A Trial of Annual in-Home Comprehensive Geriatric Assessments for Elderly People Living in the Community

Abstract. Objective: To determine the effect of a practice guideline on the process of ED care in a health maintenance organization. Methods: A prepost-intervention comparison with a one-year pre-intervention phase followed by a one-year post-educational intervention phase was used to study the effect of the guideline on ED care. Emergency physicians and nurses were provided the details of the guideline during a two-week interval between the two periods. Results: During the two years of the study, 1,140 preintervention and 759 post-intervention patients met study eligibility criteria. More patients were diagnosed as having had falls due to loss of consciousness, stroke, and seizures during the post-intervention period (pre-intervention 3.8% vs post-intervention 8.4%, p < 0.001). There was a significant improvement in documentation of six of ten history items: cause of fall (64.5% vs 72.9%), location of fall (54.7% vs 60.5%), ability to get up unassisted (5.4% vs 12.5%), long lie after fall (1.5% vs 10.1%), prescription medications (79.0% vs 92.2%), and Pneumovax immunization status (20.8% vs 43.0%); and two of the four physical examination items: visual acuity (1.5% vs 3.2%) and the ''get up and go test'' (1.3% vs 11.2%). Prescribing of calcium and vitamin D increased from 0% to 6.6%. Conclusions:The educational intervention to the practice guideline for the ED management of falls in elders led to small but significant improvements in the documentation of selected history and physical examination items and the prescribing of calcium and vitamin D, and to a greater consideration of the causes of falls. Key words: practice guidelines; accidental falls-prevention and control; aged; emergency medicine; geriatric assessment. ACADEMIC EMERGENCY MEDICINE 1999; 6:1216-1223 T HE U.S. population is growing older, with the most rapid growth among the oldest of the old.1 As a result, an increasing proportion of ED patients will be older citizens.2 Falls are a substantial problem in individuals Ն65 years of age, occurring in 32% of those 65-74, 35% of those 75-84, and 51% of those Ն85 years of age each year.3-7 Falls directly or indirectly cause 12% of all deaths in elders. 5,8 Approximately 5% of falls in older persons result in fractures and another 5-10% result in serious injuries that necessitate medical care. 9-12Though there has been considerable progress made in the evaluation and treatment of frail older citizens, recent surveys have demonstrated that practicing emergency physicians (EPs) are often uncomfortable with these patients, and attribute this to inadequacies in training, research, and continuing education in geriatric emergency medicine. 13,14 To address this issue, the Society for Academic Emergency developed a curriculum and model of care for the emergency medical treatment of elder patients. 15In a parallel attempt to improve EPs' understanding of the special problems of elders, we developed a practice guideline for the ED evaluation and treatment of falls in older persons. We chose falls because we postu...

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“…These strategies have been successfully used by others with significant results. [32][33][34][35][36][37] …”

Section: Discussionmentioning

confidence: 99%

Effect of a Practice Guideline on the Process of Emergency Department Care of Falls in Elder Patients

Baraff

Lee

Kader

et al. 1999

Academic Emergency Medicine

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“…In a Dutch RCT, preventive home visits in a general older population showed an increased risk of admission to hospitals among the controls (van Rossum et al 1993). Three other controlled trials found no differences in admission rates between intervention and control groups (Fabacher et al 1994;Stuck et al 1995;Dalby et al 2000). A systematic review and meta-analysis of six studies analysing admission to hospital among the general older population suggested that home visits had no significant effect on hospital admissions (Elkan et al 2001).…”

Section: Introductionmentioning

confidence: 97%

Preventive home visits to home-dwelling older people and hospital admissions: a municipality-randomised intervention trial

et al. 2007

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Preventive home visits to older home-dwelling people have been part of national policy in Denmark since 1996. The aim was to evaluate whether education of home visitors and GPs was associated with hospital admission rates. In a population-based prospective controlled intervention trial in 34 municipalities, intervention municipality visitors received regular education during 3 years and GPs were introduced to a short assessment programme. Participation totalled 4,034 75-and 80-year-old home-dwelling persons, of which 3,132 (78%) had no mobility disability at baseline. Complete data on hospital services were obtained for all participants. No difference was observed in time to first admission between older people living in the intervention municipalities compared with people living in the control municipalities, HR 0.93 (95%CI: 0.85, 1.02, P = 0.17). Duration of first hospital stay was the same in the two groups (7.3 days). The mean number of admissions was not associated with intervention. Accepting and receiving home visits was associated with a reduced risk of hospital admission, HR 0.84 (95%CI: 0.76, 0.92), especially among the initially disabled. Hospital admission rates were associated with functional decline patterns. Persons experiencing catastrophic and progressive decline had the highest risk. Persons experiencing reversible functional decline were more often hospitalised in the intervention municipalities, and fewer persons living in the intervention municipalities experienced progressive decline. Education of primary care professionals was not associated with risk for first hospital admission among all older people living in the community, but may be associated with older people's different functional decline patterns.

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“…Owing to all these evaluations, following benefits can be achieved: prolongation of life span, maintenance and improvement of functional status and quality of life, decrease in hospital and nursing home care, decrease in mortality and hospital costs, and low dependence for activities of daily living (ADL) (9)(10)(11). Advanced age and its adverse effects on mental state and functional capacity must be kept in mind while initiating the therapy, following-up the therapy, or planning alterations of the therapy of diabetes mellitus.…”

Section: Introductionmentioning

confidence: 99%

Evaluation of Cognitive Functions and Daily Living Activities of Elderly Diabetics under Intensive Insulin Therapy

Karabulut¹,

Basat²,

Basat³

2015

JAREM

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Objective: Our aim was to evaluate the cognitive functions and daily living activities of the elderly diabetics who were under a basal-bolus intensive insulin therapy.Methods: Our study included 108 patients admitted to our outpatient clinic who are over 65 years of age and under an intensive insulin therapy. Minimental state examination (MMSE), activities of daily living (ADL), and instrumental activities of daily living (IADL) scales were used to evaluate cognitive functions and daily living activities. Fasting glucose and HbA1c levels were measured and history of hypoglycemia was recorded.Results: MMSE revealed 24 patients (22.2%) with impaired cognitive functions. Patients with impaired cognitive functions were significantly prone to more hypoglycemic episodes and lower functionality. Conclusion:Due to the complexity of intensive insulin therapy regimen, cognitive functions and functionality of the elderly diabetics should be carefully examined before deciding on intensive insulin therapy. (JAREM 2015; 5: 47-51)

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A Trial of Annual in-Home Comprehensive Geriatric Assessments for Elderly People Living in the Community

Abstract: A program of in-home comprehensive geriatric assessments can delay the development of disability and reduce permanent nursing home stays among elderly people living at home.

Cited by 418 publications

References 30 publications

Effect of a Practice Guideline on the Process of Emergency Department Care of Falls in Elder Patients

Effect of a Practice Guideline on the Process of Emergency Department Care of Falls in Elder Patients

Preventive home visits to home-dwelling older people and hospital admissions: a municipality-randomised intervention trial

Evaluation of Cognitive Functions and Daily Living Activities of Elderly Diabetics under Intensive Insulin Therapy

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