Multidisciplinary Geriatric Assessment Research Articles

Update on the management of elderly patients with colorectal cancer

Colorectal cancer (CRC) is one of the most common tumours worldwide, and 70% of CRC patients are over 65 years of age. However, the scientific evidence available for these patients is poor, as they are underrepresented in clinical trials. Therefore, a group of experts from the Oncogeriatrics Section of the Spanish Society of Medical Oncology (SEOM), the Spanish Cooperative Group for the Treatment of Digestive Tumours, (TTD) and the Multidisciplinary Spanish Group of Digestive Cancer (GEMCAD) have reviewed the scientific evidence available in older patients with CRC. This group of experts recommends a multidisciplinary approach and geriatric assessment (GA) before making a therapeutic decision because GA predicts the risk of toxicity and survival and helps to individualize treatment. In addition, elderly patients with localized CRC should undergo standard cancer resection, preferably laparoscopically. The indication for adjuvant chemotherapy (CT) should be considered based on the potential benefit, the risk of recurrence, the life expectancy and patient comorbidities. When the disease is metastatic, the possibility of radical treatment with surgery, radiofrequency (RF) or stereotactic body radiation therapy (SBRT) should be considered. The efficacy of palliative CT is similar to that seen in younger patients, but elderly patients are at increased risk of toxicity. Clinical trials should be conducted with the elderly population and include GAs and specific treatment plans.

Barriers to and recommendations for integrating the age-friendly 4-Ms framework into electronic health records.

The Institute for Healthcare Improvement's 4-Ms framework of care for older adults recommends a multidisciplinary assessment of a patient's Medications, Mentation, Mobility, and What Matters Most. Electronic health record (EHR) systems were developed prior to this emphasis on the 4-Ms. We sought to understand how healthcare providers across the healthcare system perceive their EHRs and to identify any current best practices and ideas for improvement regarding integration of the 4-Ms. Anonymous survey of healthcare providers who care for older adults. The survey aimed to evaluate efficiency, error tolerance, and satisfaction (usefulness and likeability). The survey was distributed through organizational list serves that focus on the care of older adults and through social media. Sixty-six respondents from all geographic segments of the U.S. (n=62) and non-U.S. practices (n=4) responded. Most (82%) were physicians. Respondents used a range of EHRs and 82% had >5 years of experience with their current EHR. Over half of respondents agreed that their EHR had easy to find contact information (56%) and advance directives. Finding a patient's prior cognitive status (26% agreement), goals of care (24%), functional status (14%), and multidisciplinary geriatric assessments (27%) was more difficult. Only 3% were satisfied with how their EHR handles geriatric syndromes. In free text responses, respondents (79%) described three areas that the EHR assists in the care of older adults: screening tied to actions or orders; advance care planning, and medication alerts or review. Common suggestions on how to improve the EHR included incorporating geriatric assessments in notes, establishing a unified place to review the 4-Ms, and creating age-specific best practice alerts. The majority of healthcare providers were not satisfied with how their EHR handles multidisciplinary geriatric assessment and geriatric care. EHR modifications would aide in reporting, communicating, and tracking the 4-Ms in EHRs.

Impact of a geriatric assessment and optimisation-based preoperative clinic on the management of older patients receiving dental treatment under general anaesthetic or conscious sedation: A service evaluation.

The main objectives of the study were to review patient characteristics, recommendations made and treatment outcomes of frail/older patients referred to a specialist multidisciplinary geriatric assessment and optimisation-based preoperative clinic (PROKARE), prior to patients receiving dental treatment under general anaesthesia (GA) or conscious sedation (CS). Although the use of preoperative comprehensive geriatric assessment to improve pre/peri and postoperative mortality has been reported for many surgical domains, its use prior to dental surgery has not been reported previously. The data were collected retrospectively from the dental notes of 52 patients referred from the Special Care Dental (SCD) Department to the PROKARE service for optimisation prior to dental treatment under GA/CS using a case note study approach. The data extracted included patient demographic characteristics, medical history, clinical management and the treatment outcomes for each patient. The data extracted was analysed with descriptive statistics. Key reasons for referral were caries management, retained roots and poor co-operation. Multiple co-morbidities were noted among the patients referred, with 14 (27%) having four or more co-morbidities. The PROKARE assessment identified issues such as treatment could be carried out under CS instead of GA; consent; and the need for medication change and/or further medical investigations. As per recommendations from PROKARE, 39 patients (75%) received dental treatment while five (10%) did not receive treatment, and a further eight (15%) died prior to treatment. Geriatric assessment and optimisation-based preoperative clinics in the dental management of frail, elderly patients having treatment under GA or CS techniques is valuable, but further research and assessment of current service provision are needed to increase the evidence base.

Frailty score of older patients with haematological malignancies: unsuspected role of mild cognitive impairment

Frailty assessment in older patients with haematological malignancies is extremely beneficial in order to optimize treatment decisions and supportive interventions. A comprehensive geriatric assessment can provide a better understanding of the functional age than clinical judgement by evaluating several skills domains such as physical function, autonomy, comorbidities, nutrition, cognition, psychological status and social support. However, the use of a multidisciplinary geriatric assessment may fail to detect unsuspected vulnerability such as mild cognitive impairment among so-called "clinically fit" patients. The objective of this paper is to update the current knowledge about predictive factors for toxicity and "frailty scoring" in older patients with haematological malignancies. The unsuspected major role of cognitive impairment and how to detect it will be emphasized.

Study protocol for IMAGE: implementing multidisciplinary assessments for geriatric patients in an emergency department observation unit, a hybrid effectiveness/implementation study using the Consolidated Framework for Implementation Research

BackgroundOlder adults in the emergency department (ED) are at high risk for functional decline, unrecognized delirium, falls, and medication interactions. Holistic assessment by a multidisciplinary team in the ED decreases these adverse outcomes and decreases admissions, but there are many barriers to incorporating this type of care during the ED visit.MethodsThis is a hybrid type II effectiveness-implementation study using a pre-/post-cohort design (n = 380) at a tertiary care academic ED with an ED observation unit (Obs Unit). The intervention is a two-step protocol of (step 1) ED nurses screening adult patients ≥ 65 years old for geriatric needs using the Delirium Triage Screen, 4-Stage Balance Test, and the Identifying Seniors at Risk score. Patients who have geriatric needs identified by this screening but who do not meet hospital admission criteria will (step 2) be placed in the Obs Unit for multidisciplinary geriatric assessment by the hospital’s geriatric consultation team, physical therapists, occupational therapists, pharmacists, and/or case managers. Not all patients may require all elements of the multidisciplinary geriatric assessment. The Consolidated Framework for Implementation Research: Care Transitions Framework was used to identify barriers to implementation. Lean Six Sigma processes will be used to overcome these identified barriers with the goal of achieving geriatric screening rates of > 80%. Implementation success and associated factors will be reported. For the effectiveness aim, pre-/post-cohorts of adults ≥ 65 years old cared for in the Obs Unit will be followed for 90 days post-ED visit (n = 150 pre and 230 post). The primary outcome is the prevention of functional decline. Secondary outcomes include health-related quality of life, new geriatric syndromes identified, new services provided, and Obs Unit metrics such as length of stay and admission rates.DiscussionA protocol for implementing integrated multidisciplinary geriatric assessment into the ED setting has the potential to improve patient functional status by identifying and addressing geriatric issues and needs prior to discharge from the ED. Using validated frameworks and implementation strategies will increase our understanding of how to improve the quality of ED care for older adults in the acute care setting.Trial registrationClinicalTrials.gov Identifier, NCT04068311, registered 28 August 2019

An Emergency Department Observation Unit Is a Feasible Setting for Multidisciplinary Geriatric Assessments in Compliance With the Geriatric Emergency Department Guidelines.

The Geriatric Emergency Department (ED) Guidelines recommend providing multidisciplinary geriatric assessment in the ED, but these assessments can be difficult to coordinate and may prolong length of stay. Patients who need longer than a typical ED stay can be placed in an ED observation unit (Obs Unit). We investigated the effects of offering multidisciplinary assessments for ED patients in an Obs Unit. Evaluation by a geriatric hospital consultation team, physical therapist, case manager, and/or pharmacist was made available to all Obs Unit patients. Use of any or all of these ancillary consult services could be requested by the Obs Unit physician. A retrospective chart review of random older adult Obs Unit patients was done to assess rates of consult use and interventions by these consulting teams. All patients ≥ 65 years old in our institutional review board-approved, monthly Obs Unit quality database from October 2015 through March 2017 were included. Our quality database included 221 older patients over 18 months. The mean (±SD) age was 73.3 (±6.8) years (range= 65-96years) and 55.2% were women. The mean (±SD) observation length of stay was 14.7 (±6.5) hours. The majority (74.3%) were discharged from the Obs Unit and 72-hour ED recidivism was 3.6%. Overall, at least one of the multidisciplinary consultant services were requested in 40.3% of patients (n=89). Additional interventions or services were recommended in 80.0% of patients evaluated by physical therapy (32 of 40 patients), 100% of those evaluated by a pharmacist (five of five patients), 38% of those evaluated by case management (27 of 71 patients), and 100% of those evaluated by a geriatrician (eight of eight patients). Only 5.4% (n=12) of patients were placed in observation specifically for multidisciplinary assessment; these patients had a mean (±SD) length of stay of 12.2 (±5) hours and an admission rate of 41.7%. Incorporating elements of multidisciplinary geriatric assessment for older patients is feasible within an observation time frame and resulted in targeted interventions. An Obs Unit is a reasonable setting to offer services in compliance with the Geriatric ED Guidelines.

A quality improvement intervention in geriatric psychiatry care: Results of a pre-post design study

IntroductionInnovative approaches are needed to respond to the increasing number of elderly subjects with complex psychiatric conditions who require flexible and rapid responses, avoiding unnecessary hospital admissions. A new organizational model was implemented in our psychogeriatric service in September 2011 consisting of:– a comprehensive multidisciplinary geriatric assessment;– a helpline for caregivers for management of acute behavioral problems;– programmed visits to nursing homes.AimsTo evaluate whether the implementation of this program was associated with a reduction in hospital admissions and emergency department visits.MethodsThis is a pre-post test design study, involving 1197 patients who attended the Old Age Psychiatric (OAP) Unit three years before and three years after the implementation of the organizational intervention (1.09.2008 to 1.10.2014). An index of patient × year was calculated considering the period during which the patient was followed in OAP Unit. Data was obtained from the medical files of all eligible patients regarding demographic variables, number and type of hospital admissions and emergency department visits.ResultsDuring the 3 years before the intervention 671.2 patients × years were included (mean age of 75.8 years) while after the intervention this reached 2010.1 patients × years (mean age of 77.8 years). The intervention was associated with a decrease of 44% in psychiatry emergency visits, 48% in general emergency visits, 44% in psychiatric ward admissions and 51% in geriatric ward admissions.ConclusionsThe implementation of this new model was associated with significant reduction of hospital-based service utilization. Future research should determine if this was coupled with increased health outcomes.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Screening of frailty in elderly patients with disability by the means of Marigliano–Cacciafesta polypathology scale (MCPS) and Canadian Study of Health and Aging (CSHA) scales

Frailty is an age-related condition, characterized by a decreased homeostatic reserve and increased vulnerability to stressful events, with high risk of adverse outcomes.The aim of this study was to compare the evaluation of the frailty by the means of the MCPS and the Rockwood criteria.We enrolled 98 patients (mean age±standard deviation, m±SD, 80.7±7.0 years) and 20 controls (82.7±3.4ys), who attended our outpatient clinic for the evaluation of disability and the renewal of driving license, respectively.The multidisciplinary geriatric assessment (MGA) was performed including the administration of the following scales for frailty: MCPS scale (range 0–245), CSHA-Rules-Based Definition of Frailty (CSHA-RBDF) (range 0–3) and CSHA-Clinical Frailty Scale (CSHA-CFS) (range 0–7).The patients and controls showed MCPS=52.39±11.36 and 4.6±3.28, CSHA-RBDF=2.27±0.62 and 0.10±0.44, CSHA-CFS=6.22±0.75 and 2.95±0.51, respectively (p<0.000001).Frailty scores were higher in female than in male (p=0.065 for CSHA-RDBF and p<0.05 for CSHA-CFS). The MCPS scores were significantly related to both CSHA-RDBF (r=0.753, p<0.001) and CSHA-CFS scores (r=0.793, p<0.001). The frailty scales were significantly related to disability, cognitive impairment and polypathology.In conclusion, the frail patient may be a carrier of multiple chronic pathologies and/or of physical/cognitive decline. The frail patient has to be considered the elective geriatric patient, characterized by a continuous multidimensional care requirement.MCPS is an useful tool for the frailty screening and to set up a tailored program of geriatric rehabilitation, in order to prevent or reduce the development of frailty-related complications.

Effects of individual dietary counseling as part of a comprehensive geriatric assessment (CGA) on frailty status: A population-based intervention study

Background/PurposeIn this study, our aim was to evaluate the effects of individual dietary counseling as part of a comprehensive geriatric assessment (CGA) on frailty status among community-dwelling people aged 75 years or older. MethodsData were obtained from a subpopulation of participants in the population-based Geriatric Multidisciplinary Strategy for the Good Care of the Elderly (GeMS) intervention study in 2004 to 2007. In the present study, the population consisted of 159 persons at risk of malnutrition in the year 2005 in an intervention and a control group. Nutritional status was assessed with the Mini Nutritional Assessment (MNA). Frailty was defined according to the five frailty criteria used in the Cardiovascular Health Study (CHS). Assessment of nutritional status and frailty status was performed at the beginning of the study and at 1-year follow-up. ResultsAt baseline the mean age of the 159 community-dwelling participants with risk of malnutrition was 83 years and 126 (79%) of them were female. The proportions of frail and pre-frail persons were 25% (n = 19) and 61% (n = 47) in the intervention group, and 26% (n = 21) and 61% (n = 50) in the control group. After the 1-year nutritional intervention, compared to the control group, the intervention group tended to have a better outcome of frailty and MNA (OR = 1.89, 95% CI: 1.08–3.54, OR = 2.61, 95% CI: 1.67–5.56, respectively) and was less likely to deteriorate as assessed with MNA (OR = 0.23, 95% CI: 0.14–0.87). In multivariate analysis, change in MNA (OR = 1.12, 95% CI: 1.03–1.31) was associated independently with improved frailty status. ConclusionIt appears that multidisciplinary geriatric assessment including individual dietary counseling has a positive effect on frailty status. More emphasis on good nutrition in the older population might have a preventive effect on the incidence of frailty.

A multidisciplinary intervention program improved the outcome after hip fracture for people with dementia—Subgroup analyses of a randomized controlled trial

Background: People with cognitive impairment and dementia have a poor outcome after a hip fracture surgery, about 30–50% of all those who sustain a hip fracture have dementia. Therefore the aim was to investigate whether a multidisciplinary postoperative intervention program could reduce postoperative complications and improve functional recovery among people with dementia. Methods: A randomized controlled trial with subgroup analyses among patients with dementia. Sixty-four patients with femoral neck fracture, aged ≥70 years at Umeå University Hospital, Sweden. The intervention consisted of staff education, individualized care planning and rehabilitation, active prevention, detection and treatment of postoperative complications, especially delirium. The staff worked in teams to apply comprehensive geriatric assessment, management and rehabilitation, including a follow-up at 4 months postoperatively. The control group followed conventional postoperative routines. Results: There were fewer postoperative complications in the intervention group such as urinary tract infections, p=0.001; nutritional problems, p=0.025; postoperative delirium, p=0.002; falls, p=0.006. At 4 months a larger proportion in the intervention group had regained their previous independent indoor walking ability performance, p=0.005. At 12 months a larger proportion in the intervention group had regained the activities of daily living (ADL) performance level they had before the fracture, p=0.027. Conclusion: This study demonstrates that patients with dementia who suffer a hip fracture can benefit from multidisciplinary geriatric assessment and rehabilitation and should not be excluded from rehabilitation programs.

Factors Associated With Skilled Nursing Facility Transfers in Dementia-specific Assisted Living

Medical, functional, and behavioral problems are associated with transitions from assisted living (AL), but limited information is available on those at highest risk for transition. We conducted a multidisciplinary geriatric team assessment of individuals newly admitted to 2 dementia-specific AL communities from January 2000 to March 2002. Transitions of individuals to permanent skilled nursing facilities (SNF) was assessed for 9 months. Multidisciplinary assessment on admission included medical and cognitive evaluations, physical function, nutritional status, and psychosocial adjustment. Twenty-four men and 24 women with a mean age of 83+/-6 years were assessed. Mental status score was 15+/-6. Residents had 2.1+/-1.7 comorbidities and were prescribed 1.7+/-1.2 medications. During follow-up, 23 (47.9%) transitioned to SNF and 9 (18.8%) individuals died (censored events). Significant predictors of transfer to nursing home from AL by one-predictor Cox proportional hazards model included depression score [hazard ratio (HR) 1.19; P=0.008], dependent activities of daily living (HR 1.18; P=0.014), gait speed (HR 1.15; P=0.004), modified Berg Balance Score (HR 0.88; P=0.004), and mental status score (HR 0.924, P=0.034). Our multivariate model selected by the forward procedure indicates that the modified Berg Balance Scale score predicted transfer to permanent nursing home with a interquartile HR of 0.91 (95% CI 0.8264, 0.989). A significant number of new residents of dementia-specific AL transitioned to SNF over 9 months. In univariate analysis, depression score, walking speed, balance, and mental status score were significantly associated with transition and in multivariate analysis, balance performance predicted transfer. These results suggest that fall risk should receive attention on admission to AL to potentially mitigate the high transfer rate.

Care of the geriatric patient in chronic renal failure.

Currently, there are around one million chronic dialysis patients worldwide. More than half of these are older than 65. For various reasons this is a fast growing population. When the indication is considered to start dialysis, a distinction must be made between biological age in the third and fourth decade on the one hand, and a specific geriatric profile on the other, which implies adequate gerontological knowledge. Besides the patient-directed choice of the best tolerated treatment technique, the specific treatment of age-linked polypathology as well as the appropriate approach of inter- and intradialysis related problems regarding access and haemodynamics are the best guaranties of success in this highest age dialysis group. By means of a multidisciplinary geriatric assessment, which makes it possible to carry out an objective analysis and observation from the somatic, psychic and social points of view, an ultimate objective is achieved: the improvement of quality of life by means of rehabilitation. The survival of elderly dialysis patients has favourably evolved since the 90's after the introduction of EPO, bicarbonate dialysate, the monitoring of dialysis adequacy and support of prognostic and comorbid factors. The problems surrounding dialysis drop-out is a sensitive and controversial matter in which well founded communication with the patient, the family, the dialysis team, domestic care and the general practitioner is vital. "Add life to years and not years to life" remains a challenge for every nephrologist.

The importance of oral health in the older patient.

Oral health is important to general health because stomatologic disease affects more than the mouth. Increasing preservation of teeth among present and future cohorts of older people has increased their risk for serious disease from oral pathogens. The intent of this paper is twofold: first, to alert non-dental health personnel to the significance of oral health and oral disease in the older adult; and second, to recruit the assistance of non-dental professionals in helping patients to achieve and maintain an optimal oral condition. Normative aging processes alone have little effect on the oral cavity, but common disease processes affecting oral health include tooth loss, dental caries, periodontal diseases, and oral mucosal diseases (including candidiasis and squamous cell carcinoma). Systemic diseases and their treatments frequently affect salivary, oral motor, and oral sensory functions. As a result of bacteremia or aspiration of oral contents, organisms of oral origin can be responsible for serious nonstomatological infections. Clinicians caring for older people need to recognize the importance of stomatological health, include an oral component in the multidisciplinary geriatric assessment, support the education of patients on aspects of dental health, and advocate the expansion of personal and public oral health benefits for older adults.

Follow-up of comprehensive geriatric assessment in a family medicine residency clinic.

The objective of this study was to evaluate the effect of outpatient geriatric consultation by referring academic physicians and to verify the results of a previous study. We conducted a retrospective review of charts of 37 patients referred for geriatric consultation during a 7-month period of a university- and community-hospital-affiliated family practice residency clinic in urban northeast Washington, DC. The consultation involved team assessment, which led to formal recommendations to the attending physician. Main outcome measures included total number and category of recommendations made, as well as a total number and category of recommendations adhered to by referring physicians. There were 29 women and 8 men with an average age of 79.1 years; 5 were white and 32 were African-American. For the 23 patients for whom follow-up could be determined, the mean number of total diagnoses per patient was 11.4 (SD 3.5). The mean total number of recommendations made per patient was 18.1 (SD 5.9). The mean total number of recommendations acted upon per patient by referring physicians was 9.5 (SD 4.4). The recommendations fell into the following categories: rehabilitative 64 percent, radiologic 57.1 percent, laboratory 56.9 percent, total medication 55.6 percent, medical 50 percent, health maintenance 47.1 percent, social service 46.2 percent, sensory 33 percent, other 28.6 percent, educational 20 percent, and nutritional 14.3 percent. Multidisciplinary geriatric assessment in an academic outpatient setting provides a comprehensive assessment for faculty and resident physicians in training. Recommendations will be adhered to only 50 to 70 percent of the time, possibly because of the demographic and socioeconomic mix and overall health of the patient population, health care priorities of the referring physician, and costs and availability of various interventions. Physicians in training should be exposed through continuing medical education to various aspects of geriatric assessment.

The social construction of frailty: An anthropological perspective

This article proposes to broaden the discussion of frailty beyond instrumental definitions by exploring its socio-cultural sources and dimensions in American culture. It is based on an ongoing study of increased dependence among community-living elderly over the age of 80. The primary research goal was to investigate ways in which frailty is defined, framed, and understood by older persons, their family members, and their health care providers in the context of a multidisciplinary geriatric assessment service. I argue that frailty is socially produced in response to cultural discourses about surveillance and individualism. I suggest that frailty be conceived as an adaptational process that emerges and is fully articulated during the health care encounter.

Editorial: Community Care, Social Work, and Social Care

The focus of this Special Issue of the British Journal of Social Work has been chosen to reflect 1993 as the year in which the full implementation of the United Kingdom NHS and Community Care Act is taking place. The changes emerging from the Community Care legislation in the United Kingdom, like other countries, can be conceived of as constitut ing in general terms a move from institution based care, an accompany ing move to enhance home-based care and the development of improved mechanisms of co-ordination and enhanced case management (Challis, 1992a). The most explicitly analogous changes to those in the UK have been occurring in Australia with the development of multi disciplinary geriatric assessment teams to assess entry to publicly funded care, the development of the Home and Community Care Act to develop enhanced home care services with additional central govern ment funding and the community options programme, designed ti pro vide co-ordinated care at home for the most vulnerable through case management (Ozanne, 1990; DCS, 1986; Graham et al., 1992). Similar changes are simultaneously occurring in a large number of advanced societies (Challis, 19926; Kraan et al., 1991), albeit in slightly different ways for different client groups, Of course this simple conception of change requires further elaboration. Firstly, institutions for long-term care for elderly people in many countries consist of nursing homes and relatively few have the numbers of long-stay hospital beds evident in the United Kingdom. Those European countries which appear to place greater emphasis upon long-stay hospital care are those, such as Spain

A Multidisciplinary Clerkship in Geriatric Medicine

A multidisciplinary clerkship was developed as a required course for third year medical students. The drawbacks of traditional medical education as it applies to the field of geriatrics are reviewed. The development of a week-long clerkship in geriatric medicine is described with special focus on a multidisciplinary geriatric home assessment required of all students. Evaluation of the clerkship and the home assessment is described.

A patient-completed screening instrument for functional disability in the elderly

Although multi-disciplinary geriatric assessment of elderly patients has been shown to be effective in identifying new diagnoses and previously unknown disabilities and in decreasing hospitalization and mortality, time and financial constraints prevent most internists and office practitioners from using this approach with their older patients. Several instruments to screen older persons for functional disability have been proposed, but there are limited data regarding their utility or effectiveness in clinical medicine. This study developed a short, patient-completed screening assessment instrument (the Functional Assessment Screen), compared it to a standard, multi-disciplinary geriatric evaluation, and determined the screening instrument's ability to predict future use of home care services in a group of elderly patients. The screening instrument was piloted retrospectively using data from patients seen in the previous 2 years at a hospital-based geriatrics clinic in Wisconsin. Using these results, a revised instrument was developed and mailed to 80 consecutive new patients who presented to the clinic for multi-disciplinary geriatric assessment and primary care. These patients were interviewed 18 months later to determine use of home services, institutionalization, and death after the initial visit. Fifty-eight of 80 eligible patients (72%) completed both the clinic evaluation and 18-month follow-up. The patients were an elderly (mean age of 76), frail (average of three medical diagnoses), functionally disabled group (dependent in an average of 3.7 instrumental activities of daily living and 2.7 activities of daily living). Nine of the 58 enrolled patients (15%) were institutionalized, five (9%) died, and 31 (53%) required new home services after 18 months. The screening variables were sensitive but less specific than clinic providers' judgment in identifying abnormalities in social, economic, or physical health status. The relative risk of eventual home service use was elevated in patients reporting poor health status (relative risk of 3.5, 95% confidence interval [CI] 9.9 to 1.2), and dependency in housework (relative risk of 3.0, 95% CI 5.1 to 1.7), shopping (relative risk of 2.6, 95% CI 4.7 to 1.5), meals (relative risk of 2.4, 95% CI 3.4 to 1.7), dressing (relative risk of 2.2, 95% CI 3.0 to 1.6), or bathing (relative risk of 2.2, 95% CI 3.2 to 1.5). Home services were used in 16% of patients with no positive responses to a subset of four of the screening questions; usage rose to 22% with one positive response, and to 89% (relative risk of 4.5, 95% CI 9.2 to 2.1) with two or more positive responses. This screening instrument identified a group of elderly patients at much higher risk for increased home service use than other patients in a geriatrics clinic. If validated in other populations, such an instrument may identify frail, elderly patients in office practice at high risk for use of home services. These patients could be targeted for more complete multi-disciplinary geriatric assessment to identify and treat disease and disability responsible for increased service use and declining health.

A patient-completed screening instrument for functional disability in the elderly

purpose: Although multi-disciplinary geriatric assessment of elderly patients has been shown to be effective in identifying new diagnoses and previously unknown disabilities and in decreasing hospitalization and mortality, time and financial constraints prevent most internists and office practitioners from using this approach with their older patients. Several instruments to screen older persons for functional disability have been proposed, but there are limited data regarding their utility or effectiveness in clinical medicine. This study developed a short, patient-completed screening assessment instrument (the Functional Assessment Screen), compared it to a standard, multi-disciplinary geriatric evaluation, and determined the screening instrument's ability to predict future use of home care services in a group of elderly patients. patients and methods: The screening instrument was piloted retrospectively using data from patients seen in the previous 2 years at a hospital-based geriatrics clinic in Wisconsin. Using these results, a revised instrument was developed and mailed to 80 consecutive new patients who presented to the clinic for multi-disciplinary geriatric assessment and primary care. These patients were interviewed 18 months later to determine use of home services, institutionalization, and death after the initial visit. results: Fifty-eight of 80 eligible patients (72%) completed both the clinic evaluation and 18-month follow-up. The patients were an elderly (mean age of 76), frail (average of three medical diagnoses), functionally disabled group (dependent in an average of 3.7 instrumental activities of daily living and 2.7 activities of daily living). Nine of the 58 enrolled patients (15%) were institutionalized, five (9%) died, and 31 (53%) required new home services after 18 months. The screening variables were sensitive but less specific than clinic providers' judgment in identifying abnormalities in social, economic, or physical health status. The relative risk of eventual home service use was elevated in patients reporting poor health status (relative risk of 3.5, 95% confidence interval [CI] 9.9 to 1.2), and dependency in housework (relative risk of 3.0, 95% CI 5.1 to 1.7), shopping (relative risk of 2.6, 95% CI 4.7 to 1.5), meals (relative risk of 2.4, 95% CI 3.4 to 1.7), dressing (relative risk of 2.2, 95% CI 3.0 to 1.6), or bathing (relative risk of 2.2, 95% CI 3.2 to 1.5). Home services were used in 16% of patients with no positive responses to a subset of four of the screening questions; usage rose to 22% with one positive response, and to 89% (relative risk of 4.5, 95% CI 9.2 to 2.1) with two or more positive responses. conclusions: This screening instrument identified a group of elderly patients at much higher risk for increased home service use than other patients in a geriatrics clinic. If validated in other populations, such an instrument may identify frail, elderly patients in office practice at high risk for use of home services. These patients could be targeted for more complete multi-disciplinary geriatric assessment to identify and treat disease and disability responsible for increased service use and declining health.

Multidisciplinary assessment of applicants for sheltered housing.

Three hundred applicants for sheltered housing underwent multidisciplinary geriatric assessment for suitability as a part of a joint assessment scheme with Local Authority Housing and Social Services Departments. Ninety-four applicants sought a move for health reasons while 206 applicants quoted housing and social reasons and denied medical problems. The assessment showed no significant disability necessitating sheltered housing facilities for 41 (44%) of the 94 people applying on health grounds. Severe disability made sheltered housing placement inappropriate for ten (10%) of the applicants with health problems. In the 206 applicants denying medical problems, the assessment revealed significant unreported physical illness in 46 (22%) and undiagnosed dementia in a further 26 (13%). Allocation of sheltered housing was affected in 99 (33%) of the 300 applicants. Eighty-two applicants were considered unsuitable, whereas 17 applicants originally thought to be unsuitable were recommended for sheltered housing. Multidisciplinary geriatric assessment is of considerable benefit in determining suitability of applicants for sheltered housing and will help in achieving better placement by avoiding inappropriate moves.