diagnosisandtreatmentforosteoporosis.(Jaglal,etal.,2005;Jemal,Ward,Hao,&Thun, 2005). Overthelastfiveyears,theneedforbetterevidencehasbecomemanifestinthe healthsector.Forwardlookingdiscussionsonpopulationhealthresearchneedshavetaken placeattheNationalForumonHealthandtheFederal,ProvincialandTerritorialAdvisory CommitteeonPopulationHealth.Thesediscussionshaveleadtothecreationofvarious projectsandinfrastructurestosupportthedevelopmentofpopulationhealthevidence, notablytheproposedCanadianLongitudinalStudyofAging. Apopulationhealthapproachrecognizesthatanyanalysisofthehealthofthe populationmustextendbeyondanassessmentoftraditionalhealthstatusindicatorslike death,diseaseanddisability.Apopulationhealthapproachestablishesindicatorsrelatedto mentalandsocialwellbeing,qualityoflife,lifesatisfaction,income,employmentand workingconditions,educationandotherfactorsknowntoinfluencehealth Informationisessentialtoeffectiveplanning;researchisessentialforinformation.In healthcare,planningforfuturepopulationneedsmustbeginwithknowledgeaboutthe incidenceandprevalenceofhealthrisksandriskavoidance;aboutdisease,injuryandother healthevents;aboutpatternsofbehaviourandpreference;andaboutpatternsofutilization ofhealthservices.Evenso,theinformationcurrentlyavailableinCanadaisfragmented, partial,andunreliable(Coulas,Abernathy,&Lewis,2003). Muchmorecouldbedone;forexample,StatisticsCanadaconductsamonthlyLabour ForceSurvey(LFS)of54,000householdsorabout100,000persons.Afoundationstoneof economicplanninginCanada,LFSdataareusedtoidentifytrendsinemployment, unemployment,occupations,workforcecomposition,andsoon.Resultsareavailableto economistsandotherusersinlessthan14days. StudyDesigns Oneoftheproblemsinthisareaisthatitisalmostimpossibletorandomizedifferent interventions.Itisimpossibletoblindthem.Sogiventheselimitations,itisimportanttoset upthesetrialsrigorouslytocompareindividualinterventions.Someoftheoutcomesinthis populationneedspecialattention.Forexample,death,whichmightbeconsidereda
SettinganAgendaforFutureResearch negativeoutcomeinyoungerindividuals,maynotbeinapalliativecareunit,orwherean advancedirectivehasbeencompleted.Manyofthesepatientshavesignificantfunctional impairmentandinmanycasesitmaynotbepossibletoimproveoutcomes,iftheoutcomes areimproperlydetermined.Itmaybepossibletoimprovepatientsoverallhealth, independenceandtheirqualityoflife.Yet,oftentimeswedonotcollectthesedata.We needmeaningfuloutcomesthatareappropriatefortheelderlyandweneedtoconstruct thetrialsasrigorouslyaspossible.AswasnotedinChapterFouronelimitationofthisreview isthatsomeoftherecommendationsarederivedfromlevelIIIevidence.Longitudinalcase control,multicentrerandomizedcontroltrials,andwelldesignedcohortstudiesareneeded toevaluateprognosticfactors,toidentifyriskfactorsforcontinueddisability,andtoidentify factorsrelatedtosuccessfuloutcomes.MoreresearchaboutCGA,frailty,anddisablement mayhelptoestablishwhichcomponentsofgeriatricassessmentandmanagementof rehabilitationpatientsarecritical. Inclusion(Screening) Forscreeningweneedconsensusnotonlywhatthismeans(asdistinctfromacase finding),butalsowhatinstrumentstouse,whototarget,whatactionstotake. HeterogeneityofDifferentInstruments Oneofthebigproblemsinthisareaisthatdifferentserviceswillusedifferent instruments.Forexample,rehabilitationunitswillusetheFunctionalIndependence Measure;CommunityservicesusetheMDSRAIandacutecaresettingsuseawholevariety ofdifferentinstrumentsdependingonthesetting.Thedataisnottransferableanditis oftenhardtofollowpeoplethroughthesystemindifferentsettingsbecausetheygeta differentassessmenttoolateveryturn. HealthCareorSocialServices Weneedtoteaseouttheeffectsofhealthcareandsocialservicesonpatient outcomes.Theseinterventionsareoftenmixedtogether.Fortheelderly,thechoiceisoften astarkone:shouldeldershavebetteraccesstoSGScare,whichmayhelpforestalldeclines inmobility;ortoaccessibletransportation,whichmighthelplessentheimpactofdeclining mobility?Oneanswerisboth,buttheeconomicresourcesavailabletodobothwillalways belimited. Demand Ineconomicterms,demandisthatquantityofagoodorservicethatconsumers (patients,clients)arebothwillingandabletoobtain(assumingthatitisavailable).Demand canbegreaterorlessthansupply,oritcanmatchsupplyperfectly.Typically,effortsat healthpolicymakinginOntariofocusonneed.Thisisdonebytryingtotietogethera numberofpiecesofdataabouttrendsinhealthandinincidenceandprevalenceandto proposeapolicysolution. Thelevelofdemandinatheoreticalfreemarketispredictablebyeconomic formulae,exceptthatthevalueplacedontheserviceisagiven.ButinOntario,thereisin themainasinglepayerforhealthcareservices.Itisaninsurancemarketorriskpool,in
SettinganAgendaforFutureResearch whichthoseusingtheservicearesupportedbythosenotusingit.Ifthenumberofnonusers contractsandthenumberofusersexpands,thepoolcanbedestroyed. Informationaboutthingslikecostsandtheusefulnessofhealthcareservices productsisnotreadilyavailable(itwouldderivefromprogramevaluation)andthereare barriers(likelicensure,gatekeeperrolesincludingfamilyphysicians,andsoon)which preventthefreemarketfromoperating. Topreventdestructionoftheinsurancepool,effortstomanagedemand(for instance,usingprimarypreventionprograms)andsupply(forinstance,byoffering incentivesforprofessionalstolocateindesignatedunderservicedareas)areputinplace. Strategicplanningexercisesattempttoforecastfutureservicedemandsaswell. Healthservicesresearchisbesetwithresourceissues.Inresponse,itoftenrelieson analysisofverylargedatabases,suchasthosemaintainedbyICESandCIHI.Thesedatabases havebeencreatedforadministrativepurposes,notforresearch,butevensotheyinclude severalwidelyacceptedoutcomemeasures,suchasmortalityandreadmission(CIHIDaD) andfunction(CIHINRRS). Choice Muchpolicyresearchemphasizesanindividualchoicemodel,suggestingforinstance thateldersneedhealthpromotionorotherkindsofeducationsothattheywillmakebetter individualchoices.Insuchamodel,illhealthistheconsequenceofpoorpersonalchoices (alsoknownasriskbehaviours).Illhealthis,therefore,anindividualtroubleratherthan asocialproblem(Mills;seealsoLewisetal.,2006). Evenso,policydocumentstendtoincluderecommendationswithoutmuch commentaboutwhatelderlyOntarianswant.Onewaytofindoutwhatpeoplewantisto askthem.TheRGPsofOntariodidaliteraturereviewoftheextenttowhichseniorsare involvedinplanningtheirowncare,andfoundittoberatherlow.Therearemechanisms surveys,focusgroupswhichhavebeenusedforthispurposeinthepast.Forinstance, Roberts,KheeandPhilpsusedDelphianalysistoestablishelderlypatient,provider,and executivepreferencesfordayhospitaltreatmentoutcomesinBritain,butwearenotaware ofsimilarexercisesonthissideoftheAtlantic. Choicesaredifficulttomakewithoutinformation,and,whilethereisagreatdealof datainhealthcare,thereisnotmuchinformation.Forinstance,administrators,insurers,and providerscollectextensivestandardizeddataonactivity(e.g.,patientorclientvisits, proceduresandlengthsofstay)andcosts(perweightedpatientday,outliercosts,wait times,benchmarkcosts,andsoon)butratherlessondiagnosesandverylittleonresults. Resultsoroutcomesdatathatarecollectedtendtobenegativeoutcomesavoided,suchas mortalityrates,readmissionrates,andplacementsinlongtermcare.Thus,theytendnotto reflecttheexperienceofthetypicalclientinatypicalsetting,andtheycannotanswerthe questionwerethesepeoplebetteroffbecauseoftheirencounterwithhealthcarethan theywouldhavebeenotherwise?Ifwerecordwhatisimportanttous,thentheabsenceof thesedataistelling. AsMostellerreportedin1989,thosetalentedlaypeoplewhoareresponsiblefor allocatingresourcesbetweenalternativemedicaltechnologies,wantedtoknowwhat differenttechnologieswillproduce...whatthebenefitsandlosseswouldbe,buttheydo
SettinganAgendaforFutureResearch notliketohavethesecomplicatedproblemssummedupinsinglenumbers(ascitedin Richardson,1990). HealthRelatedQualityofLife Asalreadynoted,outcomesmeasuresinSGSvarybetweenindividualstudies,which cancreatetheimpressionthatresearchersareshoppingforthemostfavourabletools. Wehavealsonoted,healthservicesfortheelderlyaredeliveredinavarietyofsettings,and SGSclaimstodifferfromotherformsofhealthcareinthatitisholistic.Ifso,thenitis crucialtohavemeaningfuloutcomemeasuresthatcanbeusedfromonestudytothenext andthatallowforcomparisonbetweensettingsofcare.Thesestandardtoolswouldallow ustocompareservicesandtolinkcostwithbenefit.Thus,theymustmeasureasocially desirableoutcome,suchashealth;theymustbeclear,comprehensible,andwitha meaningfulinterval,anditmustbepossibletomapthehealthservicebeingstudiedintothe measuredoutcome(Richardson,1990). Moneyhasthesequalities,andpolicymakersmustoftenchoosebetweenamore expensiveandalessexpensiveintervention.Intheabsenceofanunambiguousnon monetarybenefit,thechoicecanboildowntocostminimization.Thistendstoworkagainst SGS,sinceitisusuallyalabourintensiveoperation. Death,oravoidanceofdeath,isusuallyaclearoutcomewithwideagreementabout socialdesirability.Butlifeexpectancyhasrisensteadilyforthepopulationasawholefor manygenerationsnow;whilehealthcareiscertainlyafactorinthisphenomenon,itisnot theonlyfactororeventhemostimportantone.Indeed,manyhealthinterventions, especiallyforthefrailelderly,arenotintendedtoprolongmortalitybutrathertoimprove function,reducedisability,and/orenhancequalityoflife.Thisismostobviousforpalliative care,butapplieselsewhereaswell. Richardson(1990)suggestedthatsincethequalityoflifeisindisputablyrelevantto theallocationofresources,fewwouldarguethattheadjustmentoflifeyearsforquality representsamethodologicaladvance.Therefore,ithasbecomecommontousean outcomewhichadjustslifeexpectancywithsomeothermeasuretoproducequality adjustedlifeyears(QALY),disabilityadjustedlifeyears(DALY),healthylifeexpectancy (HLE)andsoon 9.Increasingly,theadjustmentisbasedonpatientreportedoutcomes (PRO),ofwhichtwoofthemorepopulararetheRandsystem(SF36,SF12,SF3d)andthe HealthUtilitiesIndex(HUI). 10TheSF3disrecommendedbytheInstituteforHealthcare Improvement,whiletheHUIwasdesignedtobecompletedbyselfreportorbyaproxy.This latterfeatureisespeciallyusefulforpersonswhoarecognitivelyimpaired.
9 Notethatuseoftheseadjustmentsdoesnotresolveethicalordistributionalissues.Forinstance,itmaybe arguedthatagainofonehealthyyearforaninetyyearolddiffersinvaluefromthesamegainforafiveyear old. 10 Therearealsoafewqualityoflifemeasuresaimedathospiceorpalliativecare.SeeLua,P.L.,Salek,S.,Finlay, I.,LloydRichards,C.(2005).Thefeasibility,reliabilityandvalidityoftheMcGillQualityofLifeQuestionnaire CardiffShortForm(MQOLCSF)inpalliativecarepopulation.QualityofLifeResearch,14(7),16691681.; McMillan,S.(1996.)QualityofLifeAssessmentinPalliativeCare.CancerControlJournal,3,(3). OrganizationDesignforGeriatrics:AnEvidenceBasedApproach 119
SettinganAgendaforFutureResearch Bothinstrumentsareincludedinnationalsurveysofhealthconductedbiannuallyby StatisticsCanada.Becauseofthis,itispossibletocomparePROsofindividualsadmittedtoa dayhospital(forexample)withthoseofthepopulationatlarge.Riskadjustmentbyage, sex,geographicallocation,andbysomeriskbehavioursandpreexistingconditionscould alsobemade(however,thedataareconfinedtocommunitydwellingindividuals). SubsequentPROsforthesamepatientswouldproduceametricswhichcouldshowthat patientsaveragehealthstatusatenrolmentwas(presumably)belowthepopulationnorm, andthatitsignificantlyimproved(i.e.,becameclosertothenorm)bydeenrolment.Using suchanapproach,itwouldbeeasiertoadvancetheinvestigationofservicespecificissues. ServiceSpecificResearch GeriatricAssessmentandRehabilitationUnit Whatistheoptimalmixofstaff,whatpatientsorclientsshouldbetargetedandcan theybedivertedtolessexpensiveinterventionswithoutsacrificingcare.Whoshouldget intoICU?Whatoutcomesshouldwepick?Whobenefitswhodoesnot.Whichrehabsettings arethebest?ShouldweuseStrokeunitsorGARUs,andforwhatpopulation? Whichbenefitsofrehabilitationaresustainedandcosteffective?Keepoutofnursing home,keepathome,andimprovequalityoflife.Whichcomorbiditieshavethegreatest effects?Whateffectsofethnicityandclassontheseoutcomes? ConsultationTeams Outcomesresearchonconsultationsnotjustgeriatricconsultationsisnot common.Aneffectiveconsultshouldhavesustainedimpact;inaggregate,thatimpactcan beenormousbecausesomanyconsultsaredone,butitmaybeslightorevenundetectable ifthefocusisonafewpatientsovertheshortterm.Resourcestoevaluateoutcomesare scarceinanyevent,somostofwhatdoesoccurispartialandinconclusive;thefactthatit occursatallisatestamenttothedeterminationandingenuityoftheresearchers.Thus,the lackofevidencedoesnotimplythatconsultsarenecessarilyineffective,onlythatthereisa needformoreevidence. DayHospital Incontrast,dayhospitalsuffers,notfromalackofevidence,butfrom heterogeneousevidence.Questionsremainaboutwho(ifanyone)totarget,what outcomes,lengthofstayandgoalsareappropriate,howmuchpatientsandcaregivers shouldbeinvolvedinthecareplan,andwhichdisciplineandhowmuchshouldmakeupthe geriatricdayhospitalteam. Conclusion Reuben(2002)notedthattherearetwokindsoforganizationalinterventionto improvethecareoftheelderly.Incomponentmodels,nofundamentalorganizational changeisrequired;instead,theinterventionissuperimposeduponanintactsystem.He reviewsavarietyofthesebutfindsthatthereisheterogeneousevidenceabouttheir effectiveness,littleimpactonhealthcosts,andformidablebarrierstotheir
SettinganAgendaforFutureResearch implementation.Bycontrast,systematicmodelsinvolvebasicalterationinorganizational structureorcultureorboth. Reubensreviewisechoedinthiswork.InOntarioasinotherareasworldwide,the numbersofelderlyareincreasing.Thishasledtosubstantialinterestinmeetingelders needsforhealthcare.Thus,inadditiontotheorganizationaltypesdescribedinthis Handbook,thereisaplethoraofinterventionswhicharepromising,butwhicharetoonew formuchevidencetohaveaccumulated.Amongtheseare: AcuteCarefortheElderly(ACE)units,whichaimtopreventdeliriumandother declineinthehospitalizedelderly.AnewACEunitisinoperationinLondon,Ontario, butnoimpactdatahasyetbeendisseminated. GeriatricEmergencyManagement(GEM)programs.Theseinvolveplacementofan advancepracticenurseintheEmergencyRoom.HastingsandHeflin(2005) performedasystematicreviewfindinggenerallypositiveresults,butcautionthat morestudyisneeded.TheRGPsofOntarioareevaluating9GEMprogramsinfive cities. Seniorfriendlyhospitalstrategiesaimedatalteringthehospitalsystemtoprevent iatrogenicandnosocomialeffects(e.g.,alteringthephysicallayoutofthehospitalto reducetheriskforfalls). Newquestionswillsoonariseconcerningtheimpactoncomputerizationand standardizationonaservicewhosecostsavingsorbenefitsweremarginalatbest.More broadly,giventheshortageofspecialistsinthisareaandthecostsofrunningtheseservices, allcouldbeassessedusingalternativedeliverymethodsliketelemedicine.Teleconsultsin geriatricsalreadyoccur,buttheyremainuncommonandtheirimpactunknown.Yet,if peoplecandosurgerylongdistance,thensurelytheycanassessandrehabilitateby telemedicine.Inadditiontothese,theremaybeanumberofinterventionsinthehomecare andoutreachareasthataresimplyunknowntous.Thesearepotentiallypowerfulmethods, whichshouldbeshared.
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SettinganAgendaforFutureResearch References CanadianStudyofHealthandAgingWorkingGroup.(2002).Patternsandhealtheffectsof caringforpeoplewithdementia:theimpactofchangingcognitiveandresidential status.Gerontologist,42(5),64352. CentreforEvidenceBasedMedicineattheUniversityofToronto.(2004).Whatisevidence basedmedicine?RetrievedMay1,2008,from http://www.cebm.utoronto.ca/intro/whatis.htm Coggon,D.,Rose,G.,&Barker,D.J.P.(2007).EpidemiologyfortheUninitiated(4thed.). London:BritishMedicalJournalPublishingGroup. Coulas,G.C.,Abernathy,T.,&Lewis,D.L.(2003).AgingofVulnerablePopulations. RGPc/CWHPINReport.Retrieved,November,13,2006,fromwww.cwhpin.ca Fillit,H.,&Hill,J.(2005).Economicsofdementiaandpharmacoeconomicsofdementia therapy.AmericanJournalGeriatricPharmacotherapy,3(1),3949. Hastings,S.N.,&Heflin,M.T.(2005).Asystematicreviewofinterventionstoimprove outcomesforeldersdischargedfromtheemergencydepartment.Academic EmergencyMedicine,12(10),97886. Hebert,R.,Durand,P.,&Tourigny,A.(2003).Frailelderlypatients:Newmodelforintegrated servicedelivery.CanadianFamilyPhysician,49,992997. Jaglal,S.B.,Weller,I.,Mamdani,M.,Hawker,G.,Kreder,H.,Jaakkimainen,L.,&Adachi,J.D. (2005).PopulationtrendsinBMDtesting,treatment,andhipandwristfracturerates: arethehipfractureprojectionswrong?JournalofBone&MineralResearch,20(6),898 905. Jemal,A.,Ward,E.,Hao,Y.,&Thun,M.(2005).Trendsintheleadingcausesofdeathinthe UnitedStates,19702002.JournaloftheAmericanMedicalAssociation,294(10),12559. Loney,P.L.,Chambers,L.W.,Bennett,K.J.,Roberts,J.G.,&Stratford,P.W.(1998).Critical appraisalofthehealthresearchliterature:prevalenceorincidenceofahealth problem.ChronicDiseasesinCanada,19(4),1706. Lua,P.L.,Salek,S.,Finlay,I.,LloydRichards,C.(2005).Thefeasibility,reliabilityandvalidity oftheMcGillQualityofLifeQuestionnaireCardiffShortForm(MQOLCSF)in palliativecarepopulation.QualityofLifeResearch,14(7),16691681. McMillan,S.(1996.)QualityofLifeAssessmentinPalliativeCare.CancerControlJournal, 3,(3). Molnar,F.J.,&Dalziel,W.B.(1997).Thepharmacoeconomicsofdementiatherapies.Bringing theclinical,researchandeconomicperspectivestogether.Drugs&Aging,10(3),219 33. Reuben,D.B.(2002).Organizationalinterventionstoimprovehealthoutcomesofolder persons.MedicalCare,40(5),41628. Richardson,J.(1990,September).CostUtilityAnalysis:WhatShouldbeMeasured;Utility, ValueorHealthyYearEquivalents?Paperpresentedtothe1990SecondWorld CongressonHealthEconomics.Zurich,Switzerland. Rockwood,K.,Song,X.,MacKnight,C.,Bergman,H.,Hogan,D.B.,McDowell,I.,&Mitnitski, A.(2005).Aglobalclinicalmeasureoffitnessandfrailtyinelderlypeople.Canadian MedicalAssociation,Journal,173(5),48995.

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Organization Design for Geriatrics: An Evidence Based Approach

Regional Geriatric Programs of Ontario July

DR. DAVID LE WIS, EDITOR

SpecializedGeriatricOutreachServices:AnOverviewoftheRandomized ControlledTrials DavidRyanandJacquelinEsbaugh CliniciansPerspectivebyBarbaraLiu,MD

SettinganAgendaforFutureResearchinDeliveryofSpecializedGeriatric MedicineServices WilliamMolloyandDavidLewis

Kennie,Reid,Richardson, Kiamari,&Kelt,198817 Marcantonio,Flacker,Wright,& Resnick,2001

AcuteCare Utilization NursingHome Utilization Other Utilization

186 192 120

Reuben,etal.,1999 Rubin,etal.,1993 Schmader,etal.,2004 Shah,1997

194 Silverman,etal.,1995 185 170 187 143 188

Williams,etal.,1987 +resultssupportintervention resultsdonotsupportintervention f/up:followup NP:NursePractitioner TAU:Treatmentasusual Outpt:Outpatient

*mayrequireinitialsubsidy **Homecare ***Depression ****Mentalhealth Jadadscore:lowerscoresindicatehigherqualityQualityscore:higherscoresindicatehigherquality

GeriatricPrimaryCare Table6.2:KeyRecommendations Numberof Studies RCT Other 4 1

Means 22 120 2273 108 11 7.19 840.5

Outcome Measure/ Tool(s)

Intervention Outcome (studyduration) Measures

Burch,etal., Referred 2000 elderly patients

Eagle,etal., Referred 1991 elderly patients

Forster, Young& Langhorne, 2000

12studies were included involving22 day hospitals and2867 patients

Death;placeof residence; dependency; globalpoor outcome;ADL; subjectivehealth status;patient satisfaction;and resourceuse

3independent reviewers assessedstudy quality

Outcome Measure/ Tool(s)

Intervention Outcome (studyduration) Measures

Diagnosisof cerebrovascular accident

BarthelIndex; Hospital, community,and GPservices; Admissions; Satisfaction;Mood

Allpatients admittedand dischargedin 1998

SFmeasuredat adm&3months postd/c;CBIat admandd/c

Pro Malone,et spective; al.,2002 before and after

Community dwelling patientsd/c fromGDH

BarthelIndex;TUG Adm,D/C, Test;BergBalance; 3months MMSE;GDS

Outcome Measure/ Tool(s)

Intervention Outcome (studyduration) Measures

GDHand Geriatric Clinics

MortalityED orhospitaluse Placement Healthstatus Barthel EMS FAC

ns ns ns ns p<.001;42% p<.001;83% p<.001;35%

Patients completinga courseof physiotherapy (meanage=79)

Effectiveness of3scalesin aGDH followingPT intervention SMAFmeasureat enrollandD/C

GDHpatients Consecutive atatertiary patients carefacility

Functional Autonomy Measurement Systemchange

System cost benefit

Authors, date Style* (location) Dalby,etal. 1. 2000 (Canada)

Sourceof population HSOfamily practice roster

Hbert,et al.,2001 (Canada) Stevens,et al.,2001 (Australia)

Health insurance roster Seniorsliving independently onelectoral role

Followup Byphone orvisit asnecessary

Stuck,etal. Health 2000 insurance (Switzerland) rosterBerne

1visit, mailed followup surveyat 11months 4visits

CGA,careplan, 12visits teachingquarterlyvisits (36months) CGA,careplan, 12visits communications quarterlyvisits(36mos)

Sourceof population Veterans Affairsroster

Frailseniors referredby family physician Seniors discharged homefroman Emergency Department

Followup 3or6 followup visits

Structuredgeriatric assessmentprotocol andhomesafety checklist(12months)

Nurse practitionerand physiotherapy

Comprehensive fallsriskassessment. Weeklyphysiotherapy homevisitsfor3 monthsand3monthly maintenancevisits

Intervention (studyduration) Fallsassessment. Recommendations3 exercisetrainingsessions homeexercise prescription

Gagnon,et al.,1999 (Canada)

frailseniors discharged homefrom emergency departments

>70andatriskof 202/215 hospital readmission (81years)

Nikolaus,et al.,1999 (UK)

Seniors admittedto hospitalbut livingathome

livingathome, atrisk,multiple chronicor functional decline (81.4)

181/179/185 Multidisciplinary geriatricsteam

mayrequireinitialsubsidy Homecare Depression ****Mentalhealth Jadadscore:lowerscoresindicatehigherqualityQualityscore:higherscoresindicatehigherquality