Targeting Strategies: An Overview of Criteria and Outcomes

Abstract

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.

Frailty in Older Adults: Evidence for a Phenotype

“…Prior to this, frailty has primarily been evaluated in hospitalized or nursing home populations (3,4,7,8,24,46,47). Such studies, due to the selection process by which their participants arrive in these settings, are likely to characterize persons with late-stage frailty, after the occurrence of related adverse outcomes, and having highly selected correlates.…”

“…Potential definitions of frailty abound, defining frailty as synonymous with disability (1,8,9), comorbidity (8), or advanced old age (3). Increasingly, geriatricians define frailty as a biologic syndrome of decreased reserve and resistance to stressors, resulting from cumulative declines across multiple physiologic systems, and causing vulnerability to adverse outcomes (9)(10)(11)(12)(13).…”

“…RAILTY is considered to be highly prevalent with increasing age and to confer high risk for adverse health outcomes, including mortality, institutionalization, falls, and hospitalization (1)(2)(3). Numerous geriatric interventions have been developed to improve clinical outcomes for frail older adults (3)(4)(5)(6)(7).…”

“…Numerous geriatric interventions have been developed to improve clinical outcomes for frail older adults (3)(4)(5)(6)(7). A major obstacle to the success of such interventions has been the absence of a standardized and valid method for screening of those who are truly frail so as to effectively target care (1,3).…”

Subacute care and rehabilitation

“…The ability to produce sustained improvements in function is doubtful, but several studies have shown at least short term gains (Cohen, Feussner et al 2002). Careful patient selection is a critical factor in program effectiveness, with patients that are either too well, or severely ill (eg advanced dementia and terminal cancer) appearing to gain no benefit (Winograd 1991). Other success factors include the necessity for full decision-making control to rest with the geriatric team, and the ability to provide post-discharge follow-up (Reuben, Borok et al 1995).…”