Geriatric Consultation: A Functional Approach

Interdisciplinary team assessment may not be feasible in the consultative setting because of scarce institutional resources. We explored the extent to which a physician-administered multifaceted assessment could meet the needs of a geriatric consultative service and also provide for the comprehensive functional assessment of elderly patients. Fifty-one consecutive patients, mean age 78, were evaluated. Domains measured included physical and mental health, socioeconomic resources, and activities of daily living. Despite a majority of consult requests for transfer of seemingly stable patients, unrecognized remediable problems were identified in most cases. Compliance with the consultant's recommendations was consistently poor, averaging less than 33% for all of the domains assessed. Nine of the study patients subsequently were transferred to the care of an interdisciplinary team on the geriatric assessment unit. Numbers and types of problems identified by the geriatric consultation using a structured assessment format allows for the comprehensive and efficient disclosure of pertinent management issues. Improved compliance with consultant recommendations may be effected by better education of care providers to the special needs of the geriatric population.

Section: Discussionmentioning

confidence: 99%

Use of a Structured Functional Assessment Format in a Geriatric Consultative Service

Katz¹,

Dube²,

Calkins³

1985

“…For hospital‐based GEM units, the length of index hospitalization is affected by the length of the assessment itself. Thus, some programs prolong initial length‐of‐stay, 44–46 but others reduce initial stay 26,31,36,39,47 . Studies following patients for at least 1 year, however, usually showed overall reduction in use of acute‐care hospital services, even in those programs with initially prolonged hospital stays 17,20,24,29 …”

Section: Geriatric Evaluation and Management Programs: Documented Benmentioning

confidence: 99%

Impacts of Geriatric Evaluation and Management Programs on Defined Outcomes: Overview of the Evidence

Rubenstein

Stuck

Siu

et al. 1991

486

288

Comprehensive geriatric assessment is a technique for multidimensional diagnosis of frail elderly people with the purpose of planning and/or delivering medical, psychosocial, and rehabilitative care. When comprehensive geriatric assessment is coupled with some therapy, then the term geriatric evaluation and management (GEM) will be used. Following a brief history of comprehensive geriatric assessment, we describe the varied patterns of GEM program organization and review the literature of studies examining GEM effectiveness. Program diversity complicates drawing firm conclusions about GEM effects; however, the vast majority of studies report positive, if not uniformly significant, results. Our analysis suggests that much of the variability in findings is due to sample size limitations In order to reach conclusions of program effects across studies and to avoid problems of small sample sizes, we undertook a formal meta‐analysis. In this initial meta‐analysis, we sought to evaluate the effect of GEM programs on a single outcome: mortality. We pooled all published GEM controlled trials into four major groups: inpatient consultation services, inpatient GEM units, home assessment services, and outpatient GEM programs. Meta‐analysis of 6‐month mortality demonstrates a 39% reduction of mortality for inpatient consultation services (odds ratio 0.61, 95% confidence interval 0.46–0.81, P = 0.0008) and a 37% reduction of mortality for inpatient GEM units (odds ratio 0.63, 95% CI 0.42–0.93, P = 0.02). Home assessment services reduced mortality by 29% (odds ratio 0.71, 95% CI 0.55–0.90, P = 0.005). On the other hand, no significant survival effect was found for outpatient GEM programs (odds ratio 0.96, 95% confidence interval 0.61–1.49). Further use of meta‐analytic techniques should be employed to clarify the effect of GEM on other important outcomes (eg, functional status, use of hospitals and nursing homes) as well as to identify program characteristics most effective in achieving these benefits.

“…However, several descriptive studies have attributed positive outcomes to geriatric consultations requested on the basis of such intuitive impressions. The team described by Lichtenstein and Winograd 34 received consultation requests primarily from internal medicine, family medicine, surgery, and surgical subspecialties. Focusing on social and medical conditions that interfered with independent living, these geriatricians identified 50 new diagnoses.…”

Section: Strategies For Targeting Geriatric Servicesmentioning

confidence: 99%

“…Focusing on social and medical conditions that interfered with independent living, these geriatricians identified 50 new diagnoses. After consultation, 51% of patients who were slated for nursing home placement were re‐routed to lower levels of care 34 . Duthie and Gambert 35 also described a consult team that functioned by request based on implicit, intuitive criteria.…”

Section: Strategies For Targeting Geriatric Servicesmentioning

confidence: 99%

Targeting Strategies: An Overview of Criteria and Outcomes

Winograd¹

1991

Self Cite

Researchers generally agree that Geriatric Evaluation and Management (GEM) Units are effective only when they are targeted at a specific group of frail, elderly patients who are most likely to benefit. Such patients are those who are neither too sick (eg, severely demented or moribund) nor too well. Various strategies for identifying such patients have been employed by investigators with little consensus on the most efficient targeting criteria. Criteria most often used for inclusion in GEM programs are various combinations of patient age, degree of functional impairment, presence of geriatric conditions (eg falls, incontinence, confusion), particular diagnostic conditions (eg, multiple disorders), and psychosocial conditions (eg, living alone, recent bereavement, low income). Commonly used exclusion factors are severe dementia, inevitable nursing home placement, and terminal illness. Outcome studies suggest that beneficial effects of GEM care are most apparent when patients are selected using specific clinical criteria. Future research on targeting should address the potential need for differing criteria in different settings (eg, inpatient vs outpatient GEM units), simplifications of criteria for greatest ease of application, and prospective evaluation of which criteria best predict functional improvement, longer survival, and reduced health care expenditures in response to GEM care.