Health care for older adults in Europe: how has it evolved and what are the challenges?

Geriatric medicine has evolved to an accepted specialty in 23 European countries. Despite much heterogeneity of postgraduate geriatric curricula, European societies have succeeded in defining a common core curriculum with a list of minimum training requirements for obtaining the specialty title of geriatric medicine. Geriatricians play a leading role in finding solutions for the challenges of health care of multimorbid older patients. One of these challenges is the demographic shift with the number of adults aged 80 years and older in Europe expected to double by 2050. Although geriatric units will play a role in the care of frail older patients, new care models are needed to integrate the comprehensive geriatric assessment approach for the care of the vast majority of older patients admitted to non-geriatric hospital units. Over the last few years, co-management approaches have been developed to address this gap. Innovative models are also in progress for ambulatory care, prevention and health promotion programs, and long-term care. Efforts to implement geriatric learning objectives in undergraduate training, and the generation of practice guidelines for geriatric syndromes may help to improve the quality of care for older patients.

The giants of education in geriatric medicine and gerontology.

In 2014, the European undergraduate curriculum in Geriatric Medicine was published to cover the minimum requirements that a medical student should achieve by the end of medical school. In 2019, the European postgraduate curriculum in Geriatric Medicine outlined the minimum recommended training requirements to become a geriatrician at specialist level in the EU. The postgraduate dimension of Geriatric Medicine education is a highly relevant topic for all, since most physicians-independently of their specialty-are inevitably involved in the care of older patients, but for most physicians, geriatrics is not part of their postgraduate generalist or specialty training. A key area for postgraduate education remains the provision of Geriatric Medicine competencies to all specialties outside geriatrics. There is also need for wider educational initiatives to improve the gerontological education of patients and the public. Bernard Isaacs famously coined the expression 'geriatric giants' or the four clinical I's: Intellectual impairment, Incontinence, Immobility, and Instability. However, non-clinical giants exist. In education, we face challenges of Investment, Inspiration, Integration, and Interprofessionality; and in research, we need to attract Interest and Income, and generate Innovation and Impact. Without strengthening the links between all giants, we will not be able to achieve the ambition of age-attuned societies. A key goal for gerontological education is to enhance everyone's understanding of the wide diversity underlying the 'older people' demographic label, which will ultimately promote services and societies that are more responsive and inclusive to the needs of all older adults, irrespective of their health status.

Geriatric medicine learning objectives and entrustable professional activities in undergraduate medical curricula: a scoping review.

BACKGROUND: entrustable professional activities (EPAs) have become an important component of competency-based medical education. The aim of this study is to evaluate how geriatric medicine learning objectives are addressed by undergraduate medical curricula including EPAs. METHODS: we performed a scoping review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews guidelines to identify undergraduate medical curricula that include EPAs. A content analysis was conducted to examine how these curricula address the care of older individuals. In addition, we mapped the curricula to 19 geriatric medicine learning objectives identified from the European curriculum of undergraduate medical education. RESULTS: we found nine curricula, each containing between 4 and 16 core EPAs. In the sections describing the EPAs, three of the nine curricula specify that all core EPAs apply to all age groups including older patients, whereas the remaining six curricula either only refer to older patients in selected EPAs or not at all. Mapping revealed that some geriatric medicine learning objectives are covered by most curricula (e.g. medication use, multidisciplinary team work), whereas others are lacking in the majority (e.g. normal ageing, geriatric assessment, cognitive assessment, nutrition assessment, decision-making capacity assessment, long-term care). Three curricula cover most geriatric learning objectives by using a matrix aligning EPAs with geriatric competencies. CONCLUSIONS: geriatric learning objectives continue to be missing from undergraduate medical curricula, also from those adopting the novel approach of EPAs. However, this review also identified some curricula that might serve as models for how geriatric learning objectives can be successfully covered within future EPA frameworks.

Death at no cost? Persons with no health insurance claims in the last year of life in Switzerland.

BACKGROUND: Lack of health insurance claims (HIC) in the last year of life might indicate suboptimal end-of-life care, but reasons for no HIC are not fully understood because information on causes of death is often missing. We investigated association of no HIC with characteristics of individuals and their place of residence. METHODS: We analysed HIC of persons who died between 2008 and 2010, which were obtained from six providers of mandatory Swiss health insurance. We probabilistically linked these persons to death certificates to get cause of death information and analysed data using sex-stratified, multivariable logistic regression. Supplementary analyses looked at selected subgroups of persons according to the primary cause of death. RESULTS: The study population included 113,277 persons (46% males). Among these persons, 1199 (proportion 0.022, 95% CI: 0.021-0.024) males and 803 (0.013, 95% CI: 0.012-0.014) females had no HIC during the last year of life. We found sociodemographic and health differentials in the lack of HIC at the last year of life among these 2002 persons. The likelihood of having no HIC decreased steeply with older age. Those who died of cancer were more likely to have HIC (adjusted odds ratio for males 0.17, 95% CI: 0.13-0.22; females 0.19, 95% CI: 0.12-0.28) whereas those dying of mental and behavioural disorders (AOR males 1.83, 95% CI:1.42-2.37; females 1.65, 95% CI: 1.27-2.14), and males dying of suicide (AOR 2.15, 95% CI: 1.72-2.69) and accidents (AOR 2.41, 95% CI: 1.96-2.97) were more likely to have none. Single, widowed, and divorced persons also were more likely to have no HIC (AORs in range of 1.29-1.80). There was little or no association between the lack of HIC and characteristics of region of residence. Patterns of no HIC differed across main causes of death. Associations with age and civil status differed in particular for persons who died of cancer, suicide, accidents and assaults, and mental and behavioural disorders. CONCLUSIONS: Particular groups might be more likely to not seek care or not report health insurance costs to insurers. Researchers should be aware of this aspect of health insurance data and account for persons who lack HIC.

Regional Variation of Cost of Care in the Last 12 Months of Life in Switzerland: Small-area Analysis Using Insurance Claims Data.

BACKGROUND: Health care spending increases sharply at the end of life. Little is known about variation of cost of end of life care between regions and the drivers of such variation. We studied small-area patterns of cost of care in the last year of life in Switzerland. METHODS: We used mandatory health insurance claims data of individuals who died between 2008 and 2010 to derive cost of care. We used multilevel regression models to estimate differences in costs across 564 regions of place of residence, nested within 71 hospital service areas. We examined to what extent variation was explained by characteristics of individuals and regions, including measures of health care supply. RESULTS: The study population consisted of 113,277 individuals. The mean cost of care during last year of life was 32.5k (thousand) Swiss Francs per person (SD=33.2k). Cost differed substantially between regions after adjustment for patient age, sex, and cause of death. Variance was reduced by 52%-95% when we added individual and regional characteristics, with a strong effect of language region. Measures of supply of care did not show associations with costs. Remaining between and within hospital service area variations were most pronounced for older females and least for younger individuals. CONCLUSIONS: In Switzerland, small-area analysis revealed variation of cost of care during the last year of life according to linguistic regions and unexplained regional differences for older women. Cultural factors contribute to the delivery and utilization of health care during the last months of life and should be considered by policy makers.

Temporal trends in the treatment and outcomes of elderly patients with acute coronary syndrome.

AIMS: To determine whether treatment and outcomes of older acute coronary syndrome (ACS) patients changed over time. METHODS AND RESULTS: We analysed the use of guideline-recommended therapies and in-hospital outcomes of 13 662 ACS patients ≥70 years enrolled in the prospective Acute Myocardial Infarction in Switzerland (AMIS) cohort between 2001 and 2012 according to 4-year periods (2001-2004, 2005-2008, and 2009-2012). Between first and last 4-year period, percutaneous coronary intervention (PCI) use increased from 43.8 to 69.6% of older ACS patients ( ITALIC! P < 0.001). Use of guideline-recommended drugs as well increased. At the same time, in-hospital mortality of the overall population decreased from 11.6% in the first to 10.0% in the last 4-year period ( ITALIC! P = 0.020), and in-hospital major adverse cardiac and cerebrovascular events from 14.4 to 11.3% ( ITALIC! P < 0.001). Percutaneous coronary intervention was used in increasingly older and co-morbid patients over time (mean age of patients treated with PCI 76.2 years in 2001-2004 and 78.1 years in 2009-2012, ITALIC! P < 0.001; Charlson score ≥2 was found for 27.6% of patients treated with PCI in 2001-2004 and for 32.1% in 2009-2012, ITALIC! P = 0.003). Percutaneous coronary intervention use was associated with similar odds ratios (ORs) of in-hospital mortality over time (adjusted OR 0.29, 95% confidence interval, CI, 0.22-0.40, in 2001-2004; and, adjusted OR 0.26, 95% CI 0.20-0.35, in 2009-2012). CONCLUSION: Use of guideline-recommended therapies for ACS increased and in-hospital outcomes improved over the observed 12-year period. Though PCI was used in increasingly older and co-morbid patients, PCI use was associated with similar ORs of in-hospital mortality over time. This study suggests that increasing use of guideline-recommended therapies was appropriate. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01305785.

Dying among older adults in Switzerland: who dies in hospital, who dies in a nursing home?

BACKGROUND: Institutional deaths (hospitals and nursing homes) are an important issue because they are often at odds with patient preference and associated with high healthcare costs. The aim of this study was to examine deaths in institutions and the role of individual, regional, and healthcare supply characteristics in explaining variation across Swiss Hospital Service Areas (HSAs). METHODS: Retrospective study of individuals ≥66 years old who died in a Swiss institution (hospital or nursing homes) in 2010. Using a two-level logistic regression analysis we examined the amount of variation across HSAs adjusting for individual, regional and healthcare supply measures. The outcome was place of death, defined as death in hospital or nursing homes. RESULTS: In 2010, 41,275 individuals ≥66 years old died in a Swiss institution; 54 % in nursing homes and 46 % in hospitals. The probability of dying in hospital decreased with increasing age. The OR was 0.07 (95 % CI: 0.05-0.07) for age 91+ years compared to those 66-70 years. Living in peri-urban areas (OR = 1.06 95 % CI: 1.00-1.11) and French speaking region (OR = 1.43 95 % CI: 1.22-1.65) was associated with higher probability of hospital death. Females had lower probability of death in hospital (OR = 0.54 95 % CI: 0.51-0.56). The density of ambulatory care physicians (OR = 0.81 95 % CI: 0.67-0.97) and nursing homes beds (OR = 0.67 95 % CI: 0.56-0.79) was negatively associated with hospital death. The proportion of dying in hospital varied from 38 % in HSAs with lowest proportion of hospital deaths to 60 % in HSAs with highest proportion of hospital deaths (1.6-fold variation). CONCLUSIONS: We found evidence for variation across regions in Switzerland in dying in hospital versus nursing homes, indicating possible overuse and underuse of end of life (EOL) services.

Effect of health risk assessment and counselling on health behaviour and survival in older people: a pragmatic randomised trial.

BACKGROUND: Potentially avoidable risk factors continue to cause unnecessary disability and premature death in older people. Health risk assessment (HRA), a method successfully used in working-age populations, is a promising method for cost-effective health promotion and preventive care in older individuals, but the long-term effects of this approach are unknown. The objective of this study was to evaluate the effects of an innovative approach to HRA and counselling in older individuals for health behaviours, preventive care, and long-term survival. METHODS AND FINDINGS: This study was a pragmatic, single-centre randomised controlled clinical trial in community-dwelling individuals aged 65 y or older registered with one of 19 primary care physician (PCP) practices in a mixed rural and urban area in Switzerland. From November 2000 to January 2002, 874 participants were randomly allocated to the intervention and 1,410 to usual care. The intervention consisted of HRA based on self-administered questionnaires and individualised computer-generated feedback reports, combined with nurse and PCP counselling over a 2-y period. Primary outcomes were health behaviours and preventive care use at 2 y and all-cause mortality at 8 y. At baseline, participants in the intervention group had a mean ± standard deviation of 6.9 ± 3.7 risk factors (including unfavourable health behaviours, health and functional impairments, and social risk factors) and 4.3 ± 1.8 deficits in recommended preventive care. At 2 y, favourable health behaviours and use of preventive care were more frequent in the intervention than in the control group (based on z-statistics from generalised estimating equation models). For example, 70% compared to 62% were physically active (odds ratio 1.43, 95% CI 1.16-1.77, p = 0.001), and 66% compared to 59% had influenza vaccinations in the past year (odds ratio 1.35, 95% CI 1.09-1.66, p = 0.005). At 8 y, based on an intention-to-treat analysis, the estimated proportion alive was 77.9% in the intervention and 72.8% in the control group, for an absolute mortality difference of 4.9% (95% CI 1.3%-8.5%, p = 0.009; based on z-test for risk difference). The hazard ratio of death comparing intervention with control was 0.79 (95% CI 0.66-0.94, p = 0.009; based on Wald test from Cox regression model), and the number needed to receive the intervention to prevent one death was 21 (95% CI 12-79). The main limitations of the study include the single-site study design, the use of a brief self-administered questionnaire for 2-y outcome data collection, the unavailability of other long-term outcome data (e.g., functional status, nursing home admissions), and the availability of long-term follow-up data on mortality for analysis only in 2014. CONCLUSIONS: This is the first trial to our knowledge demonstrating that a collaborative care model of HRA in community-dwelling older people not only results in better health behaviours and increased use of recommended preventive care interventions, but also improves survival. The intervention tested in our study may serve as a model of how to implement a relatively low-cost but effective programme of disease prevention and health promotion in older individuals. TRIAL REGISTRATION: International Standard Randomized Controlled Trial Number: ISRCTN 28458424.

Risk factors for depressed mood amongst a community dwelling older age population in England: cross-sectional survey data from the PRO-AGE study.

BACKGROUND: The Quality and Outcomes Framework in the United Kingdom (UK) National Health Service previously highlighted case finding of depression amongst patients with diabetes or coronary heart disease. However, depression in older people remains under-recognized. Comprehensive data for analyses of the association of depression in older age with other health and functional measures, and demographic factors from community populations within England, are lacking. METHODS: Secondary analyses of cross-sectional baseline survey data from the England arm of a randomised controlled trial of health risk appraisal for older people in Europe; PRO-AGE study. Data from 1085 community-dwelling non-disabled people aged 65 years or more from three group practices in suburban London contributed to this study. Depressed mood was ascertained from the 5-item Mental Health Inventory Screening test. Exploratory multivariable logistic regression was used to identify the strongest associations of depressed mood with a previous diagnosis of a specified physical/mental health condition, health and functional measures, and demographic factors. RESULTS: Depressed mood occurred in 14% (155/1085) of participants. A previous diagnoses of depression (OR 3.39; P < 0.001) and poor vision as determined from a Visual Function Questionnaire (OR 2.37; P = 0.001) were amongst the strongest factors associated with depressed mood that were independent of functional impairment, other co-morbidities, and demographic factors. A subgroup analyses on those without a previous diagnosis of depression also indicated that within this group, poor vision (OR 2.51; P = 0.002) was amongst the strongest independent factors associated with depressed mood. CONCLUSIONS: Previous case-finding strategies in primary care focussed on heart disease and diabetes but health-related conditions other than coronary heart disease and diabetes are also associated with an increased risk for depression. Complex issues of multi-morbidity occur within aging populations. 'Risk' factors that appeared stronger than those, such as, diabetes and coronary heart disease that until recently prompted for screening in the UK due to the QOF, were identified, and independent of other morbidities associated with depressed mood. From the health and functional factors investigated, amongst the strongest factors associated with depressed mood was poor vision. Consideration to case finding for depressed mood among older people with visual impairment might be justified.

A novel multidimensional geriatric screening tool in the ED: evaluation of feasibility and clinical relevance.

PURPOSES: Geriatric problems frequently go undetected in older patients in emergency departments (EDs), thus increasing their risk of adverse outcomes. We evaluated a novel emergency geriatric screening (EGS) tool designed to detect geriatric problems. BASIC PROCEDURES: The EGS tool consisted of short validated instruments used to screen 4 domains (cognition, falls, mobility, and activities of daily living). Emergency geriatric screening was introduced for ED patients 75 years or older throughout a 4-month period. We analyzed the prevalence of abnormal EGS and whether EGS increased the number of EGS-related diagnoses in the ED during the screening, as compared with a preceding control period. MAIN FINDINGS: Emergency geriatric screening was performed on 338 (42.5%) of 795 patients presenting during screening. Emergency geriatric screening was unfeasible in 175 patients (22.0%) because of life-threatening conditions and was not performed in 282 (35.5%) for logistical reasons. Emergency geriatric screening took less than 5 minutes to perform in most (85.8%) cases. Among screened patients, 285 (84.3%) had at least 1 abnormal EGS finding. In 270 of these patients, at least 1 abnormal EGS finding did not result in a diagnosis in the ED and was reported for further workup to subsequent care. During screening, 142 patients (42.0%) had at least 1 diagnosis listed within the 4 EGS domains, significantly more than the 29.3% in the control period (odds ratio 1.75; 95% confidence interval, 1.34-2.29; P<.001). Emergency geriatric screening predicted nursing home admission after the in-hospital stay (odds ratio for ≥3 vs <3 abnormal domains 12.13; 95% confidence interval, 2.79-52.72; P=.001). PRINCIPAL CONCLUSIONS: The novel EGS is feasible, identifies previously undetected geriatric problems, and predicts determinants of subsequent care.

Predictors of functional decline in elderly patients undergoing transcatheter aortic valve implantation (TAVI).

Aims This study aimed to assess functional course in elderly patients undergoing transcatheter aortic valve implantation (TAVI) and to find predictors of functional decline. Methods and results In this prospective cohort, functional course was assessed in patients ≥70 years using basic activities of daily living (BADL) before and 6 months after TAVI. Baseline EuroSCORE, STS score, and a frailty index (based on assessment of cognition, mobility, nutrition, instrumental and basic activities of daily living) were evaluated to predict functional decline (deterioration in BADL) using logistic regression models. Functional decline was observed in 22 (20.8%) of 106 surviving patients. EuroSCORE (OR per 10% increase 1.18, 95% CI: 0.83-1.68, P = 0.35) and STS score (OR per 5% increase 1.64, 95% CI: 0.87-3.09, P = 0.13) weakly predicted functional decline. In contrast, the frailty index strongly predicted functional decline in univariable (OR per 1 point increase 1.57, 95% CI: 1.20-2.05, P = 0.001) and bivariable analyses (OR: 1.56, 95% CI: 1.20-2.04, P = 0.001 controlled for EuroSCORE; OR: 1.53, 95% CI: 1.17-2.02, P = 0.002 controlled for STS score). Overall predictive performance was best for the frailty index [Nagelkerke's R(2) (NR(2)) 0.135] and low for the EuroSCORE (NR(2) 0.015) and STS score (NR(2) 0.034). In univariable analyses, all components of the frailty index contributed to the prediction of functional decline. Conclusion Over a 6-month period, functional status worsened only in a minority of patients surviving TAVI. The frailty index, but not established risk scores, was predictive of functional decline. Refinement of this index might help to identify patients who potentially benefit from additional geriatric interventions after TAVI.

Effects of geriatric clinical skills training on the attitudes of medical students.

BACKGROUND: Physicians' attitudes, knowledge and skills are powerful determinants of quality of care for older patients. Previous studies found that using educational interventions to improve attitude is a difficult task. No previous study sought to determine if a skills-oriented educational intervention improved student attitudes towards elderly patients. METHODS: This study evaluated the effect of a geriatric clinical skills training (CST) on attitudes of University of Bern medical students in their first year of clinical training. The geriatric CST consisted of four 2.5-hour teaching sessions that covered central domains of geriatric assessment (e.g., cognition, mobility), and a textbook used by students to self-prepare. Students' attitudes were the primary outcome, and were assessed with the 14-item University of California at Los Angeles Geriatrics Attitudes Scale (UCLA-GAS) in a quasi-randomized fashion, either before or after geriatric CST. RESULTS: A total of 154 medical students participated. Students evaluated before the CST had a median UCLA-GAS overall scale of 49 (interquartile range 44-53). After the CST, the scores increased slightly, to 51 (interquartile range 47-54; median difference 2, 95% confidence interval 0-4, P = 0.062). Of the four validated UCLA-GAS subscales, only the resource distribution subscale was significantly higher in students evaluated after the geriatric CST (median difference 1, 95% confidence interval 0-2, P = 0.005). CONCLUSIONS: Teaching that targets specific skills may improve the attitudes of medical students towards elderly patients, though the improvement was slight. The addition of attitude-building elements may improve the effectiveness of future skills-oriented educational interventions.

Health risk appraisal in older people 6: factors associated with self-reported poor vision and uptake of eye tests in older people.

BACKGROUND: Although free eye testing is available in the UK from a nation-wide network of optometrists, there is evidence of unrecognised, tractable vision loss amongst older people. A recent review identified this unmet need as a priority for further investigation, highlighting the need to understand public perceptions of eye services and barriers to service access and utilisation. This paper aims to identify risk factors for (1) having poor vision and (2) not having had an eyesight check among community-dwelling older people without an established ophthalmological diagnosis. METHODS: Secondary analysis of self-reported data from the ProAge trial. 1792 people without a known ophthalmological diagnosis were recruited from three group practices in London. RESULTS: Almost two in ten people in this population of older individuals without known ophthalmological diagnoses had self-reported vision loss, and more than a third of them had not had an eye test in the previous twelve months. In this sample, those with limited education, depressed mood, need for help with instrumental and basic activities of daily living (IADLs and BADLs), and subjective memory complaints were at increased risk of fair or poor self-reported vision. Individuals with basic education only were at increased risk for not having had an eye test in the previous 12 months (OR 1.52, 95% CI 1.17-1.98 p=0.002), as were those with no, or only one chronic condition (OR 1.850, 95% CI 1.382-2.477, p<0.001). CONCLUSIONS: Self-reported poor vision in older people without ophthalmological diagnoses is associated with other functional losses, with no or only one chronic condition, and with depression. This pattern of disorders may be the basis for case finding in general practice. Low educational attainment is an independent determinant of not having had eye tests, as well as a factor associated with undiagnosed vision loss. There are other factors, not identified in this study, which determine uptake of eye testing in those with self-reported vision loss. Further exploration is needed to identify these factors and lead towards effective case finding.

The SAKK cancer-specific geriatric assessment (C-SGA): a pilot study of a brief tool for clinical decision-making in older cancer patients.

BACKGROUND: Recommendations from international task forces on geriatric assessment emphasize the need for research including validation of cancer-specific geriatric assessment (C-SGA) tools in oncological settings. This study was to evaluate the feasibility of the SAKK Cancer-Specific Geriatric Assessment (C-SGA) in clinical practice. METHODS: A cross sectional study of cancer patients ≥65 years old (N = 51) with pathologically confirmed cancer presenting for initiation of chemotherapy treatment (07/01/2009-03/31/2011) at two oncology departments in Swiss canton hospitals: Kantonsspital Graubünden (KSGR N = 25), Kantonsspital St. Gallen (KSSG N = 26). Data was collected using three instruments, the SAKK C-SGA plus physician and patient evaluation forms. The SAKK C-SGA includes six measures covering five geriatric assessment domains (comorbidity, function, psychosocial, nutrition, cognition) using a mix of medical record abstraction (MRA) and patient interview. Five individual domains and one overall SAKK C-SGA score were calculated and dichotomized as below/above literature-based cut-offs. The SAKK C-SGA was evaluated by: patient and physician estimated time to complete, ease of completing, and difficult or unanswered questions. RESULTS: Time to complete the patient questionnaire was considered acceptable by almost all (≥96%) patients and physicians. Patients reported slightly shorter times to complete the questionnaire than physicians (17.33 ± 7.34 vs. 20.59 ± 6.53 minutes, p = 0.02). Both groups rated the patient questionnaire as easy/fairly easy to complete (91% vs. 84% respectively, p = 0.14) with few difficult or unanswered questions. The MRA took on average 8.32 ± 4.72 minutes to complete. Physicians (100%) considered time to complete MRA acceptable, 96% rated it as easy/fairly easy to complete. Individual study site populations differed on health-related characteristics (excellent/good physician-rated general health KSGR 71% vs. KSSG 32%, p = 0.007). The overall mean C-SGA score was 2.4 ± 1.12. Patients at KSGR had lower C-SGA scores (2.00 ± 1.19 vs. 2.81 ± 0.90, p = 0.009) and a smaller proportion (28% vs.65%, p = 0.008) was above the C-SGA cut-off score compared to KSSG. CONCLUSIONS: These results suggest the SAKK C-SGA is a feasible practical tool for use in clinical practice. It demonstrated discriminative ability based on objective geriatric assessment measures, but additional investigations on use for clinical decision-making are warranted. The SAKK C-SGA also provides important usable domain information for intervention to optimize outcomes in older cancer patients.

Potentially Inadequate Real-Life Speech Levels by Healthcare Professionals during Communication with Older Inpatients.

BACKGROUND: The aim of this study was to investigate real-life speech levels of health professionals during communication with older inpatients in small group settings. METHODS: This is a prospective observational study assessing group interactions between geriatric inpatients and health professionals in a geriatric rehabilitation unit of a tertiary university hospital (Bern, Switzerland). We measured speech levels of health professionals during three typical group interactions (discharge planning meeting (n = 21), chair exercise group (n = 5), and memory training group (n = 5)) with older inpatients. Speech levels were measured using the CESVA LF010 (CESVA instruments s.l.u., Barcelona, Spain). A threshold of <60 dBA was defined as a potentially inadequate speech level. RESULTS: Overall, mean talk time of recorded sessions was 23.2 (standard deviation 8.3) minutes. The mean proportion of talk time with potentially inadequate speech levels was 61.6% (sd 32.0%). The mean proportion of talk time with potentially inadequate speech levels was significantly higher in chair exercise groups (95.1% (sd 4.6%)) compared to discharge planning meetings (54.8% (sd 32.5%), p = 0.01) and memory training groups (56.3% (sd 25.4%), p = 0.01). CONCLUSIONS: Our data show that real-life speech level differs between various types of group settings and suggest potentially inadequate speech levels by healthcare professionals requiring further study.

Oral and general health status in patients treated in a dental consultation clinic of a geriatric ward in Bern, Switzerland.

INTRODUCTION: This audit reports on the oral and general health of patients who were treated in a dental consultation clinic of a geriatric hospital. MATERIAL AND METHODS: Dental and medical records were obtained from 112 female and 80 male patients (mean age, 83.7 ± 8.2 years) who attended a dental consultation. Data analysis included the general health [American Society of Anesthesiologists (ASA) classification, number of diagnoses, cognitive function] and dental state in the age strata 60-69, 70-79, 80-89 and 90-99 years. RESULTS: Seventy-four per cent of patients were aged over 80 years. The prevalence of ASA-P4 and P3 varied between age groups. Most patients (>86%) had more than three chronic diseases. Cognitive impairment was present in almost half of both older age cohorts (43 and 50%). Half of the patients (52%) were edentulous. In dentate patients, the average number of teeth was 12 ± 6 and differed in the maxilla significantly between age groups (p = 0.005). There was no significant association between dental state, ASA classification and systemic conditions. CONCLUSIONS: The profile of this cohort reflects a poor oral and general health status. The results underline the importance of an interdisciplinary consultation in a geriatric ward where oral health care is an integral part.

[Hypertension in the elderly]. / Die arterielle Hypertonie im Alter.

Many aspects of hypertension diagnosis and treatment are similar in young and old patients. However, some differences exist. Due to the increasing vascular stiffness most elderly patients have isolated systolic hypertension and its prevalence in the population is high. Blood pressure should be measured in the sitting position and also with the patient standing to exclude orthostatic hypotension, a frequent problem in elderly patients. Pseudohypertension, a source of inadequate measurements in elderly patients, should be recognized. In comparison to other health problems there is good scientific evidence for antihypertensive treatment in elderly patients. As treatment does not only improve survival, but also reduces cardiovascular events such as non-fatal stroke or myocardial infarction, antihypertensive therapy is an important measure to prevent functional decline and disability.

A scoping review of the changing landscape of geriatric medicine in undergraduate medical education: curricula, topics and teaching methods.

PURPOSE: The world's population is ageing. Therefore, every doctor should receive geriatric medicine training during their undergraduate education. This review aims to summarise recent developments in geriatric medicine that will potentially inform developments and updating of undergraduate medical curricula for geriatric content. METHODS: We systematically searched the electronic databases Ovid Medline, Ovid Embase and Pubmed, from 1st January 2009 to 18th May 2021. We included studies related to (1) undergraduate medical students and (2) geriatric medicine or ageing or older adults and (3) curriculum or curriculum topics or learning objectives or competencies or teaching methods or students' attitudes and (4) published in a scientific journal. No language restrictions were applied. RESULTS: We identified 2503 records and assessed the full texts of 393 records for eligibility with 367 records included in the thematic analysis. Six major themes emerged: curriculum, topics, teaching methods, teaching settings, medical students' skills and medical students' attitudes. New curricula focussed on minimum Geriatrics Competencies, Geriatric Psychiatry and Comprehensive Geriatric Assessment; vertical integration of Geriatric Medicine into the curriculum has been advocated. Emerging or evolving topics included delirium, pharmacotherapeutics, healthy ageing and health promotion, and Telemedicine. Teaching methods emphasised interprofessional education, senior mentor programmes and intergenerational contact, student journaling and reflective writing, simulation, clinical placements and e-learning. Nursing homes featured among new teaching settings. Communication skills, empathy and professionalism were highlighted as essential skills for interacting with older adults. CONCLUSION: We recommend that future undergraduate medical curricula in Geriatric Medicine should take into account recent developments described in this paper. In addition to including newly emerged topics and advances in existing topics, different teaching settings and methods should also be considered. Employing vertical integration throughout the undergraduate course can usefully supplement learning achieved in a dedicated Geriatric Medicine undergraduate course. Interprofessional education can improve understanding of the roles of other professionals and improve team-working skills. A focus on improving communication skills and empathy should particularly enable better interaction with older patients. Embedding expected levels of Geriatric competencies should ensure that medical students have acquired the skills necessary to effectively treat older patients.

Evolution of Basic Activities of Daily Living Function in Older Patients One Year After Transcatheter Aortic Valve Implantation.

BACKGROUND/OBJECTIVES: To assess the course and prediction of basic activities of daily living (ADL) function in patients after transcatheter aortic valve implantation (TAVI). DESIGN: This was a prospective cohort study. SETTING: The setting was a single academic center in Switzerland. PARTICIPANTS: Participants included individuals aged ≥70 years (n = 330) undergoing TAVI. MEASUREMENTS: A frailty index (based on geriatric assessment) and cardiac risk scores (EuroSCORE, Society of Thoracic Surgeons [STS] score) were determined in patients before TAVI. Basic ADL function was measured with patient or proxy interviews at baseline and 1-year follow up. We used logistic regression models to investigate the association between baseline factors and functional decline. RESULTS: At 1-year follow up, 229 (69.4%) of the 330 patients had stable or improved basic ADL function, 49 (14.8%) experienced a decline in basic ADL function, and 52 (15.8%) died. The frailty index, but not cardiac risk scores, significantly predicted decline in basic ADL function. Among the 34 surviving very frail patients, 12 (35.3%) experienced a functional status decline, and the remaining 22 (64.7%) had stable or improved functional status at 1-year follow up. CONCLUSION: This study confirms that a frailty index, and not cardiac risk scores, identifies patients at an increased risk of functional status decline after TAVI. Identifying patients with a high frailty index before TAVI is clinically relevant as these patients might benefit from targeted geriatric management and rehabilitation after TAVI. However, based on current data, it is not justified to use information on frailty status as the criterion for identifying patients in whom TAVI might be futile. Although the probability of poor outcome is high, very frail patients also have a high probability of favorable long-term functional outcome.

Swiss Frailty Network and Repository: protocol of a Swiss Personalized Health Network's driver project observational study.

INTRODUCTION: Early identification of frailty by clinical instruments or accumulation of deficit indexes can contribute to improve healthcare for older adults, including the prevention of negative outcomes in acute care. However, conflicting evidence exists on how to best capture frailty in this setting. Simultaneously, the increasing utilisation of electronic health records (EHRs) opens up new possibilities for research and patient care, including frailty. METHODS AND ANALYSIS: The Swiss Frailty Network and Repository (SFNR) primarily aims to develop an electronic Frailty Index (eFI) from routinely available EHR data in order to investigate its predictive value against length of stay and in-hospital mortality as two important clinical outcomes in a study sample of 1000-1500 hospital patients aged 65 years and older. In addition, we will examine the correlation between the eFI and a test-based clinical Frailty Instrument to compare both concepts in Swiss older adults in acute care settings. As a Swiss Personalized Health Network (SPHN) driver project, our study will report on the characteristics and usability of the first nationwide eFI in Switzerland connecting all five Swiss University Hospitals' Geriatric Departments with a representative sample of patients aged 65 years and older admitted to acute care. ETHICS AND DISSEMINATION: The study protocol was approved by the competent ethics committee of the Canton of Zurich (BASEC-ID 2019-00445). All acquired data will be handled according to SPHN's ethical framework for responsible data processing in personalised health research. Analyses will be performed within the secure BioMedIT environment, a national infrastructure to enable secure biomedical data processing, an integral part of SPHN. TRIAL REGISTRATION NUMBER: NCT04516642.