Performance of a brief geriatric evaluation compared to a comprehensive geriatric assessment for detection of geriatric syndromes in family medicine: a prospective diagnostic study.

BACKGROUND: Geriatric syndromes are rarely detected in family medicine. Within the AGE program (active geriatric evaluation), a brief assessment tool (BAT) designed for family physicians (FP) was developed and its diagnostic performance estimated by comparison to a comprehensive geriatric assessment. METHODS: This prospective diagnostic study was conducted in four primary care sites in Switzerland. Participants were aged at least 70 years and attending a routine appointment with their physician, without previous documented geriatric assessment. Participants were assessed by their family physicians using the BAT, and by a geriatriciant who performed a comprehensive geriatric assessment within the following two-month period (reference standard). Both the BAT and the full assessment targeted eight geriatric syndromes: cognitive impairment, mood impairment, urinary incontinence, visual impairment, hearing loss, undernutrition, osteoporosis and gait and balance impairment. Diagnostic accuracy of the BAT was estimated in terms of sensitivity, specificity, and predictive values; secondary outcomes were measures of feasibility, in terms of added consultation time and comprehensiveness in applying the BAT items. RESULTS: Prevalence of the geriatric syndromes in participants (N=85, 46 (54.1%) women, mean age 78 years (SD 6))ranged from 30.0% (malnutrition and cognitive impairment) to 71.0% (visual impairment), with a median number of 3 syndromes (IQR 2 to 4) per participant. Sensitivity of the BAT ranged from 25.0% for undernutrition (95%CI 9.8% - 46.7%) to 82.1% for hearing impairment (95%CI 66.5% - 92.5%), while specificity ranged from 45.8% for visual impairment (95%CI 25.6-67.2) to 87.7% for undernutrition (76.3% to 94.9%). Finally, most negative predictive values (NPV) were between 73.5% and 84.1%, excluding visual impairment with a NPV of 50.0%. Family physicians reported BAT use as per instructions for 76.7% of the syndromes assessed. CONCLUSIONS: Although the BAT does not replace a comprehensive geriatric assessment, it is a useful and appropriate tool for the FP to screen elderly patients for most geriatric syndromes. TRIAL REGISTRATION: The study was registered on ClinicalTrials.gov on February 20, 2013 ( NCT01816087 ).

What is Comprehensive Geriatric Assessment (CGA)? An umbrella review.

Background: Comprehensive Geriatric Assessment (CGA) is now the accepted gold standard for caring for frail older people in hospital. However, there is uncertainty about identifying and targeting suitable recipients and which patients benefit the most. Objectives: our objectives were to describe the key elements, principal measures of outcome and the characteristics of the main beneficiaries of inpatient CGA. Methods: we used the Joanna Briggs Institute umbrella review method. We searched for systematic reviews and meta-analyses describing CGA services for hospital inpatients in the Cochrane Database of Systematic Reviews, Database of Reviews of Effectiveness (DARE), MEDLINE and EMBASE and a range of other sources. Results: we screened 1,010 titles and evaluated 419 abstracts for eligibility, 143 full articles for relevance and included 24 in a final quality and relevance check. Thirteen reviews, reported in 15 papers, were selected for review. The most widely used definition of CGA was: 'a multidimensional, multidisciplinary process which identifies medical, social and functional needs, and the development of an integrated/co-ordinated care plan to meet those needs'. Key clinical outcomes included mortality, activities of daily living and dependency. The main beneficiaries were people ≥55 years in receipt of acute care. Frailty in CGA recipients and patient related outcomes were not usually reported. Conclusions: we confirm a widely used definition of CGA. Key outcomes are death, disability and institutionalisation. The main beneficiaries in hospital are older people with acute illness. The presence of frailty has not been widely examined as a determinant of CGA outcome.

Public policy and the dependency of nursing home residents in Australia: 1968-69 to 2006-07.

OBJECTIVE: The purpose of this paper is to derive annual estimates of the aggregate dependency of the nursing home population in Australia, and to use these data to consider the impact of Government policies to target nursing home services to those with high care-needs/dependency. Two related tools, the 'Aggregate Dependency Value' and 'Aggregate Dependency Index', have been constructed using the principles of case-mixed based systems, to quantify the aggregate dependency of residents. Data on all residents 1968-1969 to 2006-2007, and on newly admitted residents 1992-1993 to 2006-2007 have been derived and analysed. METHODS: To construct the tools, the percent of residents classified into various dependency categories were weighted by proxy measures of their dependency. These were summed, and converted into index numbers to estimate rates of change in the aggregate dependency of residents. The derived data were used to consider possible impacts of the policies. RESULTS: The data indicate that the dependency of residents has, for the most part, increased over recent decades but that the rate of the increase has varied. An increase in the dependency of residents corresponds with the policies' objectives. CONCLUSIONS: The tools extend the ways the dependency of nursing home residents in Australia can be assessed. The estimates support the effectiveness of the Government's targeting policies but causal relationships have not been estimated.

Elder abuse and neglect--"old phenomenon": new directions for research, legislation, and service developments. (2008 Rosalie S. Wolf Memorial Elder Abuse Prevention Award--International Category Lecture).

This article poses the question: Is elder abuse and neglect a social problem, showing that it is. Elder abuse, though, is still the most hidden form of mistreatment and a key to governmental responses to an ageing population. It is an important facet as a family violence problem, an intergenerational concern, as well as a health, justice and human rights issue. Because the phenomenon of elder abuse and neglect is so complex and multi-dimensional, it has to be addressed by multi-professional and inter-disciplinary approaches. Raising awareness is a fundamental prevention strategy and an important step in causing changes in attitudes and behaviors. This has been accomplished by INPEA and the article was developed from the lecture given by the author on receiving the International Rosalie Wolf Award from INPEA. The discussion focuses on elder abuse as a product of global ageing, stemming from population ageing, which is consistent with an increased prevalence of abuse of all vulnerable groups, older people among them. It is pointed out that baseline and trend data on the nature and prevalence of senior abuse are crucial to policy responses and the development of appropriate programs and services. Difficulties in assessing the scope of the phenomenon, though, are due to: problems in definitions and methodology, which create difficulties in comparing data from various countries; lack of social and familial awareness; isolation of some elders, especially migrants; elder abuse as a 'hidden issue' that usually occurs in the privacy of the home and is viewed as a family affair; limited access to institutional settings. Difficulties also exist in constructing a unifying research framework in order to study the phenomenon due to a lack of comparison groups, a lack of representative national surveys and difficulties in measurement. There is currently, however, an increase in prevalence and incidence studies from both sides of the Atlantic and especially from Europe. But while prevalence studies provide base-data on numbers, little is known about key conceptual issues for policy, practice and the understanding of different forms of abuse and neglect. Theoretical under-development hampers the collection of systematic cumulative knowledge which is based on universally agreed upon and standardized tools, and reduces the ability to discover unifying themes and their relationship to local idiosyncrasies existing in the field. Additionally, there has been no attempt to develop theoretical knowledge grounded in data from the study of elder abuse itself. The following vehicles for action are, thus, suggested: Developing international, national and regional research agendas and data bases; developing policy and legislation; developing services and interventions and developing educational programs.

The development of Version 2 of the AN-SNAP casemix classification system.

This paper presents the results of a recent review of the Australian National Sub-acute and Non-acute Patient (AN-SNAP) classification system. The AN-SNAP system was developed by the Centre for Health Service Development, University of Wollongong in 1997. The review was conducted between August 2005 and September 2006. Four clinical sub-committees comprising more than 50 clinicians from sub-acute services across New South Wales as well as representatives from Queensland and the Australian Capital Territory were established to develop a set of proposals to be considered for incorporation into Version 2 of the classification. It is proposed that the final AN-SNAP Version 2 classification will be available for implementation from 1 July 2007.

[The Barthel Index in geriatrics. A context analysis for the Hamburg Classification Manual]. / Der Barthel-Index in der Geriatrie. Eine Kontextanalyse zum Hamburger Einstufungsmanual.

The Barthel Index (BI) is firmly established as an assessment instrument in geriatrics. It is a proven, clear and easy-to-use instrument for the recording of basic daily functions. However it is increasingly finding new applications beyond its original, clinically orientated use. It has been applied as a quality parameter, as an instrument for the management of service delivery provision and as an instrument to record treatment efforts relevant to care or costs. This study considers the basic suitability prerequisites of the Barthel Index for these applications.With the Hamburg Classification Manual for the BI, German geriatrics has made a contribution to the standardized operationalization of the items and to the standardized evaluation of aids. An evaluation was performed on a total of 5262 Barthel classifications at seven geriatric hospitals according to existing classification practice by comparison with 5483 classifications after introduction of the Hamburg Classification Manual. No significant differences were found in Barthel Index total scores either on admission or on discharge. With respect to further applications it is essential to be aware that the usability of the total score (including its changes over the course of time) is limited because of the ordinal scaling of the BI. Studies have been carried out which show how important this is, although they have so far received little attention. As a grading criterion the BI takes account not only of the "functional status" but also of the "extent of support effort". This can lead to positive changes in one focus -- especially with the use of aids -- without associated improvements in the other focus. Whether the BI in this form is meaningful for a specific application must be tested separately for each individual context. There is no justification for assuming that the BI has general validity irrespective of application. The results of a systematic literature survey on the testing quality criteria of the BI indicate an astonishingly generous approach to the question of the validity of the BI. Contrary to widespread opinion, cognitive-psychological components do influence the classification result of the BI. As an addition to the Hamburg Classification Manual we recommend that the extent of this influencing factor should also be more clearly operationalized and that "stimulation required" for the carrying out of an activity be included in the evaluation equivalent to the factor "supervision required" already introduced by Barthel and Mahoney. The BI has shown itself to be an efficient but nonetheless multidimensional global parameter in clinical practice, whose meaningfulness is on the level of the individual item and whose validity, particularly as total score and course parameter, needs to be proven for each new application. The Hamburg Classification Manual, as a standardized and consensus-based operationalization of the BI, provides an important basis for this.

Screening tool helps identify high-risk seniors, cut costs.

The science of delivering case management services to the elderly most in need gets a boost from a program in San Francisco. It gives physicians information while providing more detail to clinical managers.

Predictors of decline in self-assessments of health among older people--a 5-year longitudinal study.

Within the framework of the Evergreen project we examined how changes in several indicators of health and functioning and physical activity predicted a decline in self-assessments of health evaluated over a 5-year period in older people by two different measurements: self-rated health (SRH) and self-assessed change in health (SACH). The study group comprised all 75-year-old persons born in 1914 (N = 382) and living in Jyväskylä, a town in central Finland. At baseline in 1989, 91.6%, and at follow-up 5 years later in 1994, 87.3% of those eligible participated in the interview and 77.2 and 71.3%, respectively, in the examinations in the study centre, focusing on different domains of health and functional capacity. One-fifth of the subjects reported a deterioration in and one-fifth an improvement in SRH over the 5 years. The rest gave identical self-assessments of their health at baseline and at follow-up in response to the same question. Decline in SRH was associated with a decrease in physical activity and cognitive capacity. When asked directly about changes in their health (SACH), however, half the subjects said their health had declined. Negative SACH over the 5-year period was related to an increased number of chronic conditions, deterioration in functional performance and physical activity, and to the number of chronic conditions at baseline. We suggest that ageing people adapt to changes in their objective health and functional performance: the majority tend to assess their health as similar to or even better with increasing age despite an increase in chronic diseases and decline in functional performance. However, a negative SACH indicates that older people are realistic about these negative changes. These results support the assumption that the two subjective measurements of change in health are based on different criteria: assessment of current general health status tends to be based on inter-individual comparison, whereas assessment of change in health over a given time period may be based on intra-individual comparison. Physical activity seems to be an important factor when older people assess their health.

The validity of the minimum data set in measuring the cognitive impairment of persons admitted to nursing homes.

OBJECTIVES: This study examined the construct validity of two cognitive scales from the federally mandated Minimum Data Set (MDS) of the nursing home Resident Assessment Instrument. DESIGN: A cross-sectional comparisons of the MDS measures, with scales provided by the resident, a proxy person, and nursing staff. SETTING: Subjects residing in 59 nursing homes (NHs) in Maryland from 1992 to 1995. PARTICIPANTS: Subjects were 1939 new admissions to NHs, aged 65 and older, with complete MDS information at admission. MEASUREMENTS: Two MDS scales, the Cognitive Performance Scale (CPS) and the MDS Cognition Scale (MDS-COGS), were compared with the Mini-Mental State Examination (MMSE) and the staff rating on the Psychogeriatric Dependency Rating Scale (PGDRS) Orientation scale, as well as measures of functioning and functional decline. RESULTS: The CPS and the MDS-COGS were highly correlated (r = 0.92). Both correlated moderately well with the MMSE (r = -0.65 and -0.68) and with staff's rating on the PGDRS Orientation scale (r = 0.63 and r = 0.66). Correlations with the MMSE (r < 0.70) are lower than previously reported (r > or = 0.80). The proportion of cognitively impaired residents in this NH admission cohort was higher using the MDS-COGS than the CPS (65% vs 57%), but both MDS scales produced lower proportions than the MMSE (70%) and higher proportions than the PGDRS (47%). The internal consistency of the CPS was better without the comatose item (alpha = 0.80 vs 0.70). The MDS-COGS had higher internal consistency (alpha = 0.85) and was simpler to compute. CONCLUSIONS: This is the first study to examine the validity of the MDS in a large sample of residents and NHs in situations where the MDS was not completed by research-trained staff. Compared with other instruments, the MDS-COGS and the CPS had moderate and similar validity for assessing cognitive impairment. Differences in the scales could provide different estimates of impairment among persons admitted to nursing homes.

Measurement: the key to success for providers, payors, and patients in long-term care.

The complex financing structure that supports home and community-based long-term care services has resulted in the application of different quality assurance requirements to similar services. Goals for home and community-based care are viewed differently by providers, payors, and customers. This raises the issue of how goals can be harmonized and what should be used to measure goals. Current quality assurance strategies are judge insufficient to assure the delivery of high-quality services; in part due to the state of health programs and lack of unified outcome measurement. The need for multidimensional assessment to adopt a baseline measure of health status to support allocation of services and enhance successful client outcomes has become the aim for health care providers.

Equating health status measures with item response theory: illustrations with functional status items.

BACKGROUND: More than 75 instruments have been developed to measure functional status. These measures differ in number of items, type of rating scale, and item difficulty. Such variations render it impossible to compare data across different measures. One way to overcome such test dependency is test equating, which relates scores from different measures to a common metric. OBJECTIVE: We developed a bank of physical functioning items and equated them using item response theory. DESIGN: We used a common-item equating design and a self-administered survey of functional status. SUBJECTS: Individuals > or = 65 years of age who had > or = 1 ambulatory visit across a 3-month sampling frame to a Veterans Administration Medical Center or its affiliated university medical center. RESULTS: The dressing items were the most discriminating, followed by bathing, toileting, mobility, cooking/eating, and household and community activities. The 5 most discriminating items were to put underclothes on, manage clothes after toileting, move between rooms, take pants/slacks off, and get into bed. Most of the items were located on the easier end of the ability continuum. Only 6 would classify as being very difficult. CONCLUSIONS: We used item response theory to equate and calibrate a large number of activities of daily living on the same scale; by doing so, we were able to better understand the structure and order of domain-specific items to each other, as well as the interrelations among items across the ability continuum.

The delegate's dilemma: ACAT re-assessment in hostels.

The provision for 'ageing in place' in the Aged Care Act of 1997 has provided an opportunity for hostel facilities to broaden their scope of care for older people. Aged Care Assessment Teams (ACATs) are required to provide assessments to give approval for high or low level entry to these facilities, and to provide approval for reclassification from low to high care. However, guidelines for ACAT assessments are contradictory with respect to the Resident Classification Scale (RCS) which provides the facility funding formula, thus creating gatekeeping compared with advocacy difficulties for the ACAT. If the facility can support a claim of high care need for a resident via the RCS but the ACAT (using different and less in-depth criteria) does not agree with that claim, then the care of that resident might be compromised due to inadequate funding. Recommendations made to solve this dilemma include conferring the right of the hostel staff to reclassify residents when necessary, with the responsibility for confirmation of that classification to remain with the trained validation officers from the Commonwealth Department of Health and Family Services, not the ACAT.

Balancing resources and risk: selecting home care clients in Florida's CARES program.

Selecting home care patients who would otherwise go into a nursing home always involves error: serving too many or two few. To clarify the choices program and case managers must make, we propose a risk-based alternative to current selection methods that involves scientifically-derived variable weighting and conscious choice of cut-off score for bestowing home care eligibility. We illustrate our proposal with data from Florida's Comprehensive Assessment and Review of Long-term Care Services (CARES) program. Using logistic regression we identify characteristics that distinguish clients recommended for nursing home placement from those referred to the community and use these results to estimate the risk of nursing home recommendation for each client. An approach to using these risk scores to determine eligibility is demonstrated along with assessment of the impact of alternative risk score cut-offs on denying care to as many as half or as few as 5% of clients served.

Older home health care patients and their physicians: assessment of functional ability.

Assessment of a person's level of functional impairment is a key aspect of geriatric clinical practice. This study examines the agreement between functional assessments reported by 54 physician-patient dyads. Physicians were typical of those providing services to elderly patients in an urban area. Patients, all aged 65 or more years and community-living, had been referred by these physicians for in-home health care services. Generally, physicians reported less impairment than did their patients, functional assessments by both doctors and patients matching completely in only 15 of 54 (28%) dyads. Underestimation of patient impairment occurred most commonly with respect to stair climbing, control of the urinary bladder, and bathing, but was also substantial for dressing, walking, and toileting. Few patient or doctor characteristics predicted congruence or lack thereof in assessment of functional impairments. Some implications of these findings for clinical practice and medical education are examined.

[Determining the extent of nursing care need according to the nursing care insurance law in an interdisciplinary comparison]. / Die Bestimmung des Umfangs der Pflegebedürftigkeit nach dem Pflegeversicherungsgesetz im interdisziplinären Vergleich.

The quantifying of care needed is an important issue of the long-term care insurance act in Germany. In the last three decades limits of self-sufficiency have been defined in the context of law, medicine, social science and nursing science. Following these approaches this study distinguishes between determining the limits of self-sufficiency and determining the care needed. On that basis the procedure for determining in the long-term care insurance is analyzed and numerous problems are shown. Arriving at non-optimal results can only be understood in terms of briefly explained background material. One solution could lie in the use or further development of existing models which determine the limits of self-sufficiency on the basis of ADL scales.

Looking inside the black box of comprehensive geriatric assessment: a classification system for problems, recommendations, and implementation strategies.

OBJECTIVE: To develop and test the inter-rater reliability of a coding system for geriatric problems identified through Comprehensive Geriatric Assessment (CGA) of hospitalized older persons, recommendations generated by the assessment, and implementation strategies for these recommendations. DESIGN: Validation study. SETTING: A health maintenance organization and a geriatrics academic program. PARTICIPANTS: A total of 49 hospitalized older persons, who met at least 1 of 13 inclusionary "targeting" criteria, two geriatricians, and one social worker who coded forms. MEASUREMENTS: Standardized coding of CGA consultation sheets into (1) geriatric problems identified, (2) recommendations, and (3) implementation strategies; inter-rater reliability testing of coding system using two physicians and a social worker. RESULTS: On average, each assessed patient had 4.8 recommendations. The largest percentages of recommendations were for non-physician referrals (18.2%), advance directives (13.4%), medication adjustments (11.5%), diagnostic evaluation/monitoring (11.5%), and community services (10.9%). The proportions of agreement between raters in coding problems ranged from 0.77 to 0.90, in coding recommendations from 0.69 to 0.86, and in coding implementation strategies from 0.68 to 0.83. CONCLUSION: A classification system for measuring some components of the process of care of CGA has satisfactory inter-rater reliability, can be adapted for other settings, and may provide valuable insight into determining which components of CGA confer health benefits.