Geriatric Team Research Articles

Besonderheiten der physikalischen Therapie beim älteren Rheumatiker

The demographic shift is leading to a rapid rise in the number of elderly citizens. Accordingly, the number of geriatric problems is also increasing within the population of rheumatic patients. Geriatric patients are characterized through the triad of high age, multimorbidity and functional deficits. Almost all will show signs of arthritis and other degenerative musculoskeletal illnesses. Inflammatory rheumatic diseases within the geriatric population are found to be mostly in the chronic stage or with defective conditions. Problems typical of this population, such as comorbidities especially in the cardiovascular sector, must be assessed prior to the application of therapeutic concepts. The focus is on activating therapies, such as physiotherapy and occupational therapy, where the functional usefulness is proven. The use of thermal therapy, especially applied in the form of heat, as well as electrotherapy and high frequency therapy are also useful when indicated. Balneotherapy and hydrotherapy, as well as massage therapy and lymphatic drainage, must be adapted to the cardiovascular function of geriatric patients; this applies especially to heart failure patients. Physical therapy concepts in elderly rheumatic patients should preferably be implemented and managed by a multidisciplinary geriatric team.

Comparison of Complications and Length of Hospital Stay Between Orthopedic and Orthogeriatric Treatment in Elderly Patients With a Hip Fracture

Hip fractures in the elderly individuals are a complex problem. Our objective was to determine whether orthogeriatric treatment is effective in terms ofreducing length of hospital stay, morbidity, and mortalityof elderly patients witha hip fracture compared with orthopedic (traditional) treatment. FromJuly 2009 to May 2011, patients older than 65 years with a hip fracture were followedprospectively. They were co-treated by geriatricand orthopedic teams.This cohortwas compared witha retrospective cohortfollowed from January 2007to June 2009that was managed by the orthopedic surgery team only.Epidemiology,pre- and postoperative hematocrit,and renal function were registered. Also, in-hospital and distant mortality data(determined byconsulting thenational registry),mortality-associated factors, postoperative complications, hospital staylength, and transfers to other services were registered. One hundred and eighty-three patients inthe retrospective groupand 92 inthe prospective groupwere included in this study with amedian follow-up of26 months (interquartile range: 13-41).The averageage was84 years and 74% of patients were female. Intertrochantericfractureaccounted for 51%of the cases.There was no differencebetween groups with regard tohospital stay length, hematocritat discharge, in-hospital mortality, long-term survival, ortransfers to internalmedicineor the intensive care unit.It did showdifferences inthe transferto the intermediate care unit,prolonged hospitalizations (>20 days), and diagnosisofdelirium and anemia requiring transfusion. In the present study, orthogeriatric treatment is slightly more effective than traditional treatment in terms of morbidity, but there is no difference in hospital stay lengthor mortality. Further studies and longer follow-up are needed to draw more conclusions.

Adverse Drug Reactions in Older People

Adverse drug reactions (ADRs) in older adults are an important healthcare problem since they are frequently a cause of hospitalization, occur commonly during admission, and are an important cause of morbidity and mortality. Older adults are particularly susceptible to ADRs because they are usually on multiple drug regimens and because age is associated with changes in pharmacokinetics and pharmacodynamics. The presentation of an ADR in older adults is often atypical, which further complicates its recognition. One potential strategy for improving recognition of ADRs is to identify those patients who are at risk of an ADR. The recently developed GerontoNet ADR Risk Score is a practical tool for identification of older patients who are at increased risk for an ADR and who may represent a target for interventions aimed at reducing ADRs. Provision of adequate education in the domain of clinical geriatric pharmacology can improve recognition of ADRs. Besides formal surveillance systems, built-in computer programs with electronic prescribing databases and clinical pharmacist involvement in patient care within multidisciplinary geriatric teams might help to minimize the occurrence of ADRs. In addition, a number of actions can be taken in hospitals to stimulate appropriate prescribing and to assure adequate communication between primary and hospital care. In older adults with complex medical problems and needs, a global evaluation obtained through a comprehensive geriatric assessment may be helpful in simplifying drug prescription and prioritizing pharmacological and healthcare needs, resulting in an improvement in quality of prescribing.

Preventing Delirium in Older Adults with Recent Hip Fracture Through Multidisciplinary Geriatric Consultation

To evaluate the effect of inpatient geriatric consultation teams (IGCTs), which have been introduced to improve the quality of care of older persons hospitalized on nongeriatric wards, on delirium and overall cognitive functioning in older adults with hip fracture. Controlled trial. Two trauma wards in a university hospital setting. One-hundred seventy-one people with hip fracture aged 65 and older assigned to a multidisciplinary geriatric intervention (n = 94) or usual care (n = 77). Incidence and duration of delirium were measured using the Confusion Assessment Method, severity of delirium using the Delirium Index, and cognitive status using the 12-item Mini-Mental State Examination. Significantly more controls (53.2%; n = 41) than intervention group participants (37.2%; n = 35; P = .04; odds ratio (OR) = 1.92, 95% confidence interval (CI) = 1.04-3.54) were delirious at any point after surgery. No significant difference was found between the groups for duration or severity of delirium episodes. The proportion of participants with cognitive decline at discharge was higher in controls than in those assigned to geriatric intervention (38.7% vs 22.6%; P = .02; OR = 2.16, 95% CI = 1.10-4.24). Delirium episodes and cognitive decline during hospitalization were found to be common in older adults with hip fracture, as expected, but an IGCT intervention reduced the incidence of these adverse outcomes. In participants who developed delirium, a geriatric consultation had no effect on severity or duration of the delirium episode.

Prediction of risk of in-hospital geriatric complications in older patients with hip fracture

Hip fracture in older persons is a frequent reason for hospital admission and a substantial workload in orthopedic wards for geriatric liaison teams. However, robust patients who do not present in-hospital complications may not need geriatric liaison. For the sake of triage, we studied the ability of usual admission scores to identify patients who will not develop in-hospital complications, and who may therefore not be included in the overworked geriatric liaison teams. A retrospective cohort of consecutive community- living elderly patients (age ≥ 75 yrs), admitted for traumatic hip fracture in the orthopedic divisions of a teaching hospital over 18 months was examined. The predictive value of commonly used frailty scores (ISAR, VIP, KATZ) to rule out the incidence of three frequent and preventable in-hospital acute geriatric events (major behavioral problems, pressure sores, falls) was assessed by ROC curves and negative likelihood ratio (-LR). Of 145 older persons with hip fracture (median age 84 years; 76% women; 57% living alone, 44% with pre-existing geriatric syndromes), 81 (56%) presented some acute geriatric events (AGE), i.e. major behavioral problems (46%), pressure sores (19%) and/or falls (5%). The three frailty admission scores showed low power for AGE prediction (area under the ROC curve: 53- 58%) and identification of patients who will not present in-hospital AGE (-LR>0.5 at the most sensitive cut-off). None of the three scores helped in the triage of patients according to their risk of future in-hospital AGE. All older patients with hip fracture, irrespective of their admission frailty-robustness profile, should receive geriatric evaluation and intervention.

Surgical referrals from nursing homes; More evidence for a geriatric medicine liaison service

s / International Journal of Surgery 10 (2012) S53–S109 S90 ABSTRACTS 0962: SURGICAL REFERRALS FROM NURSING HOMES; MORE EVIDENCE FOR A GERIATRIC MEDICINE LIAISON SERVICE Daniel Burchette, Gagandeep Grover, Michael Booth, Margot Gosney. Royal Berkshire NHS Foundation Trust, Berkshire, UK Aims: To assess outcomes of inpatient stay in patients referred to acute surgical unit from residential homes, comparing with non-institutionalised patients with similar presenting complaints. Methods: 40 patients admitted from homes over six months were matched with following emergency surgical admission living independently aged >70. Data gathered via ‘take’ lists and discharge summaries. Results: Dementia was more prevalent in the residential care (45 vs. 28%), who also had more co-morbidities (4.4 vs. 2.6). Presenting complaints between groups were similar, abdominal pain and haematemesis being leading causes. Larger proportion of community residents underwent surgery during admission (28 vs. 5%) whilst greater proportion of residential care died during admission (15 vs. 2.5%). Residential care patients had a slightly longer average duration of stay in this study (5.5 vs 4.2 days). Conclusions: Whilst presenting with similar complaints, residential care patientsare lessoftensurgical candidates; fewerundergosurgeryanda larger proportion die during admission. This supports value of geriatric liaison, particularly discharge planning, including in those patients palliative needs, aswell asmedical optimisationof co-morbiditieswhensurgery is considered. Presented to the surgical and elderly care department: a new admission pathway for this group of patients was proposed to the trust, suggesting refferal via the geriatric team. 1045: OUTCOMES FOLLOWING EMERGENCY GENERAL SURGERY IN NONAGENARIANS Tim Sparkes, Gregory Jones, Charles Evans. Buckinghamshire Healthcare NHS Trust, Stoke Mandeville, UK Aim: In 2010 NCEPOD highlighted concerns over outcomes of elderly patients undergoing emergency surgery. This study aimed to investigate outcomes in nonagenarians undergoing emergency surgery and identify predictive risk factors for mortality and the impact on care requirements. Method: All nonagenarian patients who underwent emergency general surgery operations between June 2005 and June 2010 within one NHS Trust were retrospectively reviewed. Risk factors analysed included age, sex, ASA grade, clinical parameters, preoperative blood tests (including Creactive protein (CRP)), preoperative care dependence, operation factors and surgeon factors. Kaplan-Meier survival analysis was performed using one year mortality rates. Results: Forty six patients (30 female) underwent surgery with an inpatient mortalityof32.6%andoneyearmortalityof54.3%.Patientsundergoingmajor index surgery, a CRP> 100 or who required any form of preoperative social care had significantly reduced survival (P1⁄4 0.013, P 100, requirement for social care preoperatively and major index surgery. 1096: LAPAROSCOPIC APPENDICECTOMY – A NEGATIVE IMPACT ON EMERGENCY OPERATING? Elisabeth Royston, Catherine Bradshaw, Peter Budny, Shaun Appleton. Stoke Mandeville Hospital, Aylesbury, UK Background: Acute appendicitis is commonly managed with laparoscopic appendicectomy. However, there is a perception that it takes longer than an open operation and may, therefore, impact on the efficiency of emergency operating lists. The purpose of this study was to 1) evaluate the increase in laparoscopic appendicectomies over a five year period; 2) assess whether operating times are increased and 3) identify how this effects the provision of emergency operating lists. Methods: Data was collected retrospectively for all appendicectomies performed in a single NHS trust from 2006 to 2011 and analysed over three time periods. Results: The total number of appendicectomies performed annually ranged from 336 to 399. The percentage performed laparoscopically has progressively increased from 9% in 2006 to 56% in 2011. The average time taken to perform a laparoscopic appendicectomywas eight minutes longer than for an open procedure (p<0.001). The average duration of laparoscopic appendicectomy has not changed since 2006. Conclusion: Although laparoscopic appendicectomies took consistently more time than open appendicectomies, the average difference was only eight minutes. Given the average number of appendicectomies performed per day is one, it is unlikely this increased operating time will negatively impact on the provision of emergency surgery. 1129: IS THE USE OF LAPAROSCOPY LEADING TO A RISE IN THE NEGATIVE APPENDICECTOMY? AmyWhiteford, Carole Neff, James Mansell. Hairmyres Hospital, Hairmyres,

Impact of Interprofessional Education on Collaboration Attitudes, Skills, and Behavior Among Primary Care Professionals

Care for the frail elderly is often provided by several professionals. Collaboration between them is essential, but remains difficult to achieve. Interprofessional education (IPE) can improve this collaboration. We developed a 9-hour IPE program for primary care professionals from 7 disciplines caring for the frail elderly, and aimed to establish whether the program improved professionals' interprofessional attitudes and attitudes toward collaboration, collaboration skills, and collaborative behavior. We also evaluated learners' reactions to the program. Before-after study, using the Interprofessional Attitudes Questionnaire (IAQ, score:1 to 7); Attitudes Toward Health Care Teams Scale (ATHCTS, score: 0 to 105); and Team Skills Scale (TSS, score:17 to 85). Additionally, semistructured interviews were conducted with 10 selected participants. Participants' (N = 80) overall interprofessional attitudes improved (IAQ baseline: 5.49; follow-up: 5.67, p = 0.001); attitudes toward geriatric teams did not change (ATHCTS baseline: 69.9; follow-up: 69.1, p = 0.32). Participants' self-reported team skills improved (TSS baseline: 45.7; follow-up: 48.1, p = 0.001). In the interviews, many interviewees reported increased collaboration with professionals of other disciplines due to the program. Interviewees considered the program's interprofessional nature and attending the program with local professionals important contributing factors to the experienced improvements in collaboration. However, they also noted that not all parts of the program had met the needs of all participating disciplines, due to differences in professional background and knowledge. A brief IPE program can improve interprofessional attitudes, collaboration skills, and collaborative behavior. That such a program allows professionals to get acquainted with each other and each other's viewpoints appears to be as important as the educational content.

Effectiveness of a Geriatrics and Palliative Care Consultation on Symptom Management and Geriatric Syndromes

With the increase in geriatric patientsand the wide spectrum of their illnesses, geriatricians and palliative care physicians would benefit from combining their expertise in treating chronically and terminally ill elder patients in a hospital setting. The objective of our pilot study was to determine if a Geriatric Palliative Care consult could improve pain management and prevent geriatric syndromes in elder patients. Our data was collected from a retrospective chart review of subjects older than 65 years-old who received combined Geriatrics and Palliative Care consult from a combined Geriatrics Palliative Care team. Previously validated instruments identified pain score and level of comorbidity. A total of 60 charts were reviewed. Results showed a Geriatric Palliative Care consultation lowered pain score from pre-consult to post-consult (2.63 vs. 1.17; p=0.012) and effectively improved pain in 20% of subjects (41.7% vs. 21.7%; p=0.002). The Geriatric Palliative Care consult team effectively lowered the in-hospital complication of restraints (11.7% vs. 3.3%; p=0.025) and also had a positive effect on delirium and advance directives (p=0.5). In conclusion, Geriatric Palliative Care consults have shown to improve the quality of care for older adults by effectively managing pain symptoms and improving pain scores among 20% of the subjects.

Implementation of inpatient geriatric consultation teams and geriatric resource nurses in acute hospitals: A national survey study

BackgroundInpatient geriatric consultation teams are multidisciplinary teams that advice and sensitize health care professionals in the hospital for the care of older patients. Despite the lack of clear evidence that these teams are effective, they were rated highly relevant and introduced in Belgian hospitals in 2007. ObjectivesTo evaluate the implementation and performance of geriatric consultation teams and geriatric resource nurses (GRNs) in Belgium. DesignA cross-sectional survey was performed in March and April 2010. SettingAcute hospitals. ParticipantsSixty-six hospitals completed the questionnaire (response rate of 68.8%); 63 geriatric consultation teams were included. MethodsA newly developed questionnaire was sent to all hospitals. The head of the geriatric department completed the general parts of the questionnaire. The other parts, covering the organization of the consultation teams and geriatric resource nurses, respectively, were completed by the geriatrician or the head nurse of the geriatric consultation team. All data were analysed in a descriptive manner. ResultsThe mean number of full time equivalents (FTE) per consultation team was 4.3 (SD±1.3; range 1.9–10.1). The nurse, represented by a mean of 1.7 FTE (SD±0.8), was a core member in almost all teams (n=60; 98.4%). The occupational therapist, geriatrician, dietician, psychologist and speech therapist were core members in more than 59% of the teams. Twenty-seven teams (42.9%) estimated that more than 75% of the patients (≥75 years) were screened for having a geriatric profile. This screening was mostly performed using the Triage Risk Screening Tool (n=23) or the Identification of Seniors At Risk (n=20). A positive screening automatically resulted in a request for a geriatric consultation team intervention in 45 teams (71.4%). Thirty-five teams (55.5%) had an advisory role only, while the other 28 teams (44.5%) had both advisory and executive roles. The median number of patients for whom recommendations were formulated per year, was 423 (Q1=230; Q3=633). Most participants rated the function of GRNs as ‘poor’ or ‘bad’. ConclusionTo increase their impact, inpatient geriatric consultation teams focus on frail older persons using screening tools for detection of high-risk patients. More intense collaboration with GRNs is essential, and the function of GRNs needs further improvement.

Substance Abuse in Older Adults: Policy Issues

By 2020, it is projected that the number of older adults needing treatment for drug and alcohol addictions will increase dramatically. Although Medicare covers treatment for mental health issues, copayments can be prohibitive for those with lower incomes. The Positive Aging Act, an amendment to the Public Health Service Act, is a policy alternative that could address substance abuse in the older adult population by (a) demonstrating ways of integrating mental health services for older adults into primary care settings, and (b) supporting the establishment and maintenance of interdisciplinary geriatric mental health outreach teams in community settings where older adults reside or receive social services. Increasing funding to states to emphasize primary care provider education on the detection, evaluation, and treatment of substance abuse problems of older adults has the potential to better meet the substance abuse needs of this population. Educating primary care providers, including gerontological nurses, to recognize signs of substance abuse in this population and providing age-appropriate treatment options is critically important but will require funding beyond what is currently available.

Transitions Model: Melding of Psychotherapy and Palliative Care Using Teams

This article explains a hospital palliative model called the Transitions and Palliative Care Therapy (TPCT) and provides data. In addition, the Geriatric Interdisciplinary Team Treatment (GITT) program, using its experience with hospice and research based knowledge, applied key principles of teamwork to enhance the TPCT team approach. GITT was applied to TPCT for 1 year. The TPCT model is a transitions counselors–based model that is a hospital-centered, interdisciplinary consult service, with a focus on the patient and the family. It employs master's level counselors and mid-level providers, with a much smaller group of palliative care physicians who supervise mid-level practitioners and provide medical input and leadership. Outcomes evaluated were hospital cost, family and staff satisfaction, and number of consults that led to de-escalating treatment. In all cases the GITT model was effective; it assisted with improved cost, better satisfaction, and an increased number of consults.

Reducing "iatrogenic disability" in the hospitalized frail elderly.

Hospitalization is the first cause of functional decline in the elderly: 30 to 60% of elderly patients lose some independence in basic activities of daily living (ADL) during a stay in hospital. This loss of independence results from the acute condition that led to admission, but is also related to the mode of management. This paper is a review of the literature on functional decline in elderly hospitalized patients. It is the first stage in a project aiming to prevent dependence that is induced during the course of care. During a 2-day workshop in Monaco, a task force of 20 international experts discussed and defined the concept of "iatrogenic disability". 1- "Iatrogenic disability" was defined by the task force as the avoidable dependence which often occurs during the course of care. It involves three components that interact and have a cumulative effect: a) the patient's pre-existing frailty, b) the severity of the disorder that led to the patient's admission, and lastly c) the hospital structure and the process of care. 2- The prevention of "iatrogenic disability" involves successive stages. - becoming aware that hospitalization may induce dependence. Epidemiological studies have identified at-risk populations by the use of composite scores (HARP, ISAR, SHERPA, COMPRI, etc). - considering that functional decline is not a fatality. Quality references have already been defined. Interventions to prevent dependence in targeted populations have been set up: simple geriatric consultation teams, single-factor interventions (aimed for example at mobility, delirium, iatrogenic disorders) or multidomain interventions (such as GEM and ACE units, HELP, Fast Track, NICHE). These interventions are essentially centered on the patient's frailty and have limited results, as they take little account of the way the institution functions, which is not aimed at prevention of functional decline. The process of care reveals shortcomings: lack of geriatric knowledge, inadequate evaluation and management of functional status. The group suggests that interventions must not only identify at-risk patients so that they may benefit from specialized management, but they must also target the hospital structure and the process of care. This requires a graded "quality approach" and rethinking of the organization of the hospital around the elderly person.

Geriatric day hospital: what evidence? A systematic review

A systematic review of the international literature concerning the organisation of the Geriatric Day Hospital (GDH) was performed. From 1987 till now, few papers were found describing the activity and the effectiveness of the GDH. All the studies comparing specific geriatric approaches to regular medicine demonstrate the efficiency of geriatric care, particularly the geriatric assessment. So, with a degree of evidence 1a, a better outcome is found for patients undergoing a geriatric assessment and intervention, compared to patients having no geriatric assessment at all. However, there is no evidence of benefit for the geriatric day hospital compared to patients treated in a geriatric ward or other location of geriatric care. Moreover, there is no clear consensus on the settings and activities of a geriatric day hospital. Terms as day unit, day hospital, day care, are used interchangeably and are not always covering the same activity. The same remark can be made on the exact composition of the geriatric multidisciplinary team and its role. However nurses and paramedical workers are always mentioned as all performing geriatric assessment. The diagnostic activities on the GDH are seldom described and studied. More information is available on rehabilitation activity, often developed in specific patient populations such as stroke patients, dementia patients, cardiac patients or patients with other chronic diseases. In this selected patient populations positive effects on outcome are shown in the GDH (level of evidence 1a). Another problem is the heterogeneity of the population. For scientific reason the GDH should focus on organising care for specific medical problems. Diseases as dementia, stroke, cardiac insufficiency, could be good models to investigate the efficiency of geriatric assessment and interventions within the setting of a GDH.

Determination of geriatric patients’ drug profile and identify their pharmaceutical care requirements by determining potential risk factors

Purpose The aim of this study is to evaluate the geriatric drug usage, assess the appropriateness of their drug treatment and identify their pharmaceutical care requirements. Patients and methods The demographic, clinical and drug data of the patients was obtained. Patients’ knowledge about their drugs was also assessed. The patients at risk of drug induced problems were defined and a risk map was determined. Patients, who were 65-years-old and over and live in a nursing home in the Anatolian part of Istanbul, were included in our study. Results Polypharmacy was identified in 44% of those included in the study (total of 146 patients who take drug therapy). Eighty of the patients (54.8%) did not know reason they were taking drugs. Eighty-eight of the patients (60.3%) were not aware how or when they should take drugs. Although, 24 patients (16.4%) were using their drugs by self-administration, the drugs of 122 patients (83.6%) were administered by their nurse; 24.65% of patients were in a high-risk category. The mean of number of drug used by patients was 5.89 ± 3.61. Discussion and conclusions According to our results, patients have lack of knowledge about drug usage and they have rarely been informed about rationale drug usage. First, it is necessary to determine geriatric patients’ pharmaceutical care needs in order to prevent and solve their drug-related problems. Pharmacists will contribute to the development and spread of patient oriented pharmacy services by working in specialist geriatric teams with physicians, nurses and other health professionals.

A Geriatric Multidisciplinary and Tailor-Made Hospital-At-Home Method in Nursing Home Residents With Hip Fracture

Nursing home residents represent a large proportion of patients hospitalized with hip fracture. Generally, residents do not achieve the same physical ability level as before their fracture and have an increased risk of death within few days after discharge. This study aims to compare 2 new approaches to geriatric intervention in residents with hip fracture. In nursing home residents aged 65 or older with hip fracture, 85 received a newly developed standardized rehabilitation intervention undertaken by the geriatric orthopedic team (GO team) from December 1, 2006 to November 30, 2007. This standardized method was compared with a further developed tailor-made intervention method performed by the GO team in 153 residents from February 1, 2008 to January 31, 2010. Both the interventions began at hospital admission and until 30 days after surgery. Outcomes were length of hospital stay (LOS), difference in physical ability, 90-day acute readmission, 30-day mortality, and 90-day mortality. The tailor-made intervention method reduced the readmission rate (14% vs 26%) compared with the standardized intervention method (odds ratio [OR] = 0.47 [95% confidence interval [CI]: 0.23, 0.94]). Tailor-made intervention reduced 30-day mortality (8% vs 19%) compared with standardized intervention (OR = 0.42 [95% CI: 0.18, 0.97]). Improving 90-day survival could not be demonstrated (81% vs 73%; OR = 0.72 [95% CI: 0.37, 1.40]). Median LOS was 2 days in both the groups. A total of 7 follow-up visits were performed with tailor-made intervention versus 3 visits with standardized intervention. In both the groups, the physical ability decreased significantly within the first 30 postoperative days, with no difference between groups (β = 1.01 [95% CI: 0.82, 1.24]). A multidisciplinary and tailor-made geriatric intervention in nursing home residents has a positive effect on readmission rate and short-term mortality. Still, it is not obvious which part of the tailor-made intervention is most crucial.

Effect of an Inpatient Geriatric Consultation Team on Functional Outcome, Mortality, Institutionalization, and Readmission Rate in Older Adults with Hip Fracture: A Controlled Trial

To evaluate the effect of an inpatient geriatric consultation team (IGCT) on end points of interest in people with hip fracture: length of stay, functional status, mortality, new nursing home admission, and hospital readmission. Controlled trial based on assignment by convenience. Trauma ward in a university hospital. One hundred seventy-one people with hip fracture aged 65 and older. Participants were assigned to a multidisciplinary geriatric intervention (n=94) or usual care (n=77) during hospitalization after hip fracture. End points were functional status, length of stay, mortality, new nursing home admission, and hospital readmission 6 weeks, 4 months, and 12 months after surgery. Mean length of stay was 11.1 ± 5.1 days in the intervention group and 12.4 ± 8.5 days in the control groups (P=.24). Complete adherence to IGCT recommendations was 56.8%. A significant benefit of intervention on functional status in univariate analyses (P=.02) 8 days after surgery disappeared in a linear mixed model. Participants with dementia had better functional status in a linear mixed model than those without (P=.03), but this effect was no longer significant after Bonferroni correction for multiple testing. After 6 weeks, 4 months, and 12 months, no between-group differences could be documented for mortality, new nursing home admission, or readmission rate. This trial could not document functional benefits of an IGCT intervention in people with hip fracture. More research is needed to investigate whether a more-intensive approach with more-direct control over patient management, more-specific recommendations, and more-intense education would be effective.

Sensors vs. experts - A performance comparison of sensor-based fall risk assessment vs. conventional assessment in a sample of geriatric patients

BackgroundFall events contribute significantly to mortality, morbidity and costs in our ageing population. In order to identify persons at risk and to target preventive measures, many scores and assessment tools have been developed. These often require expertise and are costly to implement. Recent research investigates the use of wearable inertial sensors to provide objective data on motion features which can be used to assess individual fall risk automatically. So far it is unknown how well this new method performs in comparison with conventional fall risk assessment tools. The aim of our research is to compare the predictive performance of our new sensor-based method with conventional and established methods, based on prospective data.MethodsIn a first study phase, 119 inpatients of a geriatric clinic took part in motion measurements using a wireless triaxial accelerometer during a Timed Up&Go (TUG) test and a 20 m walk. Furthermore, the St. Thomas Risk Assessment Tool in Falling Elderly Inpatients (STRATIFY) was performed, and the multidisciplinary geriatric care team estimated the patients' fall risk. In a second follow-up phase of the study, 46 of the participants were interviewed after one year, including a fall and activity assessment. The predictive performances of the TUG, the STRATIFY and team scores are compared. Furthermore, two automatically induced logistic regression models based on conventional clinical and assessment data (CONV) as well as sensor data (SENSOR) are matched.ResultsAmong the risk assessment scores, the geriatric team score (sensitivity 56%, specificity 80%) outperforms STRATIFY and TUG. The induced logistic regression models CONV and SENSOR achieve similar performance values (sensitivity 68%/58%, specificity 74%/78%, AUC 0.74/0.72, +LR 2.64/2.61). Both models are able to identify more persons at risk than the simple scores.ConclusionsSensor-based objective measurements of motion parameters in geriatric patients can be used to assess individual fall risk, and our prediction model's performance matches that of a model based on conventional clinical and assessment data. Sensor-based measurements using a small wearable device may contribute significant information to conventional methods and are feasible in an unsupervised setting. More prospective research is needed to assess the cost-benefit relation of our approach.

Interdisciplinary Geriatric and Psychiatric Care Reduces Potentially Inappropriate Prescribing in the Hospital: Interventional Study in 150 Acutely Ill Elderly Patients with Mental and Somatic Comorbid Conditions

Potentially inappropriate medications and prescription omissions (PO) are highly prevalent in older patients with mental comorbidities. To evaluate the effect of interdisciplinary geriatric and psychiatric care on the appropriateness of prescribing. Prospective and interventional study. Medical-psychiatric unit in an academic geriatric department. Participants were 150 consecutive acutely ill patients aged on average 80.0 ± 8.1 years suffering from mental comorbidities and hospitalized for any acute somatic condition. From admission to discharge, daily collaboration provided by senior geriatrician and psychiatrist working in a usual geriatric interdisciplinary care team. Potentially inappropriate medications and PO were detected and recorded by a trained independent investigator using STOPP/START criteria at admission and discharge. Compared with admission, the intervention reduced the total number of medications prescribed at discharge from 1347 to 790 (P < .0001) and incidence rates for potentially inappropriate medications and PO reduced from 77% to 19% (P < .0001) and from 65% to 11% (P < .0001), respectively. Independent predictive factors for PIP at discharge were being a faller (odds ratio [OR] 1.85; 95% confidence interval [CI] 1.43-2.09) and for PO, the increased number of medications (OR 1.54; 95% CI 1.13-1.89) and a Charlson comorbidity index greater than 2 (OR 1.85; 95% CI 1.38 - 2.13). Dementia and/or presence of psychiatric comorbidities were predictive factors for both potentially inappropriate medications and PO at discharge. These findings hold substantial promise for the prevention of IP and OP in such a comorbid and polymedicated population. Further evaluations are, however, still needed to determine if such an intervention reduces potentially inappropriate prescribing medication-related outcomes, such as incidence of adverse drug events, rehospitalization, or mortality.

Impact of a multifaceted program to prevent postoperative delirium in the elderly: the CONFUCIUS stepped wedge protocol

BackgroundPostoperative delirium is common in the elderly and is associated with a significant increase in mortality, complications, length of hospital stay and admission in long care facility. Although several interventions have proved their effectiveness to prevent it, the Cochrane advises an assessment of multifaceted intervention using rigorous methodology based on randomized study design. Our purpose is to present the methodology and expected results of the CONFUCIUS trial, which aims to measure the impact of a multifaceted program on the prevention of postoperative delirium in elderly.Method/DesignStudy design is a stepped wedge cluster randomized trial within 3 surgical wards of three French university hospitals. All patients aged 75 and older, and admitted for scheduled surgery will be included. The multifaceted program will be conducted by mobile geriatric team, including geriatric preoperative consultation, training of the surgical staff and implementation of the Hospital Elder Life Program, and morbidity and mortality conference related to delirium cases. The primary outcome is based on postoperative delirium rate within 7 days after surgery. This program is planned to be implemented along four successive time periods within all the surgical wards. Each one will be affected successively to the control arm and to the intervention arm of the trial and the order of program introduction within each surgical ward will be randomly assigned. Based on a 20% reduction of postoperative delirium rate (ICC = 0.25, α = 0.05, β = 0.1), three hundred sixty patients will be included i.e. thirty patients per service and per time period. Endpoints comparison between intervention and control arms of the trial will be performed by considering the cluster and time effects.DiscussionBetter prevention of delirium is expected from the multifaceted program, including a decrease of postoperative delirium, and its consequences (mortality, morbidity, postoperative complications and length of hospital stay) among elderly patients. This study should allow better diagnosis of delirium and strengthen the collaboration between surgical and mobile geriatric teams. Should the program have a substantial impact on the prevention of postoperative delirium in elderly, it could be extended to other facilities.Trial registrationClinicalTrials.gov: NCT01316965

The terminal phase of life as a team-based clinical global judgment

In most elderly people, the final-terminal-phase of life is characterized by permanent dependency and a complete inability to perform activities of daily living. Treatment targets usually switch from rehabilitation to palliation. However, the prevalence of the clinical judgment "last phase of life" and its association with in-hospital death is unknown in geriatric patients. We retrospectively analyzed GEMIDAS data from two geriatric units. Patients without cancer and an in-hospital stay of at least 1 week were included in our study. Prevalence of the terminal phase of life was clinically assessed according to the proposals made by M. Gillick. This clinical judgment was pronounced by the geriatric team after a stay in the hospital of at least 1 week. The clinical judgment took into account all available assessment parameters, as well as the impact of a geriatric treatment trial. In addition, the association between the clinical judgment and the risk of in-hospital mortality was analyzed. Records from 2,433 (56%) patients in hospital A and from 1,912 (44%) patients in hospital B were analyzed. The frequency of a terminal phase of life was 30% and 9% (p<0.01), respectively. The frequency depended on the manner of admission to the hospital. In both hospitals, mortality was significantly higher in terminal patients (27% and 37%) than in other patients (0-8% and 0-6%). In both hospitals, the risk of in-hospital mortality was significantly associated with the clinical judgment (OR 3.1 and 2.7), heart failure (OR 2.2 and 2.1), and dementia (OR 2.0 and 1.8). Age, residency in a nursing home, and the Barthel Index on admission were all without relevant impact. The frequency of the clinical construct "terminal phase of life" varies in geriatric units between 9% and 30%. This clinical construct is significantly associated with increased in-hospital mortality. Therefore, this construct possesses external validity. Further studies are needed in order to assess the significance of such a clinical judgment, the associations with clinical burdens of symptoms, and the supply structure required to cover the needs of patients and their families.