High Risk Of Functional Decline Research Articles

Validity and reliability of a questionnaire for screening older people for comprehensive geriatric assessment

Objectives: To assess the validity of a simple questionnaire to identify outpatient elderly persons at high risk of functional decline and who are likely to benefit from a comprehensive geriatric assessment.Methods: A comparison was made between results of a 23-item screening questionnaire based on activities of daily living and data from an overall clinical geriatric evaluation (standard criterion). A total of 300 people aged 65 years or older attending three general practices were screened for functional status in office settings. Patients completed the 23-item questionnaire and underwent a geriatric evaluation by a family physician who was unaware of the results of the screening instrument. A stepwise logistic regression analysis showed that six items were independent predictors of functional disability. The discriminant ability of the questionnaire scores for the diagnosis of functional disability was evaluated using the receiver operating characteristics (ROC) curves. Interobserver reliability of the questionnaire was also assessed.Results: When used as an exclusion test, the 23 items of the questionnaire showed a sensitivity of 88% and a specificity of 40%, with 50% sensitivity and 89% specificity when used as a confirmation test. The six-item questionnaire had 81% sensitivity and 56% specificity as an exclusion test and 58% sensitivity and 89% specificity as a confirmation test. The use of the five-item plus age questionnaire provided similar results. Test-retest reliability for the different cut-off points varied between 0.55 and 0.76.Conclusions: This six-item instrument showed an acceptable validity index to facilitate the implementation of geriatric evaluation and management programmes in primary healthcare centres.

Methodologic issues in conducting research on hospitalized older people.

To describe challenges in conducting research with hospitalized geriatric patients. Quasi-experimental longitudinal study with inperson interviews at baseline and discharge and a three-month postdischarge telephone interview. Study protocol required baseline interviews within 48 hours of admission for patients or 72 hours for proxies. 813-bed urban teaching hospital. 240 patients, mean age 83.8 years, at moderate to high risk for functional decline during hospitalization, admitted from the emergency room to a general medical unit. Delays starting or interruptions continuing interviews; patient and environmental conditions potentially affecting data quality; and information on proxy use. Timely access to patients or proxies was a major difficulty, resulting in the screening of only 53.1% of 867 potentially eligible patients. Multiple patient contacts and visits were required to complete interviews. Only 61.3% of baseline and 28.1% of follow-up interviews were completed on the initial day of contact. Despite having on-site interviewers 7 days a week, 29% of discharge interviews were conducted by telephone. Interviews were >90% complete in 487 of 503 of encounters (97%). Baseline delays and interruptions were usually due to the presence of medical staff, off-unit tests, patient illness, nurse unavailability for interview, and need for a proxy. Most in-hospital interviews were conducted with others present. Proxies were required for approximately one-third of patients at all three interviews. Conducting clinical research with older adults in the current inpatient setting, where patients are more severely ill yet have shorter lengths of stay now than in the past, proves a challenging yet achievable goal. Effective procedures for negotiating the acute care environment are critical to successful studies.

Geriatric assessment in oncology.

With the anticipated growth in the numbers of elderly persons, a higher prevalence of cancers among older persons is expected; as a result, oncologists will treat larger numbers of older persons in their practices. Clinicians caring for older persons with cancer must recognize the heterogeneity of the elderly population and focus their assessments and care plans accordingly. The author reviewed literature and drew conclusions regarding geriatric assessment in several key areas: the medical, cognitive, affective, functional economic, and environmental status of patients; social support for patients; and advance directives. They concluded that for younger and healthier seniors, simple probes for the presence of common geriatric problems may suffice, but traditional means of medical assessment should be supplemented by brief screening for common geriatric conditions and nonmedical issues that are of particular relevance to the health of older persons. Assessment instruments can be used to guide these brief evaluations, but results must be interpreted in the context of the limitations of the instruments used. Patients who are frail or at high risk for functional decline or nursing home placement should receive more extensive evaluation by individual practitioners or by a multidisciplinary team of health care professionals who can provide comprehensive geriatric assessment. By broadening their assessment skills to include domains that are beyond traditional internal medicine and oncology training, oncologists can better serve their older cancer patients.

Targeting elders for geriatric evaluation and management: Reliability, validity, and practicality of a questionnaire

Geriatric evaluation and management (GEM) is most cost-effective when provided to persons at high risk for functional decline or heavy use of health services. Identifying high risk members of elderly populations is, therefore, the first step in conducting successful GEM programs. We have developed and tested a mailed, self-administered, eight-item questionnaire to identify home-dwelling elders at risk for heavy use of hospitals. Scored by a logistic formula, this questionnaire estimates each respondent's probability of repeated admission (Pra) to a hospital within four years. Its primary purpose is to help select elders who are likely to benefit from outpatient GEM. We created this instrument by analyzing data from half the subjects in the Longitudinal Study of Aging (LSOA); its test-retest reliability is high (r = 0.78). In a preliminary test of its predictive validity among the other half of the LSOA subjects, the instrument prospectively identified high-risk elders who went on to use hospitals at twice the rate of their lower-risk peers. In a separate study of its predictive validity among low-income urban elders, the instrument again identified a high-risk group that went on to use hospital days at twice the rate of its lower-risk counterpart. In a pilot study, we used the questionnaire to identify potential recipients of outpatient GEM. The identified elders appeared to be appropriate candidates for GEM. They averaged 9.6 significant medical problems, 6.7 significant prescription medications, and two IADL limitations. We are now using this instrument to identify subjects for a randomized clinical trial of outpatient GEM