Geriatric Team Research Articles

Effect of interventions to reduce potentially inappropriate use of drugs in nursing homes: a systematic review of randomised controlled trials

BackgroundStudies have shown that residents in nursing homes often are exposed to inappropriate medication. Particular concern has been raised about the consumption of psychoactive drugs, which are commonly prescribed for nursing home residents suffering from dementia. This review is an update of a Norwegian systematic review commissioned by the Norwegian Directorate of Health. The purpose of the review was to identify and summarise the effect of interventions aimed at reducing potentially inappropriate use or prescribing of drugs in nursing homes.MethodsWe searched for systematic reviews and randomised controlled trials in the Cochrane Library, MEDLINE, EMBASE, ISI Web of Knowledge, DARE and HTA, with the last update in April 2010. Two of the authors independently screened titles and abstracts for inclusion or exclusion. Data on interventions, participants, comparison intervention, and outcomes were extracted from the included studies. Risk of bias and quality of evidence were assessed using the Cochrane Risk of Bias Table and GRADE, respectively. Outcomes assessed were use of or prescribing of drugs (primary) and the health-related outcomes falls, physical limitation, hospitalisation and mortality (secondary).ResultsDue to heterogeneity in interventions and outcomes, we employed a narrative approach. Twenty randomised controlled trials were included from 1631 evaluated references. Ten studies tested different kinds of educational interventions while seven studies tested medication reviews by pharmacists. Only one study was found for each of the interventions geriatric care teams, early psychiatric intervening or activities for the residents combined with education of health care personnel. Several reviews were identified, but these either concerned elderly in general or did not satisfy all the requirements for systematic reviews.ConclusionsInterventions using educational outreach, on-site education given alone or as part of an intervention package and pharmacist medication review may under certain circumstances reduce inappropriate drug use, but the evidence is of low quality. Due to poor quality of the evidence, no conclusions may be drawn about the effect of the other three interventions on drug use, or of either intervention on health-related outcomes.

Geriatric intervention in elderly patients with hip fracture in an orthopedic ward

:Background:Hip fracture is a common cause of long hospital stay in the elderly. Approximately one third of these patients die within the first year. As a consequence geriatric and orthopedic collaboration (orthogeriatrics) has been organized in different ways. The aim of this study is to evaluate the efficiency of a multidisciplinary geriatric in-hospital intervention on patient outcome.Methods:A total of 495 elderly hip fracture patients consecutively admitted to orthopedic surgery, were followed. Data were based on medical records. The intervention group (n=233) was compared to a historical cohort group (n=262) receiving traditional orthopedic treatment. Intervention program was based on initial physical and mental screening and evaluation, geriatric-focused care, and early discharge planning. The intervention was provided by a multidisciplinary geriatric team. After discharge, follow-up home-visits by a physiotherapist were performed, except for patients discharged to nursing homes, due to a 24-hour staff and easy access to the GP.Results:Median length of stay was reduced from 15 to 13 days. More patients began treatment with calcium/vitamin-D and bisphosphonate (p=sig). There was no difference in hemoglobin variation between the time of admission and three to six months post admission, and no difference in three-month readmissions (odds ratio (OR) = 1.09 [95%CI: 0.71;1.67]). Discharge destination was unchanged (OR=0.93 [95%CI: 0.52; 1.65]). In-hospital mortality was 8% in the intervention group vs. 6% (p=0.48), in the control group. Three-month mortality was 16% in the intervention group vs. 15% (p=0.39), in the control group. In the intervention group, residents from nursing homes had a higher three-month mortality (OR=2.37 [95% CI: 0.99; 5.67]), and the risk of new fractures within two years decreased from 9.5% to 7.7%, though not statistically significant.Conclusion:Our study indicates that co-management of hip fracture patients by orthopedic surgeons and geriatricians may be associated with a reduction in length of hospital stay without negatively affecting major patient outcomes. The concept should be further developed particularly among the frail elderly.

Determining the Impact of Establishing a Psychogeriatric Outreach Team Network in Long-Term Care

The primary objective of this study was to describe a model for specialized psychogeriatric consultation to long-term care homes in a large metropolitan Canadian city and to provide an overview of the diagnostic and demographic data of patients referred for assessment. Forty long-term care homes and 13 geriatric mental health outreach teams were surveyed and provided feedback on the model. A retrospective chart review (N=88) was also conducted to confirm the survey results and to provide an overview of the types of patients being seen. Team data indicated that 96% of the homes they served (N=81) were using their services, that all referrals were appropriate, and that their recommendations were implemented in over 50% of cases. Referred patients tended to be older (41% age 85 or older); were referred mainly for agitation, aggression, or depressed mood (over 90%); and mainly had a mood or cognitive disorder (over 90%). These preliminary data suggest that the implementation of specialized psychogeriatric consultation to long-term care may be beneficial, but future studies are required to clarify its usefulness.

Iatrogenic disease in the elderly: risk factors, consequences, and prevention

The epidemiology of iatrogenic disease in the elderly has not been extensively reported. Risk factors of iatrogenic disease in the elderly are drug-induced iatrogenic disease, multiple chronic diseases, multiple physicians, hospitalization, and medical or surgical procedures. Iatrogenic disease can have a great psychomotor impact and important social consequences. To identify patients at high risk is the first step in prevention as most of the iatrogenic diseases are preventable. Interventions that can prevent iatrogenic complications include specific interventions, the use of a geriatric interdisciplinary team, pharmacist consultation and acute care for the elderly units.

Through Teaching Are We Learning? Learning Through Teaching: Facilitating Interprofessional Education Experiences

Background: Despite a growing recognition of the value of collaborative patientcentred practice (CPCP) there is a lack of evidence identifying key elements and approaches to an effective interprofessional (IP) education intervention for clinical team members. The present study was conducted to address the paucity of rigorous mixed methods research to address the question: Does clinician team facilitation and mentorship of senior pre-licensure learners participating in IP clinical placements improve team members' attitudes, knowledge, skills, and perceived behaviours in CPCP?Methods: Based on the assumption that Geriatric Day Hospital clinical teams were already highly collaborative, educational experiences for clinical team members were not designed a priori. Rather, the educational experience was grounded in Mezirow's transformative learning theory, proposing that learning is a process of becoming aware of one's assumptions and revising these assumptions based on critical self-reflection. The option to participate in structured observation and feedback by an external observer using the Team Observation Scale provided important and unique opportunities for team reflection. Using the Controlled Before and After (CBA) design, the Attitudes Toward Health Care Teams Scale (ATHCTS), Team Skills Scale (TSS), and Knowledge Questionnaire were administered pre- and post-clinical placements to intervention and control groups. Data were analyzed by descriptive, bivariate, and repeated measures ANOVA. Qualitative data (evaluation and self-reflective forms) were analyzed using content analysis techniques.Results: Eleven IP clinical placements at 3 sites occurred between January 2007 and March 2008 (intervention N = 48; control N = 7). There was no significant change over time between intervention and control groups for the ATHCTS Quality of Care or Physician Centrality subscale scores, the TSS scores, or the Knowledge scores. Qualitative results suggested that participants were more aware of IP teaming, reflective of their own practice, and reported making changes in their own practice and mentorship of students as a result of their engagement in the study.Conclusions: This study demonstrated the viability of using structured observation and feedback processes as a reflective learning exercise. Further research is required to help identify key approaches and elements to an effective IPE intervention in clinical practice.

Delirium. A Swedish perspective

The incidence and duration of delirium is probably the best measurement of the quality of acute hospital care of old people. A patient with delirium is always seen as a diagnostic challenge to the geriatric team since the only effective treatment is to prevent, detect and treat the underlying causes of delirium. Predisposing and precipitating factors has to be dealt with simultaneously and the best conditions for the recovery of the brain have to be created. New threats to the brain have to be prevented and harmful medication should be avoided. Long-term follow-up of the patient with delirium is necessary since delirium can be the first symptom of a preclinical dementia.

Optimizing the management of elderly colorectal surgery patients

With the ever increasing number of geriatric surgical patients, there is a need to develop efficient processes that address all of the potential issues faced by patients during the perioperative period. This article explores the physiological changes in elderly surgical patients and the outcomes achieved after major abdominal surgery. Perioperative management strategies for elderly surgical patients in line with the practices of the Geriatric Surgical Team of Alexandra Health, Singapore, are also presented. A coordinated transdisciplinary approach best tackles the complexities encountered in these patients.

Innovative Use of Electronic Health Record Reports by Clinical Nurse Specialists

The purpose of the study was to demonstrate how clinical nurse specialists (CNSs) can use information pulled from the electronic health record (EHR) in innovative ways to improve nursing care of vulnerable older adults. As the number of older adults increases, the need will grow for easier access to evidence-based practice nursing interventions for the older population. Clinical nurse specialists are the experts in evaluating research and will also need to find innovative ways to bring the evidence-based practice pertinent to the care of older adults to the bedside nurse. Clinical information from various parts of the EHR is pulled into computer-generated reports that focus on identifying older adult patients with specific high-risk indicators. The specific clinical information pulled into the reports and examples of how the reports are used will be presented. Four reports are described including new hospital admissions of patients older than 65 years, current hospitalized patients with dementia/delirium, current hospitalized patients on cholinesterase inhibitors, and a comprehensive report of all current hospitalized patients older than 65 years focusing on specific geriatric indicators identified in the literature. Computerized reports can be used to facilitate the use of nursing practice guidelines and evidence-based clinical tools such as the confusion assessment method and to increase use of nursing plans of care. The reports can also provide real-time key indicators that can be used to facilitate identification of older adult patients in need of CNS and/or geriatric team consultation. More research still needs to be done regarding the impact of the EHR on nursing indicators such as number of falls, delirium, and use of restraints.

A randomised clinical trial on a comprehensive geriatric assessment and intensive home follow-up after hospital discharge: the Transitional Care Bridge

BackgroundOlder patients are at high risk for poor outcomes after acute hospital admission. The mortality rate in these patients is approximately 20%, whereas 30% of the survivors decline in their level of activities of daily living (ADL) functioning three months after hospital discharge. Most diseases and geriatric conditions that contribute to poor outcomes could be subject to pro-active intervention; not only during hospitalization, but also after discharge. This paper presents the design of a randomised controlled clinical trial concerning the effect of a pro-active, multi-component, nurse-led transitional care program following patients for six months after hospital admission.Methods/DesignThree hospitals in the Netherlands will participate in the multi-centre, double-blind, randomised clinical trial comparing a pro-active multi-component nurse-led transitional care program to usual care after discharge. All patients acutely admitted to the Department of Internal Medicine who are 65 years and older, hospitalised for at least 48 hours and are at risk for functional decline are invited to participate in the study. All patients will receive integrated geriatric care by a geriatric consultation team during hospital admission. Randomization, which will be stratified by study site and cognitive impairment, will be conducted during admission. The intervention group will receive the transitional care bridge program, consisting of a handover moment with a community care Care Nurse (CN) during hospital admission and five home visits after discharge. The control group will receive 'care as usual' after discharge. The main outcome is the level of ADL functioning six months after discharge compared to premorbid functioning measured with the Katz ADL index. Secondary outcomes include; survival, cognitive functioning, quality of life, and health care utilization, satisfaction of the patient and primary care giver with the transitional care bridge program. All outcomes will be measured at three, six and twelve months after discharge. Approximately 674 patients will be enrolled to either the intervention or control group.DiscussionThe study will provide new knowledge on a combined intervention of integrated care during hospital admission, a proactive handover moment before discharge and intensive home visits after discharge.Trial registrationTrial registration number: NTR 2384

Delirium in the Netherlands

In the Netherlands, it is estimated that yearly between 40,000 and 160,000 patients develop delirium in the hospital. In a substantial part of the hospitals, a hospital-wide policy regarding prevention, treatment and care of patients with delirium is missing. However, in 2010, The Dutch Health Care Inspectorate launched new regulatory that requires that by 2012, every hospital has to have a delirium screening program and a hospital-wide protocol for delirium in patients of 70 years and older. Secondly, despite the fact that at this moment only around two-third of the hospitals are equipped with a geriatric team, there has to be 24 h availability of specialized personnel for the management of delirium. In this article, the management for an average patient with delirium is described based on the Dutch national guideline for delirium of 2005. We expect that the insufficiencies in delirium care found by the Inspectorate will not be solved in 2012, but hopefully this new policy will help doctors and hospitals with tools and new incentives to develop better standard care for patients with delirium in the future in the Netherlands.

Effectiveness of Short-Term Interdisciplinary Intervention on Postacute Patients in Taiwan

To evaluate the effectiveness of community hospital-based postacute care (PAC) for frail older patients and to provide a baseline profile of functional gain during PAC for use in further long-term outcome studies. Prospective cohort study. A community hospital in Taiwan. Elderly patients admitted to a community hospital with acute or postacute conditions. Barthel Index, Instrumental Activities of Daily Living, Mini-Mental State Examination, and Geriatric Depression Scale. A comprehensive geriatric assessment-based functional re-ablement program. Data were collected for 251 patients recruited between July 2006 and June 2008 from Taipei Veterans General Hospital and the acute wards of Yuanshan Veterans Hospital. Overall, clinical improvement was significant in various dimensions, including cognition (Mini-Mental State Examination from 11.9 ± 8.1 to 15.1 ± 8.3, P < .001), physical function (Barthel Index from 42.2 ± 34.1 to 64.9 ± 33.7, P < .001; Lawton-Brody Instrumental Activities of Daily Living from 1.8 ± 2.4 to 3.0 ± 2.8, P < .001), depression (Geriatric Depression Scale from 0.9 ± 1.9 to 0.6 ± 1.3, P < .001), ambulation (timed up-and-go test from 16.4 ± 19.6 to 10.1 ± 19.0, P < .001), and nutrition (Mini Nutritional Assessment from 15.0 ± 4.2 to 17.4 ± 3.7, P < .001). A short-term inpatient physical re-ablement program conducted by an interdisciplinary geriatric team in a community hospital can successfully improve the physical and mental function, mood, ambulation, and nutritional conditions of postacute patients. Further study is needed to evaluate long-term clinical outcomes of patients with different rates of functional recovery during treatment in a PAC unit.

Will We Better Manage Chronic Disease?

Will We Better Manage Chronic Disease?

The Impact of Disclosure of Unfitness to Drive in Persons with Newly Diagnosed Dementia: Patient and Caregiver Perspectives

Health professionals caring for those with dementia must frequently address fitness to drive, which is often the most difficult and emotional task in dementia care. This qualitative study explores the perspectives of patients with dementia who were told to cease driving and their caregivers. Most patients agreed with or resigned themselves to the geriatric team's recommendations regarding the need for driving cessation. Of those who did not, reactions included shock, anger, and denial. Almost all caregivers agreed with the recommendations to cease driving. Caregiver suggestions included: addressing the driving concern earlier, more detail about the tests, focusing on physical problems, providing a letter of explanation, and discussing alternative transportation. The study findings were used to develop a practical list of recommendations on how to address cessation to drive in patients with dementia.

Interdisciplinary Geriatric and Palliative Care Team Narratives: Collaboration Practices and Barriers

Despite the development and implementation of team training models in geriatrics and palliative care, little attention has been paid to the nature and process of teamwork. Geriatrics and palliative care in the clinical setting offer an interdisciplinary approach structured to meet the comprehensive needs of a patient and his or her family. Fellowship members of an interdisciplinary geriatric and palliative care team participated in semistructured interviews. Team members represented social work, chaplaincy, psychology, nursing, and medicine. A functional narrative analysis revealed four themes: voice of the lifeworld, caregiver teamwork, alone on a team, and storying disciplinary communication. The content-ordering function of narratives revealed a divergence in team members' conceptualization of teamwork and team effectiveness, and group ordering of narratives documented the collaborative nature of teams. The study findings demonstrate the potential for narratives as a pedagogical tool in team training, highlighting the benefits of reflective practice for improving teamwork and sustainability.

Closing the osteoporosis care gap – Increased osteoporosis awareness among geriatrics and rehabilitation teams

BackgroundA care gap exists between recommendations and practice regarding the diagnosis and treatment of osteoporosis in fracture patients. The current study was designed to determine rates and predictors of in-hospital diagnosis and treatment of osteoporosis in patients admitted with fragility hip fractures, and to assess differences in these rates since the outset of the multipronged "Fracture? Think Osteoporosis" (FTOP) Program, which includes education of geriatrics and rehabilitation teams.MethodsThis is a retrospective cohort study conducted with data from two Hamilton, Ontario, university-based tertiary-care hospitals, and represents a follow-up to a previous study conducted 8 years earlier. Data pertaining to all 354 patients, age >/= 50, admitted between March 2003 and April 2004, inclusive, with a diagnosis of fragility hip fracture were evaluated. Twelve patients were excluded leaving 342 patients for analysis, with 75% female, mean age 81.Outcomes included: Primary – In-hospital diagnosis of osteoporosis and/or initiation of anti-resorptive treatment ("new osteoporosis diagnosis/treatment"). Secondary – In-hospital mortality, BMD referrals, pre-admission osteoporosis diagnosis and treatment.ResultsAt admission, 27.8% of patients had a pre-existing diagnosis of osteoporosis and/or were taking anti-resorptive treatment. Among patients with no previous osteoporosis diagnosis/treatment: 35.7% received a new diagnosis of osteoporosis, 21% were initiated on anti-resorptive treatment, and 14.3% received a BMD referral. The greatest predictor of new osteoporosis diagnosis/treatment was transfer to a rehabilitation or geriatrics unit: 79.5% of rehabilitation/geriatrics versus 18.5% of patients receiving only orthopedics care met this outcome (p < 0.001).ConclusionNew diagnosis of osteoporosis among patients admitted with hip fracture has improved from 1.8% in the mid 1990's to 35.7%. Initiation of bisphosphonate therapy has likewise improved from 0% to 21%. Although multiple factors have likely contributed, the differential response between rehabilitation/geriatrics versus orthopedics patients suggests that education of the geriatric and rehabilitation teams, including one-on-one and group-based sessions, implemented as part of the FTOP Program, has played a role in this improvement. A significant care gap still exists for patients discharged directly from orthopedic units. The application of targeted inpatient and post-discharge initiatives, such as those that comprise the entire FTOP Program, may be of particular value in this setting.

“Pedogeriatrics”: a pediatric nephrologist’s outlook on common challenges facing pediatric and geriatric nephrologists

Dramatic demographic changes longevity and medical progress helped create a new population made up of the survivors of previously fatal diseases. These trends pose new major social and economic challenges that should be accounted for in health policy making. This paper discusses the similarities between the specialties of pediatrics and geriatrics, especially in the realm of patient care. Children and the elderly share a limited autonomy and dependence on the human environment (i.e., willing and able caregiving persons) due to age or disease. The long-term care of dependent patients (DP) requires caregiving persons who share with dependent persons the risk of losing autonomy, facing burnout, family disruption, and interference with work and educational activities. Families with DPs may face potential losses of income because both patients and caregivers are partially or completely unable to work, the former for medical reasons and the latter due to the new demands on their time and energy. Additionally, new expenses have to be met because while direct medical expenses might be covered by insurance or the State, other expenses have to be financed by the family, such as co-payments for medicines, new water or electricity home installations, and transport and eventual hotel costs if they have to stay overnight near a hospital outside of their town. The main objectives of long-term care should be to maximize patients' independence and prevent their physical and psychological deterioration while minimizing the social, economic and personal costs to caregivers. To achieve these goals, one needs a holistic approach, a multidisciplinary professional team (doctors, nurses, social workers, nutritionists and psychologists) and auxiliary staff (secretaries, electricians, administrators, messengers, cleaning staff, doormen, nursing aids and coordinators of medical appointments and medical procedures). Optimal management of DPs on chronic treatments such as chronic dialysis requires adequate communication skills, respectful attitudes toward patients and caregivers and effective use of communication and information technologies. Auxiliary personnel require specific training to contribute effectively to the DP attention processes. This paper postulates that pediatric and geriatric teams and their patients would benefit from closer training and sharing of experiences and systems.

On-Site Mental Health Services for PACE (Program of All-inclusive Care for the Elderly) Centers

On Lok Lifeways (On Lok), the original Program of All-inclusive Care for the Elderly (PACE), provides comprehensive health care for over a thousand community-dwelling frail seniors in San Francisco and Fremont, California. Prior to 2005, participants were referred to off-site contracted psychiatrists and psychologists for all mental health services. In 2005, On Lok introduced an on-site mental and behavioral health (MBH) team that included a psychologist, a bilingual psychiatric social worker, and a marriage and family therapist. Two part-time psychiatrists were added to the core team in 2006 and another full-time marriage and family therapist was added in 2008. We report our experience of implementing an on-site MBH program. In particular, we observed quadrupling of the number of appointments to mental health clinicians. There was a reduction in psychiatric inpatient utilization from 129.4 days/1000 patients in 2004 to 27.1 days/1000 patients in 2005. This reduction was sustained in 2006 and 2007 (41.2 and 23.6/1000 patients respectively). Inclusion of mental and behavioral health clinicians on geriatric interdisciplinary teams at On Lok appeared to improve the quality of care we provided by increasing timely access to mental health services, reduced the rate of psychiatric inpatient admissions, and reduced reported anxiety and stress of On Lok interdisciplinary teams caring for elders with mental health diagnoses.

Impact of a geriatric nursing home palliative care service on unnecessary medication prescribing

Background: There is a lack of studies concerning improvement of medication use in palliative care patients in nursing homes. Objective: This study was conducted to evaluate whether a geriatric palliative care team reduced unnecessary medication prescribing for elderly veterans residing in a nursing home. Methods: This was a retrospective, descriptive study of patients who died while residing in a geriatric palliative care unit between August 1, 2005, and July 31, 2007. Prescribed medications were evaluated using the Unnecessary Drug Use Measure, which contains 3 items from the Medication Appropriateness Index concerning lack of indication, lack of effectiveness, and therapeutic duplication. This measure was applied at 2 time points: on transfer/admission to the palliative care unit and at the last 30-day pharmacist medication review before death. Paired t tests and McNemar tests were used to compare medication use at these 2 points. Results: Eighty-nine patients were included in the study. The majority were male (97.8%) and white (78.7%), with a mean (SD) age of 79.7 (7.8) years. The median length of stay on the unit was 39.0 days, and the mean number of chronic medical conditions was 8.4 (4.3). At baseline, the mean number of scheduled medications was 9.7 (4.3). The number of unnecessary medications per patient decreased from a mean of 1.7 (1.5) at admission to 0.6 (0.8) at closeout ( P = 0.003). The decrease was seen in all 3 categories of the Unnecessary Drug Use Measure. Conclusions: The geriatric palliative care team was associated with a reduction in the number of unnecessary medications prescribed for older veterans in this nursing home. Future studies should evaluate the impact of decreasing unnecessary prescribing on clinical outcomes such as adverse drug reactions.

Letters

Letters

Treating Older Persons with Severe Mental Illness in the Community: Impact of an Interdisciplinary Geriatric Mental Health Team

Little information is available concerning community-based interventions to treat the growing number older persons with severe mental illness. This study examined treatment efficacy of a specialized interdisciplinary geriatric mental health team (mental health geriatric interdisciplinary teams or MHGITs) for 69 older clients with severe mental disorders. Depression, life satisfaction, health, and psychiatric and medical hospitalization data were gathered. A decrease in depressive symptoms and in psychiatric hospitalizations, and an increase in life satisfaction at 6 months were found. No change in health nor medical hospitalizations were reported. This study provides preliminary support for the feasibility and efficacy of a MGHIT approach in treating older community-dwelling adults with severe mental illnesses. Implications for social workers are discussed.