Inpatient Geriatric Evaluation Research Articles

Patient safety for people experiencing advanced dementia in hospital: A video reflexive ethnography.

Patient safety for people experiencing dementia in acute hospitals is a global priority. Despite national strategies as well as safety and quality guidelines, how safety practices are enacted within the complexities of everyday work are poorly understood and articulated. Using video reflexive ethnography, this 18-month study was conducted within an inpatient geriatric evaluation and management unit for people experiencing dementia and/or delirium in Australia. Patients, family members, and staff members participated by: allowing researchers to document fieldwork notes and video-record their practices and/or accounts thereof; and/or interpreting video-recordings with researchers to co-analyse and make sense of the data. Safe care for people experiencing advanced dementia involved: negotiating risk via leadership, teamwork, and transparency; practice-based learning through situated adaptation; managing personhood versus protocols by doing the 'right' thing; joyful and meaningful work; as well as incorporating patient and family voices to do safety together. Patient safety for people experiencing dementia requires continuous responsiveness and prioritising in the context of multiple risks by a staff collective with a shared purpose. Ongoing research to better understand how the nuances of patient safety unfold in everyday complex clinical realities in diverse contexts and with key stakeholders is required.

Fundamental care for people with cognitive impairment in the hospital setting: A study combining positive organisational scholarship and video-reflexive ethnography.

To clarify how high-quality fundamentals of care for people with dementia and/or delirium were practised in a specialist geriatric evaluation and management unit. Older people with cognitive impairment represent a significant number of people who are admitted to hospital. They are at increased risk of dying, readmission and long hospital stays, relative to those without cognitive impairment. There is an urgent need to elucidate the conditions that underpin safe and high-quality fundamental care for these patients and their families. Using the innovative methodologies of positive organisational scholarship in healthcare and video-reflexive ethnography, this 18-month study was conducted within an inpatient geriatric evaluation and management unit for people with dementia and/or delirium in South Australia. Patients, family members and staff members (managerial, clinical and nonclinical) participated by allowing researchers to document ethnographic fieldwork notes and film their practices and/or accounts thereof; and/or interpreting digital recordings with researchers in order to make sense of data in a process of co-analysis. This study is reported using Standards for Reporting Qualitative Research reporting guidelines. High-quality fundamental care for people with dementia and/or delirium in hospital and their families was associated with the special space of the hospital unit; an aptitude for people with dementia; a capacity to translate person-centred fundamentals of care from rhetoric to reality; and an appreciation for teamwork. This study clarified how teams working in hospital can practise high-quality fundamentals of care for older people with dementia and/or delirium. Delivery of high-quality fundamental care in this setting was dependent, not only on nurses, but the entire ward team working cohesively in a "weave of commitment." Efforts to improve fundamental care for people with cognitive impairment need to encompass values and philosophy of person-centred care, including the contributions by all staff to care delivery.

Geriatrics Evaluation and Management in the Veterans Administration-An Historical Perspective.

Comprehensive geriatric assessment, defined as an interdisciplinary assessment and development of an overall plan of treatment and follow-up, has become a fundamental part of clinical geriatric care. Since the 1970s, the US Department of Veterans Affairs (VA) has encouraged the development of geriatric evaluation and management programs. Evolution of geriatric evaluation and management has occurred over time and many VA medical centers have transferred inpatient geriatric evaluation programs to long-term care Community Living Centers, home, and outpatient settings. Availability of geriatric resources and trained personnel across the continuum of care as well as administrative collaboration between care components are critical to the successful implementation of geriatric services. Facilities may need to prioritize their resources and utilize the most effective and relevant elements of geriatric evaluation and management according to patient population needs, available space, resources, and institutional priorities. New risk assessment tools derived from the VA’s experience in geriatric evaluation may be useful for targeting services for other high-risk populations.

Measuring Outcomes on an Inpatient Geriatric Evaluation and Management Unit: The Effectiveness of Goal Attainment Scaling in Patients with Dementia

disease stages and at higher doses. The ACTivities of daily living and cognitION (ACTION) study investigated the benefit/risk of a higher-dose rivastigmine patch in patients with severe AD. Methods: ACTION was a 24-week, prospective, randomized, double-blind, multicenter study of 13.3 mg/24 h versus 4.6 mg/24 h patch in patients with severe AD. Patients aged 50 years, with a diagnosis of probable AD and a Mini-Mental State Examination score of 3-12 were randomized to 13.3 mg/24 h or 4.6 mg/24 h patch. Co-primary outcome assessments were the change from baseline at Week 24 on the Alzheimer’s Disease Cooperative Study-Activities of Daily Living scale-Severe Impairment Version (ADCS-ADL-SIV) and the Severe Impairment Battery (SIB). Secondary outcome assessments included the ADCS-Clinical Global Impression of Change (ADCS-CGIC) and the 12-item Neuropsychiatric Inventory (NPI-12). Safety and tolerability were also assessed. Results: In total, 716 patients were randomized to the study drug; n 1⁄4 356 to 13.3 mg/24 h patch and n 1⁄4 360 to 4.6 mg/24 h patch. Similar proportions of patients in both groups completed the study (13.3 mg/24 h, 64.3%; 4.6 mg/24 h, 65.0%). Baseline characteristics and demographics were comparable. Significantly less deterioration was observed on the ADCS-ADL-SIV and SIB with 13.3 mg/24 h versus 4.6 mg/24 h patch (p 1⁄4 0.0247 and p < 0.0001, respectively). Significant differences, in favor of the 13.3 mg/24 h patch, were observed on the ADCS-CGIC (p 1⁄4 0.0023 versus 4.6 mg/24 h); there were no significant betweendose differences on the NPI-12. The incidence of adverse events (AE) and serious AE (SAE) was comparable between the 13.3 mg/24 h and 4.6 mg/24 h patch groups (AE, 74.6% and 73.3%; SAE, 14.9% and 13.6%). The most common AE were psychiatric (31.0%; 26.7%), and skin and subcutaneous tissue disorders (25.6%; 26.2%). Discontinuation due to AE and SAE was higher with 13.3 mg/24 h than 4.6 mg/24 h patch (AE, 13.5% and 10.9%; SAE, 8.2% and 4.5%). Conclusions: The 13.3 mg/24 h rivastigmine patch showed benefit over the 4.6 mg/24 h patch on ADLs and cognition at Week 24 in this population with severe AD. Preliminary safety review of 13.3 mg/24 h patch appears to be consistent with that observed in previous studies.

The Geriatric Floating Interdisciplinary Transition Team

Older adults often receive suboptimal care during hospitalizations and transitions to postacute settings. Inpatient geriatric services have been shown to increase care quality but have not improved patient outcomes consistently. Acute Care for the Elderly units improve patient outcomes but are resource intensive. Transitional care has been shown to reduce hospital readmissions and healthcare costs. This article describes the Geriatric Floating Interdisciplinary Transition Team (Geri-FITT), a model that combines the strengths of inpatient geriatric evaluation and comanagement and transitional care models by creating an inpatient comanagement service that also delivers transitional care. The Geri-FITT model is designed to improve the hospital care of older adults and their transitions to postacute settings. In Geri-FITT, a geriatrician-geriatric nurse practitioner team assesses patients, comanages geriatric syndromes, provides staff education, encourages patient self-management, communicates with primary care providers, and follows up with patients soon after discharge. This pilot cohort study of Geri-FITT included hospitalized patients aged 70 and older on four general medicine services (two Geri-FITT, two usual care) at an academic medical center (N=717). The study assessed the effect of Geri-FITT on patients' care transition quality (Care Transitions Measure) and their satisfaction with hospital care (four questions). The results indicate that Geri-FITT is associated with slightly higher, though not statistically significantly so, quality care transitions and greater patient satisfaction with inpatient care. Geri-FITT may be a feasible approach to enhancing inpatient management and transitional care for older adults. Further study of its effect on these and other outcomes in other healthcare settings seems warranted.

The Effectiveness of Inpatient Geriatric Evaluation and Management Units: A Systematic Review and Meta‐Analysis

To examine how geriatric evaluation and management units (GEMUs) are organized and to examine the effectiveness of admission on a GEMU. Systematic review and meta-analysis based on literature search of multiple databases and the references lists of all identified articles and by contacting authors. GEMUs. Elderly people admitted to a GEMU. Quality of the studies was assessed on 10 criteria. The outcome parameters were mortality, institutionalization, functional decline, readmission, and length of stay at different follow-up points. A random-effects meta-analysis was performed using Hedges' gu and variance of relative risk (RR). GEMUs are organized in a heterogeneous way and the included studies gave no thorough description of comprehensive geriatric assessment (CGA). Involvement of a multidisciplinary team was a key element in all GEMUs. The individual trials showed that admission to a GEMU has one or more favorable effects on the outcomes of interest, with two significant effects in the meta-analysis: less functional decline at discharge from the GEMU (RR=0.87, 95% confidence interval (CI)=0.77-0.99; P=.04) and a lower rate of institutionalization 1 year after discharge (RR=0.78, CI=0.66-0.92; P=.003). For the other outcomes in the meta-analysis, a GEMU did not induce significantly different outcomes than usual care. This meta-analysis shows a significant effect in favor of the GEMU group on functional decline at discharge and on institutionalization after 1 year. There is heterogeneity between the studies, poor quality of some randomized controlled trials, and shortage of information about CGA. Multidisciplinary CGA offered in a GEMU may add value to the care for frail older persons admitted to the hospital, but the limitations confirm the need for well-designed studies using explicit CGA and more-structured and -coherent assessment instruments such as the Minimum Data Set Resident Assessment Instrument.

Inpatient geriatric evaluation and management did not reduce mortality but reduced functional decline

Inpatient geriatric evaluation and management did not reduce mortality but reduced functional decline

Beyond the Black Box of Comprehensive Geriatric Assessment

At times, comprehensive geriatric assessment (CGA) appears to be a black box. The patient enters from one side, frail and with unknown and unaddressed medical needs. After undergoing the assessment process and suggested therapeutic interventions, the patient emerges functionally improved. It may be blasphemous to compare the only “technology” that geriatrics will probably ever have to a black box. But it is an appropriate metaphor about the process of geriatric assessment, whether conducted within the realm of a specialized unit or in a clinic. It is generally unclear which part of the process is responsible for improved outcomes. Therefore, the entire process of CGA is applied to each patient. The article by Naughton and colleagues1 in this issue of the Journal presents the results of a randomized trial in which the intervention should be commended for its simplicity. The assessment process used in the study removed most of the trappings of specialized units and has reduced geriatric assessment to its essence; the evaluation and management of chronically ill and functionally frail older adults by a geriatrician and a social worker. Naughton et al have given us a starting point for the next generation of trials of CGA. We already understand a great deal about CGA and where it appears to be effective. A recent meta-analysis of 28 controlled trials examined the impact of five different models of CGA on patient outcomes. Different types of CGA have different effects on patient outcomes. For example, inpatient Geriatric Evaluation and Management Units (GEMUs) have the greatest effect on reducing mortality, while outpatient interventions have failed to demonstrate an impact on mortality. However, all types of CGA have been shown to increase the likelihood of a patient living at home. Finally, there is convincing evidence that CGA with continued long term management appears to be more effective in maintaining the positive effects of the intervention. There is an even greater amount of information that we do not know about CGA. For example, what is the optimum number and composition of an assessment team to maximize patient outcomes? Does every team need a physician, nurse practitioner, social worker, and a cadre of therapists to evaluate each patient? Could complex patients first be screened by a trained health professional with triage to other health professionals as appropriate? There are a large number of screening instruments available to assess such important domains of the frail elderly as cognitive status, gait, and balance. A structured approach to the assessment process is important to its success. But how are these instruments utilized in clinical practice, and who is the best professional to administer them to the patient? This most recent study allows us to shed some light into the black box and the process of geriatric assessment. It is important to understand that the complexity of patient medical problems will vary according to where CGA is delivered; therefore, not only the intervention components, but also the assessment goals and outcomes are different for each type of CGA. In this study, the assessment was designed to efficiently manage the acute care hospitalization. The geriatrician-led intervention was efficient; it produced the same or similar clinical patient outcomes at a lower cost. The intervention team focused on those functional needs and limitations of the acutely ill patients that would interfere with hospital discharge. The intervention was not a predetermined mix of services, but individually tailored to meet patient needs. Instead of applying all parts of CGA to all patients, the patient undergoing assessment should be exposed to increasingly finer filters to detect impairment and make the appropriate interventions. This study utilized this principle in the initial assessment of the patient. Because of this fundamental change in structure, the intervention was not a costly add-on for the hospital; rather it was a value-added intervention for the patient. If CGA is to survive under our evolving system of health care reimbursement, it has to be value-added; CGA must produce the same or better patient outcomes, compared with usual clinical care, at the same cost. When appropriately utilized for the right group of patients, CGA is an effective clinical intervention. However, as objective clinicians and researchers, we cannot afford to have CGA provide excellent care at higher costs. If we do, CGA will probably cease to exist as a clinical intervention. The next phase of evaluation of CGA should not be where to put the box, but what is inside of it. What components of the assessment process lead to improved patient outcomes, and who is best trained to provide each component? If CGA is to evolve and become a powerful clinical tool, we must focus on creating the most efficient and effective models for delivering assessment services. Achievement of that goal will improve health care delivery for frail older adults.

Inpatient Geriatric Evaluation and Management Units: Organization and Care Patterns in the Department of Veterans Affairs

Geriatric evaluation and management units (GEMs) are designed to improve the functional health and placement of frail elderly hospital inpatients. We surveyed Department of Veterans Affairs (VA) GEMs to describe their care patterns and organization. GEMs meeting consensus standards (n = 46) varied considerably. Hospital, GEM, and patient-admission factors (e.g., hospital psychiatric mix, GEM location, proportion of GEM admissions from nursing homes) predicted length-of-stay, readmission rate, and discharge status. Ongoing monitoring may improve the effectiveness of VA GEMs systemwide.

Inpatient Geriatric Evaluation and Management Units (GEMs) in the Veterans Health System: Diamonds in the Rough?

Research suggests that inpatient geriatric evaluation and management units (GEMs), which undertake interdisciplinary diagnosis to improve the health of frail elderly patients, are effective. The Department of Veterans Affairs (VA) helped pioneer U.S. GEMs and mandates that every facility shall have a GEM by 1996. We conducted a population survey of VA GEMs in 1991 to assess their dissemination. Various organizational and performance characteristics of GEMs were entered in a data base derived from a piloted questionnaire and administrative records. Basic criteria from consensus reports were used to classify and compare "standard" and "nonstandard" GEMs. The criteria covered performance of assessment, team structure, patient selection, GEM location, and treatment functions. We analyzed the effect of GEM type and other factors on length of stay and placement. Reasons for closure of GEMs inactive in 1991 were recovered, and GEMs active in 1991 but later closed are described. As of 1991, 41 of 73 GEMs were classified as standard, and 32 nonstandard. Standard compared to nonstandard GEMs had shorter stays (25.4 vs 69.9 days; p < .001), higher home discharge rates (63.4% vs 40%; p < .001), and lower nursing home placement rates (19.1% vs 40.3%; p < .001). Eleven hospitals had closed their programs by 1991. By 1993, 6 additional GEMs had closed; all were nonstandard in 1991. Most VA GEMs are organized according to basic consensus standards, and appear to be discharging most patients back to the community after reasonably short stays. However, various resource constraints are common, apparently reflected in nonstandard organization and GEM closure. Additional work is needed to monitor GEM proliferation, implementation, and performance in and out of the VA system.

Working Group Recommendations: Methods for Geriatric Evaluation and Management Research

Methodological issues relating to multi-site studies of inpatient geriatric evaluation and management units were the focus of this working group's deliberations. The group favored a randomized clinical trial in which the inpatient geriatric evaluation and management unit was coupled with outpatient geriatric care. Inclusion of a broad spectrum of patients stratified according to risk for poor hospital outcomes was proposed in order to obtain information on the types of patients that would be most likely to benefit. The need for a detailed definition and description of care in the unit and of "usual care" was emphasized. Serious concerns were raised about including both VA medical centers and private hospitals in the same trial due to differences in the implementation of such a program. Furthermore, fears of contamination of the control group suggested that hospitals could be randomized either to provide usual care or have a GEM unit. However, this strategy would necessitate that hospitals that have already developed inpatient GEM units would be excluded from the trial and could be costly because of the number of hospitals that would be required.

The Sepulveda VA Geriatric Evaluation Unit: data on four-year outcomes and predictors of improved patient outcomes.

Data from its first four operating years indicate that the Sepulveda VA Geriatric Evaluation Unit is having consistent beneficial effects on patient care. These benefits include improved diagnostic accuracy, reduced use of drugs, improved functional status, and improved placement location. However, not all patients benefit equally, and differences between patient responses highlight the need to select those who will benefit most from relatively costly Geriatric Evaluation Unit services. Discriminant and regression analyses were performed on 98 consecutive patients to determine which patients admitted to the Geriatric Evaluation Unit would show greatest improvement in terms of placement, functional status, one-year survival, and living location, and which patients would be treated most efficiently in terms of length of stay. Patient characteristics on admission significantly associated with discharge home included a relatively high functional and cognitive status, the absence of an unstable medical problem, and not being expected to need nursing home placement by the referring physician. The latter two factors alone predicted actual placement location on the next 101 patients admitted to the Geriatric Evaluation Unit with high predictive accuracy (88.5 per cent). Factors predictive of patients whose functional status would improve on the Geriatric Evaluation Unit included absence of an unstable medical problem and being over 75 years old (predictive accuracy was 82.5 per cent). Two major factors associated with long patient stays on the Geriatric Evaluation Unit were low functional status scores and not living in own home or with family. These analyses indicate criteria that may be useful in selecting patients for inpatient geriatric evaluation and rehabilitation programs.