Geriatric Evaluation And Management Research Articles

Can a personalised music listening intervention decrease agitation in hospitalised patients with dementia? A feasibility trial.

Agitation is a common manifestation of the behavioural and psychological symptoms of dementia (BPSD). Pharmacotherapy is not the first-line management because of its potential harms, particularly in the elderly. Music as a non-pharmacological intervention for agitation has been explored in residential aged-care facilities, but few studies have been situated in hospitals. This pilot aims to evaluate the feasibility of a personalised music listening intervention for reducing agitation in hospitalised patients with dementia in a metropolitan Geriatric Evaluation and Management (GEM) unit. Two-arm randomised control feasibility trial. Eligible patients were assigned to the music intervention or control group, with the intervention group receiving music daily between 15:00-16:00, and agitation levels measured in both groups hourly based on the Pittsburgh Agitation Score (PAS) over 5 days of hospitalisation. Post-trial semi-structured interviews assessed feasibility of the intervention. Twenty-one patients were recruited over 8 months. Interviews with staff involved indicated that the music intervention was manageable to deliver, assisted engagement with patients which increased efficiency of some clinical tasks, and challenged staff mindset around using psychotropic medication to address agitation. PAS results were inconclusive, because of underpowered numbers in this pilot study. It is feasible for nursing staff to deliver a personalised music listening intervention to patients with dementia in a geriatric unit of a tertiary hospital, without compromising on usual clinical care.

Protocol paper: Multi-site, cluster-randomized clinical trial for optimizing functional outcomes of older cancer survivors after chemotherapy

BackgroundCancer survivors over the age of 65 have unique needs due to the higher prevalence of functional and cognitive impairment, comorbidities, geriatric syndromes, and greater need for social support after chemotherapy. In this study, we will evaluate whether a Geriatric Evaluation and Management-Survivorship (GEMS) intervention improves functional outcomes important to older cancer survivors following chemotherapy. MethodsA cluster-randomized trial will be conducted in approximately 30 community oncology practices affiliated with the University of Rochester Cancer Center (URCC) National Cancer Institute Community Oncology Research Program (NCORP) Research Base. Participating sites will be randomized to the GEMS intervention, which includes Advanced Practice Practitioner (APP)-directed geriatric evaluation and management (GEM), and Survivorship Health Education (SHE) that is combined with Exercise for Cancer Patients (EXCAP©®), or usual care. Cancer survivors will be recruited from community oncology practices (of participating oncology physicians and APPs) after the enrolled clinicians have consented and completed a baseline survey. We will enroll 780 cancer survivors aged 65 years and older who have completed curative-intent chemotherapy for a solid tumor malignancy within four weeks of study enrollment. Cancer survivors will be asked to choose one caregiver to also participate for a total up to 780 caregivers. The primary aim is to compare the effectiveness of GEMS for improving patient-reported physical function at six months. The secondary aim is to compare effectiveness of GEMS for improving patient-reported cognitive function at six months. Tertiary aims include comparing the effectiveness of GEMS for improving: 1) Patient-reported physical function at twelve months; 2) objectively assessed physical function at six and twelve months; and 3) patient-reported cognitive function at twelve months and objectively assessed cognitive function at six and twelve months. Exploratory health care aims include: 1) Survivor satisfaction with care, 2) APP communication with primary care physicians (PCPs), 3) completion of referral appointments, and 4) hospitalizations at six and twelve months. Exploratory caregiver aims include: 1) Caregiver distress; 2) caregiver quality of life; 3) caregiver burden; and 4) satisfaction with patient care at six and twelve months. DiscussionIf successful, GEMS would be an option for a standardized APP-led survivorship care intervention. Trial RegistrationClinicalTrials.govNCT05006482, registered on August 9, 2021.

Use of a Structured Framework with Novel Outcome Measures to Describe a Consultation-Liaison Psychiatry Service and its Effectiveness

This article describes a new consultation-liaison psychiatry (CLP) service at a subacute hospital in Melbourne, Australia, using a structured framework and novel outcome measures. It also describes the psychiatric needs of the rehabilitation and geriatric evaluation and management (GEM) units. The “structure-process-outcomes” framework was used to anchor objective measures of CLP effectiveness. Relevant information was collected on all admissions and CLP referrals between February and July 2019. Planned and post hoc statistical tests were performed to determine significant associations. Results showed that 22.3% of patients in the rehabilitation unit and 44.2% in GEM unit had active psychiatric disorders (APD); this cohort had significantly greater length of stay (LOS) and less funding per day of admission. Geriatricians refer a significantly lower proportion of those with APD than rehabilitation physicians, likely due to shared clinical expertise in managing neurocognitive disorders. Those referred have significantly greater psychiatric comorbidity and LOS than those not referred. Despite this, CLP interventions was associated with a significantly reduced number of readmissions in the 180 days post-initial discharge. Describing a CLP service using a structured framework with objective outcome measures allows for deeper and more nuanced evaluation of service effectiveness. A substantial proportion of patients at rehabilitation and GEM units have APD. [ Psychiatr Ann . 2021;51(8):382–393.]

123 Acceptability of the Ambient Intelligent Geriatric Management (AMBIGEM) System: A Technological Solution to Prevent in-Patient Falls

Abstract AmbIGeM is a technological solution to prevent in-patient falls in patients aged >65. It has been evaluated in a 100-week stepped wedge pragmatic design in two geriatric evaluation and management (GEM) wards and a general medical ward in two Australian hospitals (Visvanathan, Ranasinghe, Wilson et al., Injury Prevention, 2017,0:1). Evaluation of acceptability of the AmbIGeM system from the perspectives of patients and staff who experienced it is reported here. 30 patients completed a 24-item survey, 27 patients were interviewed, 22 staff participated in 3 focus groups and 51 staff completed a 39-item survey. Survey data were descriptively analysed, and focus group and interview data were thematically analysed. In patient surveys, patients were overall strongly positive, with means 8+ (on 11-point scale) on most items. In patient interviews, the AmbIGeM system was considered a good idea to prevent falls. Most patients thought the singlets comfortable and had no concerns for their privacy nor impact on normal activity. Patients and families felt reassured, although sometimes they misunderstood the purpose of AmbIGeM. In staff focus groups, staff perceived AmbIGeM beneficial in that it can detect and alert movement in patients who require supervision. In both GEM wards, AmbIGeM was considered particularly beneficial,practical and valuable to use on night shift. Factors such as perceived technical limitations (false and delayed alerts) and felt staff burden impacted on acceptability. In staff surveys, 56% agreed/strongly agreed that AmbIGeM has the capability to prevent falls while 16% disagreed/strongly disagreed, 62% thought AmbIGeM would be more user friendly if it was consistently accurate and 76% believed that AmbIGeM takes a moderate/lot of extra work. Conclusion AmbIGeM is largely acceptable to patients and requires further refinement for staff. Feedback is valuable to further refine the system.

Understanding of diagnosis and medications among non-English-speaking older patients.

To determine whether non-English-speaking background (NESB) patients had a poorer understanding of diagnosis and medications compared to English-speaking background (ESB) patients. English-speaking background and NESB patients admitted to inpatient geriatric evaluation and management (GEM) unit were asked standardised questions about their admission diagnosis, reason for GEM admission and medications. Accuracy of answers, as compared to medical notes, ranked as 'full credit', 'partial credit' or 'no credit'. Of the 66 patients recruited (30 NESB), understanding of diagnosis and purpose of GEM admission was good. There was no difference between ESB and NESB patients. Understanding of medications taken prior to admission was poor, with 67% of overall patients scoring 'no credit'. NESB patients were more likely to score 'no credit' compared to ESB (80% vs 56%, P = 0.036). Reassuringly, patients had a reasonable understanding of diagnosis and purpose of GEM admission. Lack of understanding of medications, especially among NESB patients, should be improved.

Association between older adults’ functional performance and their scores on the Mini Mental State Examination (MMSE) and Montreal Cognitive Assessment (MoCA)

Purpose The paper aims to investigate if the performance of older adults on the Mini-Mental State Examination (MMSE) and the Montreal Cognitive Assessment (MoCA) were associated or predictive of their functional performance in a geriatric evaluation and management (GEM) inpatient hospital setting. This will inform the occupational therapy assessment and management of older adults admitted to sub-acute GEM settings. Design/methodology/approach In all, 20 participants (11 men, 9 women, mean age 82 years, SD = 6.93) were recruited from a GEM ward in an Australian hospital. Participants’ cognitive abilities were assessed using the MMSE and MoCA, and their functional performance were assessed using the Functional Independence Measure (FIM). Spearman’s rho correlations and linear regression analyses were completed. Bootstrapping was applied to the regression analyses to accommodate the small study sample size. Findings No statistically significant correlations were obtained between the total and subscale scores of the MMSE and FIM or between the total and subscale scores of the MoCA and FIM. In other words, the cognitive and functional abilities of older adults admitted to a GEM setting were not significantly associated in this study. Originality/value The findings suggest that the MoCA and the MMSE were not predictive of participants’ functional performance as measure by the FIM in a sub-acute GEM setting. Occupational therapists should be cautious when interpreting participants’ MMSE, MoCA and FIM results and not depend solely on these results in the goal setting and intervention planning processes for clients on GEM wards. Further studies are recommended to confirm these findings.

Is Concern About Falling Preventing Appropriate Anticoagulation of Elderly Patients With Atrial Fibrillation? A Retrospective Cohort Study

Aims: Optimal management of atrial fibrillation (AF) includes anticoagulation for patients at high risk of stroke or systemic embolism. However, many elderly patients with AF are not anticoagulated, due to concern regarding risk of bleeding following falls. Falls are a significant problem among elderly patients in the inpatient setting, with fall rates of one to nine per 1,000 inpatient days. This study reviewed a cohort of patients with AF who fell during admission at Geriatric Evaluation and Management (GEM) units to determine the rate of anticoagulation and incidence of injury or major bleeding.

Changes in Nutritional and Functional Status in Longer Stay Patients Admitted to a Geriatric Evaluation and Management Unit.

Malnutrition and functional decline are common in older inpatients admitted to subacute care settings. However the association between changes in nutritional status and relevant functional outcomes remains under-researched. This study examined changes in nutritional status, function and mobility in patients admitted to a Geriatric Evaluation and Management (GEM) unit who had a length of stay (LOS) longer than 21 days. A prospective, observational study. Two GEM units at St Vincent's Hospital Melbourne, Australia. Patients admitted to the GEM units who stayed longer than 21 days were included in the study. Patients were assessed on admission and prior to discharge using the Subjective Global Assessment (SGA), Functional Independence Measure (FIM) motor domain and the Modified Elderly Mobility Scale (MEMS). Fifty-nine patients (Mean age 84.0 ± 7 years) met the required length of stay and were included in the study. Fifty-four per cent (n=32) were malnourished on admission (SGA B/C) and 44% (n=26) were malnourished on discharge. Twenty-two per cent (n=13) improved SGA category, 75% remained stable (n=44) and 3% deteriorated (n=2) from admission to discharge. Total Motor FIM scores significantly increased from admission to discharge in both the improved (p<0.001) and stable or deteriorated (p<0.001) nutritional status groups. Subjects who improved in nutritional status had a significantly higher MEMS score at discharge (p<0.001). On admission to the GEM unit, just over half the included patients were rated as malnourished defined by SGA category. Nearly one quarter of the sample had improved their nutritional status at the time of discharge. Improvement in nutritional status was associated with greater improvement in mobility scores. Further studies are required to investigate the effectiveness of nutrition interventions, which will inform models of care aiming to optimise nutritional, functional, and associated clinical outcomes in patients admitted to GEM units.

Improving care coordination for community-dwelling older Australians: a longitudinal qualitative study.

Objective The aim of the present study was to describe the care transition experiences of older people who transfer between subacute and primary care, and to identify factors that influence these experiences. A further aim of the study was to identify ways to enhance the Geriatric Evaluation and Management (GEM) model of care and improve local coordination of services for older people. Methods The present study was an exploratory, longitudinal case study involving repeat interviews with 19 patients and carers, patient chart audits and three focus groups with service providers. Interview transcripts were coded and synthesised to identify recurring themes. Results Patients and carers experienced care transitions as dislocating and unpredictable within a complex and turbulent service context. The experience was characterised by precarious self-management in the community, floundering with unmet needs and holistic care within the GEM service. Patient and carer attitudes to seeking help, quality and timeliness of communication and information exchange, and system pressure affected care transition experiences. Conclusion Further policy and practice attention, including embedding early intervention and prevention, strengthening links between levels of care by building on existing programs and educative and self-help initiatives for patients and carers is recommended to improve care transition experiences and optimise the impact of the GEM model of care. What is known about the topic? Older people with complex care needs experience frequent care transitions because of fluctuating health and fragmentation of aged care services in Australia. The GEM model of care promotes multidisciplinary, coordinated care to improve care transitions and outcomes for older people with complex care needs. What does this paper add? The present study highlights the crucial role of the GEM service, but found there is a lack of systemised linkages within and across levels of care that disrupts coordinated care and affects care transition experiences. There are underutilised opportunities for early intervention and prevention across the system, including the emergency department and general practice. What are the implications for practitioners? Comprehensive screening, assessment and intervention in primary and acute care, formalised transition processes and enhanced support for patients and carers to access timely, appropriate care is required to achieve quality, coordinated care transitions for older people.

Planning for subacute care: predicting demand using acute activity data.

Objective The aim of the present study was to develop a robust model that uses the concept of 'rehabilitation-sensitive' Diagnosis Related Groups (DRGs) in predicting demand for rehabilitation and geriatric evaluation and management (GEM) care following acute in-patient episodes provided in Australian hospitals. Methods The model was developed using statistical analyses of national datasets, informed by a panel of expert clinicians and jurisdictional advice. Logistic regression analysis was undertaken using acute in-patient data, published national hospital statistics and data from the Australasian Rehabilitation Outcomes Centre. Results The predictive model comprises tables of probabilities that patients will require rehabilitation or GEM care after an acute episode, with columns defined by age group and rows defined by grouped Australian Refined (AR)-DRGs. Conclusions The existing concept of rehabilitation-sensitive DRGs was revised and extended. When applied to national data, the model provided a conservative estimate of 83% of the activity actually provided. An example demonstrates the application of the model for service planning. What is known about the topic? Health service planning is core business for jurisdictions and local areas. With populations ageing and an acknowledgement of the underservicing of subacute care, it is timely to find improved methods of estimating demand for this type of care. Traditionally, age-sex standardised utilisation rates for individual DRGs have been applied to Australian Bureau of Statistics (ABS) population projections to predict the future need for subacute services. Improved predictions became possible when some AR-DRGs were designated 'rehabilitation-sensitive'. This improved methodology has been used in several Australian jurisdictions. What does this paper add? This paper presents a new tool, or model, to predict demand for rehabilitation and GEM services based on in-patient acute activity. In this model, the methodology based on rehabilitation-sensitive AR-DRGs has been extended by updating them to AR-DRG Version 7.0, quantifying the level of 'sensitivity' and incorporating the patient's age to improve the prediction of demand for subacute services. What are the implications for practitioners? The predictive model takes the form of tables of probabilities that patients will require rehabilitation or GEM care after an acute episode and can be applied to acute in-patient administrative datasets in any Australian jurisdiction or local area. The use of patient-level characteristics will enable service planners to improve their forecasting of demand for these services. Clinicians and jurisdictional representatives consulted during the project regarded the model favourably and believed that it was an improvement on currently available methods.

Developing an Australian health and aged care research agenda: a systematic review of evidence at the subacute interface.

Objective The aim of the present study was to systematically review articles describing recent interventions that aimed to improve access and outcomes for older people at the interface between health and aged care, with a focus on subacute care programs of palliative care, rehabilitation, geriatric evaluation and management (GEM) and psychogeriatrics. Methods Australian studies published between 2008 and 2013were evaluated using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and National Health and Medical Research Council of Australia (NHMRC) guidelines. Included studies were summarised according to focus areas and results discussed in the current Australian subacute health care context. Results Eleven Australian research articles were identified. Three did not achieve any NHMRC rating level because of methodological approach. Focus areas included: discharge planning; information management or communication; rehabilitation; hospital treatment in residential care; screening and intervention; and Telehealth. Interventions were primarily system centred; only three studies featured patient-level outcome measures. Conclusions There is limited high-quality research investigating the effectiveness of interventions at the health and aged care interface of subacute care. Further research is needed. What is known about the topic? Subacute care offers important healthcare programs for older people, operating at the interface between health and aged care. However, for the most part this has not been subject to research scrutiny. What does this paper add? Identified studies were predominantly hospital oriented and designed to avoid hospital admission and associated costs. Locally integrated, collaborative and multidiscipline based interventions improve system-level outcomes. Alternative and individualised models of care, particularly when provided in their home setting, yields positive outcomes for older people. What are the implications for practitioners? Health and aged care reforms and related research agenda must include the perspectives and experiences of patients and/or carers accessing subacute care programs, yet these are under-reported. The present review highlights opportunities to improve the quality of existing evidence and create a research agenda for the future.

Outpatient health care utilization in a sample of cognitively impaired veterans receiving care in VHA geriatric evaluation and management clinics.

Within the Veterans Health Administration (VHA), Geriatric Evaluation And Management (GEM) clinics are designed specifically to address the needs of older veterans with complex age-related concerns, including dementia and comorbid medical and mental health conditions. Previous literature describes aging veterans as having greater health care needs compared with age-matched nonveteran samples, and multimorbidity is of particular concern in this population. Using data extracted from electronic medical records (EMRs), the present study describes the demographic characteristics, mental health diagnoses, and health care utilization of a sample of 476 VHA GEM patients with diagnosed cognitive impairment or dementia seen in clinics across Upstate New York. Examination of EMR data demonstrated that in addition to diagnosed cognitive impairment and dementia, over 66% of the sample had at least 1 additional mental health diagnosis coded during the study period. Many were prescribed dementia medications and/or other psychotropic medications, predominantly antidepressants. These veterans utilized a variety of outpatient services, including high rates of mental health consultation subsequent to GEM evaluation, though low rates of mental health follow-up were observed. Results from the current study provide insight into the important role mental health providers such as psychologists and psychiatrists can play as collaborators in interdisciplinary geriatrics care for veterans.

The changing epidemiology of klebsiella pneumoniae Carbapenemase (KPC) Resistance in Australia

Aims The aims of this study were to firstly describe the epidemiology, risk factors and outcomes of patients with KPC producing organisms at our institution, and secondly, to describe an outbreak involving seven patients admitted to a geriatric evaluation and management (GEM) ward. Methods A retrospective review was conducted to assess 29 patients with KPC producing organisms in a tertiary referral centre in Australia from 2012 to 2014. In addition, a prospective assessment of an outbreak was conducted including a molecular evaluation of the isolates and patient outcomes. Results Of the 29 patients, 55% were male with a median age of 69 years. The greatest risk factors for acquiring a KPC producing organism were length of hospital stay and recent exposure to broad spectrum antibiotics. The 30 day mortality rate was 17.2%, which increased to 37.9% at 60 days. The seven patients identified in the outbreak were exposed to an index case where a KPC was isolated from urine. The whole genome sequence analysis revealed all seven isolates were highly clonally related. Two of the patients died of causes not directly attributable to KPC colonisation. Discussion This study highlights the increasing threat of KPC producing organisms in Australia.

Optimizing strategies to improve interprofessional practice for veterans, part 1.

IntroductionInterprofessional patient care is a well-recognized path that health care systems are striving toward. The Veteran’s Affairs (VA) system initiated interprofessional practice (IPP) models with their Geriatric Evaluation and Management (GEM) programs. GEM programs incorporate a range of specialties, including but not limited to, medicine, nursing, social work, physical therapy and pharmacy, to collaboratively evaluate veterans. Despite being a valuable resource, they are now faced with significant cut-backs, including closures. The primary goal of this project was to assess how the GEM model could be optimized at the Pittsburgh, Pennsylvania VA to allow for the sustainability of this important IPP assessment. Part 1 of the study evaluated the IPP process using program, patient, and family surveys. Part 2 examined how well the geriatrician matched patients to specialists in the GEM model. This paper describes Part 1 of our study.MethodsThree strategies were used: 1) a national GEM program survey; 2) a veteran/family satisfaction survey; and 3) an absentee assessment.ResultsTwenty-six of 92 programs responded to the GEM IPP survey. Six strategies were shared to optimize IPP models throughout the country. Of the 34 satisfaction surveys, 80% stated the GEM clinic was beneficial, 79% stated their concerns were addressed, and 100% would recommend GEM to their friends. Of the 24 absentee assessments, the top three reasons for missing the appointments were transportation, medical illnesses, and not knowing/remembering about the appointment. Absentee rate diminished from 41% to 19% after instituting a reminder phone call policy.DiscussionMaintaining the sustainability of IPP programs is crucial for the health of our veterans. This project uncovered tools to improve the GEM IPP model for our veterans that can be incorporated nationally. Despite the lengthy nature of IPP models, patients and families appreciated the thoroughness, requested transportation and food, and responded well to reminder phone calls. A keen eye on these issues and concomitant medical complexity needs to be observed when planning IPP models to ensure sustainability.

People with dementia and the hospital environment: the view of patients and family carers

A metropolitan geriatric evaluation and management (GEM) facility in Australia was undergoing expansion, and consideration for the needs of individuals with dementia and their family carers was identified as important in planning the new facility. Existing literature revealed that people in hospital value privacy, minimal noise, family amenities and homeliness, but these findings did not consider the perspectives of the person with dementia specifically. The aim was to elicit the perspectives of current inpatients with dementia, and their family carers, about the environment/design features that they believe are necessary for people with dementia, and their family carers. This qualitative study utilised in-depth semi-structured interviews to obtain information from current inpatients with dementia and their family carers. Participants described how the care received was more important than the physical environment; however, participants also valued homeliness, privacy for the patient and for conversations, a shared space without a television and a connection to the outside. Participants described how accommodating carers, providing quiet spaces and appropriate amenities were also important. While participants valued care over the physical surroundings, they also offered valuable information about their experience in the ward environment. Despite cognitive difficulties, people with dementia were able to provide useful information about the environment within which they were being cared. Consumer opinions about hospital design/environment should be considered as an important source of data. Privacy and personal space for people with dementia and their family carers, a connection with the outside environment , and the needs of carers and visitors are all important considerations when designing healthcare environments.

Reducing the burden of morbidity and medical utilization of older patients by outpatient geriatric services: Implications to primary health‐care settings

That geriatric evaluation and management (GEM) is associated with better quality of care for elderly patients has been reported by previous studies, but evidence supporting that GEM can reduce the burden of morbidity (BOM) was lacking. The aim of this study was to evaluate the benefits of outpatient GEM on reducing BOM and medical utilization in Taiwan. Data of this retrospective case-control study were obtained from the 2004-2006 Taiwan National Health Insurance Research Database (NHIRD). Patients who attended the outpatient GEM program for over 6 months in a tertiary medical center in 2005 were enrolled as the case group, and a 1:5 age and gender-matched control group was formed by randomly-selected patients from the same medical center for comparisons. BOM was obtained by applying the Adjusted Clinical Group (ACG) program, and medical utilization variables were totalled for each patient from the NHIRD. Patients were further reassigned to two morbidity categories, the low (resource utilization bands ≤ 3) and high (resource utilization bands > 3) morbidity category, according to their degree of morbidity before statistical analyses. Data of 4254 elderly patients (709 cases, 3545 controls) were included in the study. BOM and medical utilization were increased in both groups in both morbidity categories during the study period. However, the growth of BOM, total medical expenditure, number of emergency department visit, and days and expenditure of hospitalization were significantly reduced in the case than the control group in the low morbidity category, not the high morbidity category. Outpatient GEM could effectively reduce growth of BOM and medical utilization for relatively healthy elderly patients in Taiwan where elderly patients have relatively free access to general and specialty care. The results of this study implied the potential benefits of systematically implementing GEM in primary health-care settings to improve the quality of care and slow down the growth of BOM for elderly patients.

Demographic characteristics and clinical benefits of outpatient geriatric evaluation and management service in Taiwan

As Taiwan has become the fastest aging country in the world, developing elderly-friendly health care services is of great importance. Compared with traditional health-care service models, healthcare needs of older people may differ extensively. It has been reported that geriatric evaluation and management (GEM), helps to differentiate the atypical presentations of frail older patients, to discover hidden health-social problems, and to promote long-term clinical outcome. The main purpose of this study was to explore the demographic characteristics of older patients visiting outpatient GEM service and its impact to health-care utilization in a tertiary medical center in Taiwan. From January to October of 2008, 1054 patients visited the outpatient GEM service, and comprehensive geriatric assessment was performed for 140 patients (62.9% males with the mean age was 81.0±6.6 years), and 34.8% of them were college graduates. Overall, the prevalence of functional impairment was 11.4%, depressive symptoms 20.7%, cognitive impairment 32.1%, and abnormal timed up-and-go test 32.1%. During the 12-month follow-up, items of mean oral medications were significantly reduced (3.2±2.7 vs. 3.8±2.8, p<0.001) and the health-related quality of life was significantly improved (64.6±8.0 vs. 61.6±4.0, p<0.001). In conclusion, patients visiting outpatient GEM services in Taiwan are old and well-educated, and they possessed various functional impairments. The outpatient GEM services significantly reduced the items of oral medications and improved quality of life. The possible better compliance of this cohort due to high educational status may overestimate the clinical effectiveness of outpatient GEM services. Further investigations are needed to clarify the long-term benefits of outpatient GEM services.

Will We Better Manage Chronic Disease?

Will We Better Manage Chronic Disease?

Validity and reliability of the de Morton Mobility Index in the subacute hospital setting in a geriatric evaluation and management population

To investigate the clinimetric properties of the de Morton Mobility Index (DEMMI) in a Geriatric Evaluation and Management (GEM) population. A longitudinal validation study (n = 100) and inter-rater reliability study (n = 29) in a GEM population. Consecutive patients admitted to a GEM rehabilitation ward were eligible for inclusion. At hospital admission and discharge, a physical therapist assessed patients with physical performance instruments that included the 6-metre walk test, step test, Clinical Test of Sensory Organization and Balance, Timed Up and Go test, 6-minute walk test and the DEMMI. Consecutively eligible patients were included in an inter-rater reliability study between physical therapists. DEMMI admission scores were normally distributed (mean 30.2, standard deviation 16.7) and other activity limitation instruments had either a floor or a ceiling effect. Evidence of convergent, discriminant and known groups validity for the DEMMI were obtained. The minimal detectable change with 90% confidence was 10.5 (95% confidence interval 6.1-17.9) points and the minimally clinically important difference was 8.4 points on the 100-point interval DEMMI scale. The DEMMI provides clinicians with an accurate and valid method of measuring mobility for geriatric patients in the subacute hospital setting.

The effect on caregiver burden of a problem-based home visiting programme for frail older people

caregiver effects of geriatric care models focusing primarily at the patient have not been consistently studied. We studied caregiver effects of a nurse-led comprehensive geriatric evaluation and management (GEM) programme for community-dwelling frail older people that showed-in a randomised comparison with usual care--health-related quality of life benefits for the care receivers. this randomised trial included 110 caregiver/patient dyads who were followed up for 6 months. Primary analyses were intention-to-treat analyses of caregiver burden assessed with Zarit Burden Interview (ZBI; 0-88; higher means more burden). Preplanned subgroup analyses were conducted for cognition, living arrangement and patient/caregiver co-residence. overall, perceived caregiver burden showed no significant differences between study groups in changes over time. However, perceived burden was at baseline more than eight points higher in caregivers sharing a household with patients (n = 23) compared to caregivers living separately (n = 87). The intervention performed better in caregivers living together with the patient than in caregivers living separately (P for interaction = 0.04). Co-resident caregivers experienced six-Zarit point improvement compared with four-point deterioration in the non-co-resident caregivers. GEM at home benefited patients, but maybe not caregivers. Caregiver effects are related to whether caregivers live with the patient or not.