Measuring case-mix and outcome for older people in acute hospital care across Europe: the development and potential of the ACMEplus instrument.

AIM: To identify case-mix variables measured shortly after admission to be included in a patient classification system (ACMEplus) that best explains hospital outcome for older people in different health care systems. DESIGN: Observational prospective cohort study collecting patient factors (sociodemographics, functional, mental, clinical, administrative and perceived health) at different time assessments. METHODS: Multicentre study involving eight hospitals in six European countries (United Kingdom, Spain, Italy, Finland, Greece and Poland). It included consecutive patients aged 65 years or older admitted to hospital for acute medical problems. MAIN OUTCOME MEASURES: discharge status, hospital readmission, mortality and length of stay. RESULTS: Of the 1667 included patients (mean age = 78.1 years; male gender = 43.5%) two-third had at least one 'Geriatric Giant' (immobility, confusion, incontinence or falls) on admission or shortly after. The most frequently affected system was cardiovascular (29.2%) and 31% of patients declared poor or very poor health. Mean length of stay was 17.9 days, 79% of patients were discharged to their usual residence; in-hospital and 1-month follow up mortality were 7.4% and 11.6%, respectively. Physical function explained the highest variation (between 8% and 21%), followed by cognitive status and number of Geriatric Giants, for almost all outcomes except readmission. CONCLUSION: Factors other than diagnosis (physical function, cognition and presenting problems) are important in predicting key outcomes of acute hospital care for older people and are consistent across countries. Their inclusion in a standardized system of measurement may be a way of improving quality and equity of medical care in older people.

The COPE index--a first stage assessment of negative impact, positive value and quality of support of caregiving in informal carers of older people.

Data was collected in five countries from informal carers of older people (n = 577) via a common protocol. Carers completed: (1) a 17-item version of the Carers of Older People in Europe (COPE) Index, an assessment of carers' perceptions of their role : (2) a questionnaire on demographic and caregiving circumstances : and (3) three instruments included for the criterion validation of the COPE Index (the General Health Questionnaire, the Hospital Anxiety and Depression Scale, and the World Health Organization Quality of Life-BREF). Principal Component Analysis of the COPE Index was followed by internal consistency analysis of emergent components. Scales derived by summing items loading on the components were analyzed for their association with the criterion measures. Two components, negative impact and positive value, emerged consistently across countries. A third component, quality of support was less consistent across countries. Scales derived from the negative impact and positive value components were internally consistent and significantly associated with the criterion validity measures. These two scales and four items drawn from the quality of support component were retained in the final COPE Index. While further testing is required, the COPE Index has current utility in increasing understanding of the role perceptions of carers of older people.

Repeatability of standardized tests of functional impairment and well-being in older people in a rehabilitation setting.

PURPOSE: The aim of this study was to establish the repeatability of standardized tests of vision (Snellen chart testing), hearing (whispered voice test), communication (Frenchay aphasia screening test), loneliness (UCLA loneliness scale), morale (Philadelphia geriatric centre morale scale), and a multidimensional instrument (EASY-care) when used in a rehabilitation setting. METHOD: The tests were administered by a research nurse to 50 older subjects attending a day rehabilitation unit, with repeat administration one or two weeks later by a nurse on the unit. Kappa statistics were used for level of agreement for categorized data and interclass correlation coefficient were used for data based on scores. RESULTS: Moderate repeatability for Snellen chart testing. whispered voice test; good to excellent for the FAST, UCLA loneliness scale and Philadelphia geriatric centre morale scale. Moderate to very good repeatability for all EASY-care items except communication, feeding, use of telephone and cognitive impairment, which had poor spread of data. CONCLUSIONS: Poor repeatability for commonly used tests of vision and hearing is worrying, whereas the positive results for the other tests will increase confidence in using them more in routine practice.

UK geriatricians' attitudes to active voluntary euthanasia and physician-assisted death.

AIM: To describe the views of British geriatricians on active voluntary euthanasia and physician-assisted death. METHOD: Postal questionnaire to 742 consultant members of the British Geriatrics Society. RESULTS: 81% considered active voluntary euthanasia never to be justified ethically, although 23% supported legalization in some situations and 13% would be willing to administer active voluntary euthanasia in some situations. With regard to physician-assisted death, 68% opposed it on ethical grounds and 24% supported its legalization in some instances, with 12% stating they would be willing to provide such assistance in some situations. Free text comments frequently cited good palliative care as an important response to such issues in clinical practice.

The effectiveness of very short scales for depression screening in elderly medical patients.

OBJECTIVE: To compare very short scales for screening for depression with longer, widely used scales. METHODS: Eighty-seven patients over the age of 60 who were admitted to rehabilitation wards or were attending a day rehabilitation facility at a British teaching hospital were screened for depression using the 1-item mental health inventory, and the 4-item, 15-item and 30-item geriatric depression scales. The sensitivity, specificity, and areas under receiver operating characteristic curves were compared, with the diagnostic criteria for research of ICD-10 providing the criterion diagnosis of depressive episode. RESULTS: All the scales had comparable sensitivity (82.4-100%), specificity (60.0-71.4%), and positive predictive values (33.3-42.9%). Comparison of receiver operating characteristic curves for each scale showed no statistically significant difference between them (range 0.80-0.88). CONCLUSIONS: The very short scales performed just as well as the widely used longer screening scales in this population. They are worthy of further examination in elderly populations at risk of depression, and may be particularly suitable for older adults due to their brevity and ease of use.

Geriatric assessment in primary care: formulating best practice.

Comprehensive geriatric assessment (CGA) is a structured approach to measuring physical, mental and social functioning of older people to identify needs and to plan care. Meta-analysis of trials of CGA suggest that it is cost-effective, but there is no agreed approach to its implementation in primary care. Our aim was to develop a best-practice model for geriatric assessment in primary care. We took an iterative approach to development, combining expert and local stakeholder opinion, and using semi-structured interviews to assess patient and practitioner experience in nine general practices in Sheffield. Patients were aged 75 and over, living at home. The best-practice model was the use of a standardized instrument (EASY-Care) to unselected patients aged 75 years and over living at home or in residential care, administered by a practice nurse in the context of an over-75s health check. There was high patient and practitioner acceptability, and significant cost savings were noted. Key beneficial features were the assessment of mental health and sources of support; goal-setting; generation of a disability score; and high patient satisfaction from contact with nursing staff. We conclude that geriatric assessment in primary care is feasible, economical and beneficial to patients and practitioners. Nursing staff are central to successful implementation of geriatric assessment in primary care.

Getting the questions right: an example of loss of validity during transfer of a brief screening approach for depression in the elderly.

Screening for depression in the elderly has been advocated to improve detection and management. This article summarises the trend towards briefer screening instruments, and the integration of mental health screening with other assessments. The study aimed to validate a single question depression screen which has previously shown adequate sensitivity and specificity in a new context: a multi-faceted assessment instrument used by nurse practitioners within a community sample of over 75 year olds. The GMS-AGECAT computerised interview assessment was used as a 'gold standard' to determine the accuracy of the depression question in this new setting. Three hundred and twenty-eight patients were screened by their own nurse practitioners, of whom 100 consenting patients underwent a further interview with a research assistant using the GMS-AGECAT. The prevalence of depression was 30%, the sensitivity of the question was 67%, and its specificity 60% (compared with 88% and 71% previously). Responses indicating disability and loneliness were more closely correlated with depression than the depression screen itself. Relevant factors may include: the derivation of the question, the effect of a different sample, altered reliability when used by multiple interviewers, differing patient expectations, and the wording and context of the question within the multi-faceted screening instrument. Depression screening questions need repeated validation when used in different contexts. Patient and staff expectations may influence how screening instruments are used in practice in a way that may also alter reliability. Further studies are needed to establish the causes of loss of validity when screening approaches are used in new settings.

The educational preparation of staff in nursing homes: relationship with resident autonomy.

The following paper reports on a survey of nursing homes in three health regions in England which formed part of a wider study to evaluate educational preparation for the nursing care of older people. The aims of the survey were to describe the educational preparation of staff employed within nursing homes and to explore relationships between educational preparation and one indicator of quality of care. A self-completion questionnaire was addressed to the senior nurse within a random sample of nursing homes. The instrument included a previously validated scale to measure resident autonomy. A total of 976 questionnaires were posted and 676 were returned, a response rate of 69%. The survey revealed wide variation in the educational preparation of staff in nursing homes and in the degree of contact with local centres providing nurse education. Statistically significant associations were found between resident autonomy and a composite measure of educational preparation, the proportion of qualified staff undertaking continuing professional education and the degree of contact with educational centres. The findings have implications for both purchasers and providers of education in this field.

COPE: towards a comprehensive assessment of caregiver need.

Supporting family carers is a common policy objective across Europe. However, if appropriate help is to be provided there is a need for a sensitive assessment process. This article describes the COPE project, the purpose of which is to develop a first-stage assessment tool that can be used to identify carers requiring a further in-depth consideration of their support needs.