The primary care physician and Alzheimer's disease: an international position paper.

This paper aims to define the role of the primary care physician (PCP) in the management of Alzheimer's disease (AD) and to propose a model for a work plan. The proposals in this position paper stem from a collaborative work of experts involved in the care of AD patients. It combines evidence from a literature review and expert's opinions who met in Paris, France, on July 2009 during the International Association of Geriatrics and Gerontology (IAGG) World Congress. The PCP's intervention appears essential at many levels: detection of the onset of dementia, diagnostic management, treatment and follow-up. The key role of the PCP in the management of AD, as care providers and care planners, is consolidated by the family caregiver's confidence in their skills. In primary care practice the first step is to identify dementia. The group proposes a "case finding" strategy, in target situations in which dementia should be detected to allow, secondarily, a diagnosis of AD, in certain cases. We propose that the PCP identifies 'typical' cases. In typical cases, among older subjects, the diagnosis of "probable AD" can be done by the PCP and then confirm by the specialist. While under-diagnosis of AD exists, so does under-disclosure. Disclosure to patient and family should be done by both specialist and PCP. Then, the PCP has a central role in management of the disease with the general objectives to detect, prevent and treat, when possible, the complications of the disease (falls, malnutrition, behavioural and psychological symptoms of dementia). The PCP needs to give basic information to the caregiver on respite care and home support services in order to prevent crisis situations such as unplanned institutionalisation and "emergency" hospital admission. Finally, therapeutic research must be integrated in the daily practice of PCP. It is a matter of patients' right to benefit from access to innovation and clinical research whatever his age or diseases, while of course fully respecting the rules and protective measures that are in force.

Assessment of pain in cognitively impaired older adults: a comparison of pain assessment tools and their use by nonprofessional caregivers.

OBJECTIVES: To compare self-reporting of pain by cognitively impaired (CI) older adults living in the community with reports of their caregivers; to identify the factors associated with differences in agreement; and to identify those pain assessment tools that are most useful to nonprofessional caregivers. DESIGN: Prospective observational cohort of patients with dementia and their caregivers. SETTING: In-home assessments of community-dwelling CI older adults and family members, adult foster care providers, or aides in residential care facilities. All CI subjects were enrolled in a Program for All-inclusive Care of the Elderly program (ElderPlace) in Portland, Oregon. PARTICIPANTS: A total of 156 CI adults and their caregivers. METHODS: Standardized pain assessment instruments were administered to the CI subjects and their caregivers in the subject's home by trained research assistants between June and October 1998. CI subjects were assessed with the Nonverbal Visual Analog scale ("line"), the Faces Pain Scale ("faces"), and the Philadelphia Pain Intensity Scale (PIS). Research assistants observed pain behaviors in the CI subjects using the Hospice Approach Discomfort Scale. The CI subject's caregivers completed the "line," "faces," PIS, and Cornell Scale for Depression in Dementia. A baseline Mini-Mental State Exam, Functional Assessment Stage Test, and Geriatric Depression Scale were performed on all CI subjects by ElderPlace medical, nursing, or social work staff. RESULTS: The mean age of the CI subjects was 83, and 83% were women. The mean Mini-Mental State Exam score was 15.7. One-third of the CI subjects were unable to complete any of the three pain assessment tools. Of the 104 subjects completing at least one tool, 13 (12.5%) reported no pain and 91 (87.5%) reported some pain. Sixteen (10%) of the subjects were depressed as measured with the GDS or Cornell instrument. In 70 of the 104 subjects (67%) able to complete any tool, the caregiver and CI subject agreed as to the level of pain experienced by the CI subject. The number of tools completed by the CI subjects decreased with increased cognitive impairment. The Pain Intensity Scale was the tool most likely to be completed by both CI subjects and caregivers. The means of test scores were not significantly different for the paired groups of CI subject and caregiver, and the nonparametric correlation of each tool was significant: "faces" (Spearman's rho (p) = .417); "line" (p = .420); and PIS (p = .452). The Hospice Approach Discomfort Scale did not correlate well with other tools. The Pain Intensity Scale seems to be more useful than other pain assessment tools in assessing pain in cognitively impaired patients and can be used by nonprofessional caregivers in a community-based care setting.

Hospitalization in the Program of All-Inclusive Care for the Elderly (PACE): rates, concomitants, and predictors.

BACKGROUND: The Program of All-Inclusive Care for the Elderly (PACE) replicates the model of comprehensive, community-based geriatric care pioneered by On Lok, that enrolls frail older adults who meet states' criteria for nursing home care, and that uses interdisciplinary teams to assess the participants and to deliver care in appropriate settings. As managed care, PACE receives capitated payment from Medicare and Medicaid. Thus, PACE's fiscal incentives are thought to be aligned with the goals of optimizing health, function, and quality of life through the delivery of effective primary, preventive, restorative, supportive, and palliative care and through the avoidance of inappropriate and expensive hospital and nursing home utilization. OBJECTIVES: To describe short-term hospital utilization, hospital discharge diagnoses, time from enrollment to first hospitalization and its clinical predictors, and hospitalization in relation to mortality among PACE participants. METHODS: Data on short-term hospitalization and participants were recovered from PACE's minimum data set. Bed use was evaluated in annual cross-sections of current participants. Primary hospital discharge diagnoses were available for discharges from September 1, 1993 through March 31, 1997. The time from enrollment to hospitalization was calculated for the participants (n = 5478) who were admitted between January 1, 1990 and March 31, 1997. The characteristics of this inception cohort were used to develop a Cox regression model of hospitalization. All PACE deaths were identified and the place of death was recovered, together with the medical records used in the hospital during PACE enrollment or 6 months before death. RESULTS: Bed-days per 1,000 PACE participants per year were comparable with the general Medicare (fee-for-service) population, at 2,046 (in 1998) versus 2014 (in 1997) despite the greater morbidity and disability for PACE participants, as reflected in their enrollment characteristics and primary hospital discharge diagnoses. The time to hospitalization was 773 days (median); 95% confidence interval, 725, 814, and was predicted by disease, treatment, social and demographic factors. Whereas 8% of PACE deaths occurred in acute hospitals, less than one-third of the decedents spent any time in the hospital in the 6-month interval before death. CONCLUSIONS: Overall, short-term hospital utilization among PACE participants is low in contrast with that for other older and disabled populations. Participant predictors of hospitalization in PACE are generally consistent with other studies in older clinical and community populations. Both utilization and risk vary considerably across PACE sites, independent of participant-level risk factors, hence suggesting that further investigation is required to study PACE's management of acute illness and hospitalization decisions. Critical to maintaining PACE's success is an understanding of the independent impact of the organization and the environment of health care on this management.

Physician orders for life-sustaining treatment (POLST): outcomes in a PACE program. Program of All-Inclusive Care for the Elderly.

OBJECTIVES: To evaluate whether terminal care was consistent with Physician Orders for Life-Sustaining Treatment (POLST), a preprinted and signed doctor's order specifying treatment instructions in the event of serious illness for CPR, levels of medical intervention, antibiotics, IV fluids, and feeding tubes. DESIGN: Retrospective chart review. SETTING: ElderPlace, a Program of All-Inclusive Care for the Elderly (PACE) site in Portland, Oregon. PARTICIPANTS: All ElderPlace participants who died in 1997 were eligible (n = 58). Reasons for exclusion were no POLST (1), missing POLST (1), and insufficient documentation of care (2). MEASUREMENTS: POLST instructions for each participant and whether or not each of the treatments addressed by the POLST was administered in the final 2 weeks of life. RESULTS: The POLST specified "do not resuscitate" for 50 participants (93%); CPR use was consistent with these instructions for 49 participants (91%). "Comfort care" was the designated level of medical intervention in 13 cases, "limited interventions" in 18, "advanced interventions" in 18, and "full interventions" in 5. Interventions administered were at the level specified in 25 cases (46%); at a less invasive level in 18 (33%), and at a more invasive level in 11 (20%). Antibiotic administration was consistent with POLST instructions for 86% of 28 subjects who had infections in the last 2 weeks of life, and less invasive for 14%. Care matched POLST instructions in 84% of cases for IV fluids and 94% for feeding tubes. CONCLUSIONS: POLST completion in ElderPlace exceeds reported advance directive rates. Care matched POLST instructions for CPR, antibiotics, IV fluids, and feeding tubes more consistently than previously reported for advance directive instructions. Medical intervention level was consistent with POLST instructions for less than half the participants, however. We conclude that the POLST is effective for limiting the use of some life-sustaining interventions, but that the factors that lead physicians to deviate from patients' stated preferences merit further investigation.

Recognition of neurologic diseases in geriatric inpatients.

OBJECTIVES: To determine the prevalence of neurologic disease and the diagnostic impact of neurologic consultation on a geriatric inpatient unit. MATERIAL AND METHODS: Consecutively admitted patients were prospectively assessed by a neurologist and by medical house staff on a geriatrics unit over a 4-month period. Neurologic diagnoses were compared. RESULTS: Fifty-eight men, aged 76.4+/-8.7 years old (mean+/-SD), had 1.4+/-1.1 new or revised neurologic diagnoses made by the neurologist. The prevalence of neurologic disorder was: gait or balance disorder (90%); cognitive disorders (71%); neuromuscular disorder (59%); cerebrovascular disorder (38%); and extrapyramidal disorders (22%). New diagnoses were made by the neurologist among the cognitive (40%), neuromuscular (36%) and cerebrovascular disorders (19%). CONCLUSIONS: Neurologic disease is highly prevalent in geriatric inpatients. A neurologist's assessment resulted in altered diagnoses suggesting that neurologists should play a role in geriatric assessment and in education of health professionals caring for the elderly.

Geriatric rehabilitation: state of the art.

OBJECTIVES: To provide a clinically useful conceptual framework for the evaluation and treatment of disability in older persons, to review the rehabilitation of common conditions affecting function in older persons, and to discuss the effects of the ongoing changes in the healthcare system on geriatric rehabilitation. METHODS: MedLine search and review of relevant texts for information on (1) geriatric disability and its treatment, (2) recent high quality research, guidelines, and review articles relevant to the rehabilitation of conditions commonly causing geriatric disability, (3) effects of recent changes in the healthcare system on geriatric rehabilitation. RESULTS: Several pertinent models for geriatric disability were identified. These are explicated, along with information on the epidemiology of geriatric disability and its causes and relevant clinical applications. Rehabilitation is reviewed for musculoskeletal disorders, stroke and peripheral vascular disease, amputation, cardiopulmonary disorders, hip fracture, and deconditioning. Changes in the healthcare system appear to be affecting geriatric rehabilitation, especially the advent of managed care; relevant articles and opinions are reviewed, along with strategies to accommodate these changes. CONCLUSIONS: Our understanding of the causes of disability in the older population has improved significantly over the last decade. There has also been noteworthy progress in our knowledge about the effects of selected rehabilitation interventions, especially exercise-related interventions. However, the cost-effectiveness of many rehabilitative interventions remains unclear, particularly for differing patient groups across the continuum of care. More research will be needed to evaluate the effects of managed care on rehabilitation outcomes in older persons.

Geriatrics for orthopaedists.

The care of older patients is challenging and fraught with pitfalls, but the orthopaedic surgeon has the opportunity to give the elderly patient a gift that is of the highest value at that time of life, the chance to function better and more independently. By avoiding hospital-induced problems detecting and managing risk factors, and optimizing physical functioning, orthopaedists make major contributions to elders' lives.

When patients ask about assisted suicide. A viewpoint from Oregon.

The passage of the Oregon Death With Dignity Act has profound implications for the prevailing model of care for dying patients. Patients are already asking for assisted suicide. Most physicians have not been trained in evaluating these requests in a therapeutic way. We discuss the issues around the needs of dying patients and, regardless of the legal status, what to do when patients ask for a lethal dose of medication. With the tools to explore the meaning of these requests, physicians will be better able to understand and meet the needs of their dying patients.

Management of the poststroke patient.

Most patients survive the acute episode, their subsequent life affected by some degree of functional deficit. The classic neurologic findings are well known. Their implications for decisions on rehabilitation, long-term care, and prevention of complications are perhaps less well appreciated.

Research in rehabilitation.

The field of geriatric rehabilitation is fertile ground for a wide variety of research investigations. Because the functional approach is the foundation of good geriatric care, opportunities for collaborative projects between geriatricians and physiatrists, rehabilitation therapists, psychologists, social workers, and nurses are numerous. Rehabilitation research is particularly appropriate for the emerging field of outcomes research. Because of the crisis in health care costs in the United States, it is likely that there will be an increasingly strong demand on the part of both government and insurers that rehabilitation clearly demonstrate positive outcomes in care. It will be the job of those in geriatric rehabilitation to ensure that the outcomes that are measured are geared to detecting real benefits for our patients and not just cost savings.

The first certifying examination in geriatric medicine.

On April 22, 1988, the first Certifying Examination in Geriatric Medicine was administered jointly by the American Board of Internal Medicine and the American Board of Family Practice to 4,282 diplomates (ABIM = 2,202; ABFP = 2,080). This paper addresses both an analysis of the examination and the relationship between performance on that examination and a group of characteristics of the examinees, collected as part of the registration process. The pass rate was 56%. Performance on the examination was positively correlated with scores on the general certifying examinations and with training in geriatric medicine. Data provided by the candidates in an addendum to the application were also available for analysis and were used to derive correlations with groups of questions. The performance of candidates was positively correlated with seeing large numbers of elderly in hospitals, nursing homes, or home settings, working in a University Hospital, teaching and research, and the size of the community in which the candidate practiced. Physicians from long-term care settings did exceptionally well. Working in a solo practice setting was negatively correlated with performance on the examination as was working in a for-profit setting.

Falls in the aged.

A fall is a major problem for the elderly person. Finding that a patient has a history of falls should lead to an aggressive investigation to search for treatable causes. The investigation should be based on a functional approach that emphasizes the underlying medical problems that contribute to falling, the psychologic reactions of the patient to having fallen, and the hazards of the patient's environment. Functionally oriented interventions may decrease further falls even when specific causes are elusive.

Decreasing the burden in families caring for a relative with a dementing illness. A controlled study.

The purpose of this study was to investigate the efficacy of a specifically designed group support program for relatives of patients with Alzheimer's disease and related disorders. The group program included educational/supportive activities and used basic principles of the cognitive-behavioral approach. Twenty-two subjects participated in an eight-session program. Eighteen control subjects received no treatment. Measures of family burden, levels of depression, and knowledge of dementia were obtained. Experimental subjects showed a significant decrease in total family burden, whereas control subjects actually showed a significant increase, experimental subjects also showed reduction in their levels of depression. Experimental subjects showed a significantly greater improvement than did control subjects on knowledge of dementia. The acquisition of new knowledge was an important ingredient in reducing perception of burden and levels of depression, but other facets of the intervention also accounted for the improvement. Results indicated that a relatively short but intensive support experience can have a positive effect in reducing some of the burden and depression associated with the care of a demented relative.