Comprehensive Geriatric Evaluation Research Articles

Recommendations for Treating Depression in Community-Based Older Adults

To present recommendations for community-based treatment of late-life depression to public health and aging networks. An expert panel of mental health and public health researchers and community-based practitioners in aging was convened in April 2006 to form consensus-based recommendations. When making recommendations, panelists considered feasibility and appropriateness for community-based delivery, as well as strength of evidence on program effectiveness from a systematic literature review of articles published through 2005. The expert panel strongly recommended depression care management-modeled interventions delivered at home or at primary care clinics. The panel recommended individual cognitive behavioral therapy. Interventions not recommended as primary treatments for late-life depression included education and skills training, comprehensive geriatric health evaluation programs, exercise, and physical rehabilitation/occupational therapy. There was insufficient evidence for making recommendations for several intervention categories, including group psychotherapy and psychotherapies other than cognitive behavioral therapy. This interdisciplinary expert panel determined that recommended interventions should be disseminated throughout the public health and aging networks, while acknowledging the challenges and obstacles involved. Interventions that were not recommended or had insufficient evidence often did not treat depression primarily and/or did not include a clinically depressed sample while attempting to establish efficacy. These interventions may provide other benefits, but should not be presumed to effectively treat depression by themselves. Panelists also identified primary prevention of depression as a much under-studied area. These findings should aid individual clinicians as well as public health decision makers in the delivery of population-based mental health services in diverse community settings.

2183: Rectal Adenocarcinoma in Patients Aged 80 Years or More Towards Conservative Treatment

In elderly patient conservative treatment of rectal cancer is a goal of prime importance, not only to increase sphincter saving procedure, but also to avoid as much as possible radical open surgery which is in this population associated with a non negligeable risk of postoperative death and morbidity. Such a conservative approach has been promoted in our institute and we present a preliminary analysis of our Results. Between 2001 and 2005, 29 patients presenting primary adenocarcinoma without distant metastasis and aged 80 years or more, have been treated in CAL. A conservative radiotherapy treatment with curative intent was given in 10 patients (5 men, 5 women). Staging performed with endorectal ultrasonography showed T2 = 7pts, T3 = 3. All patients were treated with contact x ray (mean dose = 100 Gy/4 fractions). External beam radiotherapy with 45 Gy was performed in 7 patients. Concurrent chemotherapy (Capecitabine) in 2 patients. One patient underwent local excision. Median follow-up time was 2 years (1–4 years). Primary local control was achieved in 8 patients. Good anorectal function was preserved in all the patients. None required palliative stoma. All treatments were ambulatory without severe toxicity. One patient had a local recurrence with moderate symptoms. Six patients are alive without symptoms (1–4 years). Three died from intercurrent disease, none from rectal cancer. Elderly patients with rectal cancer deserve a specific approach with a comprehensive geriatric evaluation. Open surgery is often associated with mortality and morbidity or poor anorectal function after LAR. Curative radiotherapy especially combining external RT and endocavitary contact x ray (+ chemotherapy) should play an increasing role to obtain a good balance between survival and quality of life in this group of population which is increasing regularly. Specific end points as time without symptom or stoma should be more often utilized in this group of population to assess relevance of management.

Cognitive Impairment Is the Major Risk Factor for Development of Geriatric Syndromes during Hospitalization: Results from the GIFA Study

Objective: To detect the main factors associated with the occurrence of specific geriatric syndromes (namely pressure sores, fecal incontinence, urinary incontinence and falls) in elderly patients during hospitalization. Design: Observational prospective study. Setting: Eighty-one community and university hospitals throughout Italy. Participants: 13,729 patients aged 65 years and more, consecutively admitted to medical or geriatric acute wards during 20 months in the period between 1991 and 1998. Measurements: Occurrence of pressure sores, fecal incontinence, urinary incontinence and falls during the stay in hospital. Results: Pressure sores were already present in 3% of hospitalized subjects, fecal incontinence in 7.3%, while urinary incontinence, evaluated on a subgroup of total population (4,268 subjects), had a prevalence of 22.3%. During hospitalization (mean stay of 15 days), 74 subjects developed new pressure sores, 55 became fecal and 35 urinary incontinent, and 279 subjects had at least one episode of fall. In multivariate analyses, cognitive impairment, advanced age (85+ years), length of stay (more than 3 weeks) and severe disability were the main independent predictors of development of the four geriatric syndromes, with cognitive impairment as the most significant risk factor for all the four outcomes (OR 4.9, 95% CI 2.4–9.9 for pressure sores; OR 6.3, 95% CI 3.0–13.0 for fecal incontinence; OR 5.3, 95% CI 2.3–12.0 for urinary incontinence; OR 1.6, 95% CI 1.2–2.3 for falls). Conclusion: Very old people have a significant increased risk of several geriatric syndromes during the stay in hospital, particularly if it is long and they are cognitively impaired. A standardized comprehensive geriatric evaluation at admission could be helpful in detecting all subjects at risk and preventing the development of hospital-acquired geriatric syndromes.

Non-Hodgkin's lymphoma (NHL) in elderly patients (pts): Patient-tailored treatment according to a comprehensive geriatric evaluation

6678 Background: Elderly patients affected by aggressive NHL are generally not treated in an optimal way. Therefore, we designed a new approach for elderly pts (>70 years) with aggressive NHL, that allows a pt-tailored treatment with the aim of maintaining a balance between the desire of curing the tumor and the need of providing a good quality of life. Methods: The study was started in March 2000. Pts with an ADL and IADL score of at least 5 and whose hepatic and renal function and hemopoietic reserve are sufficiently good, are treated with curative intent. These pts receive CHOP (those with a very good functional status) or CEOP (if mild cardiopathy is present) or CVP (if severe cardiopathy is present) or CEO (if diabetes mellitus is present). Dose reductions of chemotherapy (CT) are also applied according to IADL and ADL. Rituximab is administered if CD20+; G-CSF is administered from day 7 to 12. Results: So far, 61 pts have been enrolled. Median age was 75 years (range: 70–89). Fifty patients are eval...

Non-Hodgkin's lymphoma (NHL) in elderly patients (pts): Patient-tailored treatment according to a comprehensive geriatric evaluation

6678 Background: Elderly patients affected by aggressive NHL are generally not treated in an optimal way. Therefore, we designed a new approach for elderly pts (>70 years) with aggressive NHL, that allows a pt-tailored treatment with the aim of maintaining a balance between the desire of curing the tumor and the need of providing a good quality of life. Methods: The study was started in March 2000. Pts with an ADL and IADL score of at least 5 and whose hepatic and renal function and hemopoietic reserve are sufficiently good, are treated with curative intent. These pts receive CHOP (those with a very good functional status) or CEOP (if mild cardiopathy is present) or CVP (if severe cardiopathy is present) or CEO (if diabetes mellitus is present). Dose reductions of chemotherapy (CT) are also applied according to IADL and ADL. Rituximab is administered if CD20+; G-CSF is administered from day 7 to 12. Results: So far, 61 pts have been enrolled. Median age was 75 years (range: 70–89). Fifty patients are evaluable for response (see table). Hematologic toxicity was evaluated in 42 patients (173 cycles) and G3-G4 toxicity at nadir was registered in 16 cycles (9.2%). Non-hematologic toxicity was evaluated in 56 patients (239 cycles) and was as follows: G3 gastrointestinal in 2 cycles, G3 neurologic in 9 cycles, G3 infection in 4 cycles. Median follow up is 13 months (range 1–43). Five pts relapsed. Thirty-four patients are still in CR. Nine patients died (2 early deaths, 6 PD and 1 respiratory failure in CR one month after the end of CT). Conclusions: Our results demonstrate that this completely new approach is feasible for elderly pts with NHL. We strongly believe that it is highly effective and without significant toxicity. We also believe that a similar approach should be employed for future studies aimed at determining the best treatment for elderly pts affected by any cancer type. No significant financial relationships to disclose.

Anticoagulation orale en pratique gériatrique

Purpose. – Atrial fibrillation and venous thromboembolism are particularly frequent in the elderly. Whether or not prescribe oral anticoagulant treatment in the elderly is therefore a common question for the physician. Despite the benefits of anticoagulation demonstrated in clinical trials, oral anticoagulant therapy is underused in the elderly. Current knowledge and key points. – Indications for oral anticoagulation are discussed specifically in the elderly with a literature review. Only the length of anticoagulation treatment after a venous thromboembolism remained a purpose of discussion regarding the severity of the pathology. The frequency of systemic thromboembolism in nonvalvular atrial fibrillation is increasing with age. Oral anticoagulation reduces this risk. This benefice is to compare with the increasing rate of major bleeding complications in the elderly and in patient who had stroke, hyper-tension, diabetes mellitus or gastrointestinal bleeding. The objective of this article is to focus on the mode to measure oral anticoagulant benefice/risk ratio in the elderly and to propose several ways to minimize the risk for bleeding. Future prospects and projects. – The potential drug side effect severity of oral anticoagulation must lead to find the “reasonable” clinical indications in term of benefice/risk ratio and what measures should be take to increase the safety of oral anticoagulation in the elderly. The comprehensive geriatric evaluation should be considered as a decision-aid tool in long-term oral anticoagulation in the frail elderly. Anticoagulation clinics, informatics'-prescription coupled with dose-adaptation decision-aid adapted to the elderly should be helpful in this research of quality. Finally, prescribers education supports must insist on the early course of therapy that is at higher risk of bleeding.

Physical Impairment and Disability: Relationship to Performance of Activities of Daily Living in Community-Dwelling Older Men

The decline of physical function of older adults, associated with loss of independent living status, is a major public health concern. The purpose of this study was to examine the relationship of physical impairment and disability to performance of activities of daily living (ADL) among community-dwelling older adults. Eighty-three community-dwelling older men who were referred to a comprehensive outpatient geriatric evaluation program (mean age=75.5 years, SD=7.0, range=64-97) were examined. Measurements of physical impairment (muscle force production, flexibility, and fitness) and physical disability (gait speed, stride length, risk for recurrent falls, and physical function) were recorded. A stepwise linear regression was used to determine the relationship of physical impairments and disability measures with ADL. The results indicated that walking speed, fall risk, and muscle force contributed independently to the characterization of the activities of daily living of the community-dwelling older men studied (adjusted R2=.68; F=56.81; df=3,80; P<.001). Using a principal components factor analysis, 4 domains were identified that explained 68.2% of the variance in performance of ADL: (1) mobility/fall risk=26.5%, (2) coordination=15%, (3) fitness=14.7%, and (4) flexibility=12.0%. The identification of domains of physical function may be useful to physical therapists in the development of interventions targeted for physical impairments and disabilities that contribute to deficits in performance of ADL. Targeting interventions for physical impairments and disabilities related to function may improve the effectiveness of physical therapist interventions and reduce the loss of independence among community-dwelling older people.

Compliance of frail elderly with health services prescribed at discharge from an acute-care geriatric ward.

A model of compliance by frail elderly with prescribed healthcare services was developed and tested. The discrepancy between primary care, geriatric and community health center (CLSC) services prescribed at discharge after comprehensive geriatric evaluation and treatment was measured, as were those services actually used during a 6-week interval (compliance). In this model, compliance was directly related to elders' intention to adhere to prescribed services, but this relationship was modified by organizational factors, reinforcing factors, and changes in health status during the observation period. Intention to adhere resulted from individual and reinforcing factors existing before discharge. This model was tested on 211 patients discharged to community settings from an acute-care hospital geriatrics ward. Information was obtained through interviews with the patients or care givers and from hospital, outpatient, and local community health center charts. On average, patients used 56.9% of services prescribed; 13% of patients did not use any of the services prescribed for them, whereas 22% used all the services prescribed. Intention to adhere was influenced by patients' perception of the benefits of prescribed services and by their perception of the ease of access to transportation. Intention itself was not found to be an important determinant of overall compliance. Among organizational factors, having the ward staff make a follow-up appointment with the patients' family doctor and with the geriatric clinic before discharge and communication with the local community health center increased overall compliance. Moreover, patients who perceived they had access to transportation and to an accompanying person were more likely to comply. The results suggest that when discharging patients to the community, steps taken for them by the discharging healthcare providers will improve compliance.

Functional Assessment: A Holistic Approach to Rehabilitation of the Geriatric Client

Functional assessment of the elderly client provides a structured approach to the complex and multidimensional issues in rehabilitation. Rehabilitation nurses may be familiar with some of the long-standing functional assessment tools, such as Barthel's index. It is important to have a working knowledge of a variety of tools, as well as an ongoing awareness of newer ones as they are developed (e.g., the Functional Independence Measure). Functional assessment is part of comprehensive geriatric evaluation. After initial assessment by rehabilitation team members, the team considers the patient's strengths and supports and develops a problem list (NIH, 1987). The individualized plan of care is developed with the elderly client to achieve maximum rehabilitation potential. Functional assessment tools assist in measuring rehabilitation progress and in clinical decision making. They also can be used in clinical research in geriatric rehabilitation. The number of elderly persons in this country is growing rapidly. Rehabilitation nurses will need to expand their clinical skills to integrate holistic geriatric assessment.

Medicare Reimbursement for Geriatric Assessment: Report of the American Geriatrics Society Ad Hoc Committee on Geriatrics Assessment

This ad hoc committee report from the American Geriatrics Society proposes the prompt initiation of Medicare reimbursement for geriatric assessment (GA) services (also termed comprehensive geriatric assessment or geriatric evaluation and management services). Despite an extensive body of literature documenting the effectiveness of GA for improving health care outcomes in many settings for identifiable groups of frail elderly patients, no explicit Medicare reimbursement mechanisms currently exist to cover GA services provided by either hospital or physician. We believe that new physician reimbursement codes specific for geriatric assessment should be established in the Current Procedural Technology (CPT-4) manual and that reimbursement for GA should be specifically provided under Part B of Medicare. Further, we believe that hospital reimbursement within the Medicare prospective payment system should be modified to encourage GA during inpatient stays for appropriate patients. This paper summarizes the background for these recommendations. It defines the major content of GA at three levels of intensity--screening, intermediate, and comprehensive. It describes the major sites for conducting GA--hospital, office, home, nursing home. Finally, it proposes criteria for targeting patients most likely to benefit from GA.

Working Group Recommendations: Research on Content and Efficacy of Geriatric Evaluation and Management Interventions

Methods of conducting comprehensive geriatric evaluation and management (GEM) are proliferating in a variety of clinical settings. However, rigorous evaluations of efficacy for this new approach to care of older patients have demonstrated a favorable impact on patient outcome in only a few studies. All of these have been controlled single site studies, and replication is needed. If replication studies show similar results, further studies should be undertaken to define the minimum necessary intervention to achieve the desired outcome. Controlled trials are needed to determine if consultative geriatric evaluation and/or primary patient management is effective. Further innovative work is needed in model development for geriatric assessment and management in outpatient settings. Finally, studies of geriatric evaluation and management in other environments, such as home care or the nursing home, are recommended.

Prognostic evaluation in geriatric oncology: problems and perspectives

The optimal management of older patients with malignant diseases may be prevented by two antithetic conditions: inadequate treatment and excessive treatment. A likely root of this problem appears to be paucity of prognostic information, which may hamper management-related decisions in the older person with cancer. The prognostic value of performance status and nutritional status may fade with aging, while the influence of mental, emotional and socioeconomic status on the outcome of neoplastic diseases may become more prominent. The Comprehensive Geriatric Evaluation (CGE), which encompasses emotional mental and social domains in addition to physical health and function, may prove a valuable clue for the selection of those older patients who are suitable candidates for antineoplastic treatment.