The outcomes of treatment for homebound adults with complex medical conditions in a hospital-at-home unit in the southern district of Israel.

BACKGROUND: A model of hospital-at-home services called the Home Care Unit ("the unit") has been implemented in the southern region of the Clalit Healthcare Services in Israel. The aim of the present study was to characterize this service model. METHODS: A retrospective cross-over study. included homebound patients 65 years of age and above who were treated for at least one month in the framework of the unit, between 2013 and 2020. We compared the hospitalization rate, the number of hospital days, the number of emergency room visits, and the cost of hospitalization for the six-month period prior to admission to the unit, the period of treatment in the unit, and the six-month period following discharge from the unit. RESULTS: The study included 623 patients with a mean age of 83.7 ± 9.2 years with a mean Mini-mental State Examination (MMSE) score of 12.0 ± 10.2, a mean Charlson Comorbidity Index (CCI) of 3.7 ± 2.2 and a Barthel Index score of 23.9 ± 25.1. The main indications for admission to the unit were various geriatric syndromes (56.7%), acute functional decline (21.2%), and heart failure (12%). 22.8% died during the treatment period and 63.4% were discharged to ongoing treatment by their family doctor after their condition stabilized. Compared to the six months prior to admission to the unit there was a significant decrease (per patient per month) in the treatment period in the number of days of hospitalization (2.84 ± 4.35 vs. 1.7 ± 3.8 days, p < 0.001) and in the cost of hospitalization (1606 ± 2170 vs. 1066 ± 2082 USD, p < 0.001). CONCLUSIONS: Treatment of homebound adults with a high disease burden in the setting of a hospital-at-home unit can significantly reduce the number of hospital days and the cost of hospitalization. This model of service for homebound patients with multiple medical problems maintained a high level of care while reducing costs. The results support the widespread adoption of this service in the community to enable the healthcare system to respond to the growing population of elderly patients with medical complexity.

[PILOT PROGRAM OF HOME HOSPICE FOR OLDER PEOPLE WITH ADVANCED DEMENTIA].

INTRODUCTION: Dementia is a terminal illness and in an advanced stage it is suitable for palliative care. OBJECTIVES: To examine the results of a pilot program of home hospice for the elder patients with advanced dementia. METHODS: Patients aged 65 years and over who met the criteria for advanced dementia and palliative care were treated as part of the geriatric team-based home hospice program. The program included home visits by a multidisciplinary team that was available 24/7. During the program, special questionnaires are used to assess the patients' condition, the caregivers' burden and the caregivers' satisfaction with the treatment. RESULTS: Between August 2017 and July 2020, 44 patients were treated in hospice, the mean age was 86.1 ± 6.2 years and 26 (59%) of the patients were women. The average length of stay in the hospice was 129.4 ± 155.5 days (median 68 days) and most patients (36) died at home. The home hospice program leads to statistically significant improvement in the intensity of the behavioral and psychological effects of dementia, the severity of the pain and the intensity of the patients' suffering. In addition, there was a statistically significant decrease in the level of distress and the intensity of anxiety and depression of the family members. Almost all family members noted high satisfaction with end-of-life care. CONCLUSIONS: A home hospice program for patients with advanced dementia, based on a multidisciplinary geriatric team and the use of dedicated tools to evaluate the effectiveness of the intervention makes it possible to prevent the suffering of patients and their families and enable them to die in their preferred place. DISCUSSION: Home hospice is a worthy treatment alternative for terminally ill patients with advanced dementia who want to end their lives at home The home hospice care alleviates the patient's suffering, allows him/her to die in his/her preferred place and alleviates the distress of the family members, who express satisfaction from the treatment.

Ageism, Aging Anxiety, and Death and Dying Anxiety Among Doctors and Nurses.

Ageism is an important phenomenon that affects individuals and how society relates to older adults. It is important to evaluate ageism in the medical staff because of its potential effect on treatment for older adults. A cross-sectional study to assess the negative attitudes of doctors and nurses toward older adults was conducted using the Fraboni Scale of Ageism (FSA), a method for evaluating attitudes toward ageism in medical teams. Additional variables associated with ageism such as aging anxiety, and death and dying anxiety were also assessed. The study population included doctors and nurses working in a large university hospital or in community clinics in southern Israel. In all, 431 questionnaires were collected, 203 from the hospital (47.5%) and 224 from the community (52.5%). Of these, 216 (50.1%) were from doctors and 215 (49.9%) from nurses. The mean ageism score in the FSA was 2.8. In a linear regression model, doctors were less ageist than nurses; ageism was directly associated with aging anxiety, and dying anxiety, and was inversely associated with death anxiety. Among doctors, prominent ageist attitudes were directly associated with aging and dying anxiety, inversely associated with graduation from medical school in Israel, and death anxiety. Among nurses, prominent ageism attitudes were directly associated with dying anxiety and inversely associated with work in the hospital. Ageist attitudes were found among doctors and nurses in both the hospital and community clinics. The results emphasize the need to raise awareness of ageism in medical teams and to include this subject in professional training programs designed to reduce its prevalence.

Ageism Among Physicians and Nurses in Russia.

The phenomenon of ageism has been studied extensively in the Western world, but there is only a small number of studies among medical staff in Russia. The aim of this study was to assess the prevalence of ageism and to identify variables that can explain ageism in a sample of physicians and nurses in Russia. This is a prospective cross-sectional study of physicians and nurses who participated in a training course in the years 2016-2018 in Russia. Data collected before the start of training included the Fraboni scale of ageism (FSA) questionnaire, and sociodemographic characteristics including age, gender, profession, professional seniority, place of work, and number of older adults treated by the study participant over the past half year. In total, 903 physicians and nurses participated in the study. The mean FSA score was 2.75 ± 0.49, which indicates a moderate degree of ageism. There was a trend to higher scores among nurses compared with physicians (2.78 ± 0.50 vs. 2.76 ± 0.48, p < 0.465). There was a weak, but statistically significant, correlation between ageism and age (r = 0.157, p < 0.0001), professional seniority (r = 0.098, p < 0.003), and the number of older adult patients treated by the participant over the prior half year (r = 0.075, p < 0.025). There were no differences in other characteristics including gender, profession, work setting, or serving as main caregiver for a family member and the magnitude of ageism. The phenomenon of ageism exists among physicians and nurses in Russia. Older participants with greater professional seniority and a larger number of older patients had stronger ageism attitudes.

Methylphenidate for Mild Cognitive Impairment: An Exploratory 3-Day, Randomized, Double-Blind, Placebo-Controlled Trial.

Background: To evaluate the efficacy, safety and tolerability of methylphenidate (MPH) for cognitive function in older patients with mild cognitive impairment (MCI). Methods: Male and female subjects aged 65 years and older with a clinical diagnosis MCI were included in an exploratory randomized, double-blind, placebo-controlled trial. Eligible subjects were assigned to either treatment with immediate-release MPH or placebo. The active compound was administered in an increasing-dose stepwise fashion, namely 10 mg MPH on day 1, 20 mg on day 2, and 30 mg on day 3. Subjects remained under observation for 4 h following drug administration and were monitored for changes in blood pressure and for adverse events. Cognitive outcome measures included the Montreal Cognitive Assessment (MoCA) and the Neurotrax Mindstreams computerized cognitive assessment battery. Results: Of 17 subjects enrolled, 15 subjects completed the study, 7 in the active MPH group and 8 in the placebo group. The average age of the participants was 76.1 ± 6.6 years and 10 (66.7%) were men. Following the final dose a significant benefit on memory (predominantly non-verbal memory) was found in the MPH group. While 12 adverse events were reported, they were all rated as mild to moderate. Conclusions: Our finding of modest beneficial effects of MPH on memory tests in older subjects with MCI in this exploratory study is of interest and should be investigated in further studies.

Intensive Inpatient vs. Home-Based Rehabilitation After Hip Fracture in the Elderly Population.

Background: As the population ages, the rate of hip fractures and the need for rehabilitation increases. Home-based rehabilitation (HBR) is an alternative to classic inpatient rehabilitation (IR), which is an expensive framework with non-negligible risks. Methods: A retrospective study of patients 65 years and above following surgery to repair a hip fracture who underwent HBR or IR between 2016 and 2019. The two rehabilitation frameworks were compared for rehabilitation outcome and factors predicting successful rehabilitation. The outcome was determined with the Montebello Rehabilitation Factor Score-Revised (MRFS-R). Results: Data were collected for 235 patients over 3 years. The mean age was 81.3 ± 8.0 and 172 (73.3%) were women. Of these, 138 underwent IR and 97 HBR. The HBR group had better family support and fewer lived alone. There were also differences in the type of fracture and surgery. The medical condition of the IR group was more complex, as reflected in a higher Charlson's comorbidity scores, higher rates for delirium and more infectious complications, a lower Norton score, lower serum hemoglobin, and albumin levels, and higher serum creatinine and urea levels. It also had a more significant functional decline after surgery and required a longer rehabilitation period. However, no difference was found in the rehabilitation outcomes between the two groups (MRFS-R ≥ 50). The independent predictors for rehabilitation in the IR group were serum albumin level, comorbidity, and cognitive state. There were no independent predictors in the HBR group. Conclusions: In this retrospective study, there was no significant difference in short-term rehabilitation outcomes between the HBR and IR groups event though the patients in the IR group were medically more complex. This result should be taken into account when planning rehabilitation services after hip fracture and tailoring rehabilitation frameworks to patients.

Validation of the Russian Version of the MoCA Test as a Cognitive Screening Instrument in Cognitively Asymptomatic Older Individuals and Those With Mild Cognitive Impairment.

Background: Cognitive impairment is a common condition in older people, and age-related cognitive symptoms may progress to Mild Cognitive Impairment and Dementia. Physical exercise and cognitive training may be useful in maintaining cognitive function, and those developing impaired cognitive function should be advised to plan for the future. The MoCA test is a useful cognitive screening instrument, but the Russian version of this test has not yet been validated. The aim of the present study was to validate the Russian version of the MoCA test. Methods: The study population included 160 residents of Israel aged 65 years and older with Russian as their mother tongue, 80 of whom were cognitively asymptomatic (AC) and 80 with a clinical diagnosis of MCI. All participants underwent cognitive screening using the Russian version of the MoCA test (MoCA-Ru) as well as evaluation by means of a validated computerized cognitive assessment battery (Neurotrax). Results: The mean age of the study population was 78 ± 6.6 years and 123 (76.9%) were women. The MoCA-Ru score was higher in the AC group than in those with MCI (24.3 ± 3.74 vs. 20.2 ± 3.07, P < 0.0001). At a cutoff value of ≥25, sensitivity was 0.99 and specificity 0.54, with area under the curve (AUC) of 0.81. Conclusions: We found the Russian language version of the MoCA test to be a useful cognitive screening instrument for older people with mild cognitive impairment.

[FEMORAL HEAD FRACTURE IN PATIENTS 65 YEARS AND OLDER WITH ATRIAL FIBRILLATION: THE EFFECT OF ANTI-COAGULATION ON COMPLICATIONS AND PROGNOSIS].

BACKGROUND: Atrial fibrillation and hip fractures are common problems in elderly patients. Delay in the timing of surgical repair can lead to increased complications and anti-coagulation could be a reason for delay. OBJECTIVES: To assess morbidity and mortality in patients 65 years and older with atrial fibrillation (AF) and hip fracture in relation to the type of anti-coagulation. METHODS: A retrospective cross-sectional study of patients with AF and hip fracture aged 65 and older was conducted in a tertiary hospital. Data collected included co-morbidity, medical history, medications, the timing of surgery, thromboembolic events, estimated risk for stroke by CHADS2 score, for significant bleeding by HAS-BLED score and mortality rate for the six-month period following surgery. RESULTS: During the period 2014-2016, 186 patients 65 years and older with atrial fibrillation underwent surgical repair of a hip fracture, 113 (60.7%) women. The mean age was 81.9±7.1 years. Eighty-nine (47.8%) did not receive any anti-coagulation, 60 (32.3%) received new oral anticoagulants (NOAC), and 37 (19.9%) warfarin. There were no differences between these groups on pre-and post-operation burden of co-morbidity, timing of surgery, surgical delay, complication rate, or mortality rate during the six months following surgery. CONCLUSIONS: Anti-coagulation for patients 65 years and older with atrial fibrillation and hip fracture did not affect the timing of surgery or the rate of complications and mortality. Based on these results the concern over emergency surgery and its complications in patients with AF is not justified.

[REVIEW OF DECISION-MAKING CAPACITY (DMC) ASSESSMENT TOOLS FOR TREATMENT AMONG ELDERLY PATIENTS WITH COGNITIVE IMPAIRMENT].

INTRODUCTION: The need to evaluate decision-making capacity for treatment among patients over 65 with cognitive impairment has increased because of the ageing of the population. The inability to make decisions about treatment may be part of cognitive impairment and the prevalence of this phenomenon increases according to the age and severity of the cognitive impairment. The lack of a clear definition of the law regarding the assessment of the decision-making capacity for treatment, the lack of structured training as part of the formal medical education and the lack of uniformity in performing assessment of the decision-making capacity for treatment among physicians leads to many errors and inconsistencies in assessment. In addition to physicians' clinical judgement, additional tools have been developed that enable more accurate assessment of the decision-making capacity for treatment of the older patients. Enhancement of the knowledge of the medical staff on the issue of assessment of the decision-making capacity for treatment, together with encouraging the use of validated tools can reduce the rate of errors, evaluate all the components of decision-making capacity for treatment and help older people realize their constitutional rights and maintain individual autonomy. The current review will discuss existing tools for assessing the decision-making capacity for treatment among those aged over 65 with cognitive impairment.

Implementation of Geriatric Recommendations by Doctors: A Comparison of Models of Geriatric Assessment for Mobile and Home-Ridden Patients.

In the present study we assessed the rate of implementation of recommendations given following geriatric assessment for home-ridden patients; a retrospective review of medical records to evaluate the implementation of geriatric recommendations given to patients in the Home Geriatric Service (HGS) between 2015 and 2016. The patients were categorized into two groups: the HGS-clinic (HGS-C) group, in which the primary care physician was responsible for implementation of the recommendations, and the HGS-home care (HGS-H) group, in which the responsibility for implementation of the recommendations was on the geriatrician. The results were compared with the implementation of recommendations in other ambulatory models for mobile patients-Clinic-Based Geriatric Assessment Services (CBGAS). The study included 865 patients. The highest rate of implementation was in the HGS-H group (85.7%), compared with 66.6% in the HGS-C group and 52.7% in the CBGAS group (p < 0.0001). In the logistic regression model for prediction of patients with implementation rates above 75%, the only variable that entered the prediction model was affiliation with the HGS-H group (odds ratio [OR] = 4.8, 95% confidence interval [CI] 2.3-9.6, p < 0.0001) or the HGS-C group (OR = 1.7, 95% CI 1.0-2.9, p = 0.046). The implementation rate for geriatric recommendations is higher for home-ridden patients compared with mobile patients, with the maximum recommendation rate in the subgroup, where geriatricians implemented the recommendations themselves. These findings raise the possibility that the most successful model, in terms of the implementation of recommendations, is the model in which implementation is carried out by the same staff that conducted the assessment.

The Effect of the Feuerstein Project on the Cognitive and Functional State of Community-Dwelling Individuals Aged 65 Years and Older with Mild Cognitive Impairment: A Pilot Study.

BACKGROUND: The rate of elderly individuals with mild cognitive impairment (MCI) has increased over recent decades. The Feuerstein Instrumental Enrichment (FIE) program for the elderly has been shown to be effective in various age groups but is has never been tested as a treatment for MCI in elderly patients. The aim of this study was to assess the effect of the FIE on the cognitive and functional state of elderly patients with MCI. METHODS: This was an interventional pilot study in community-dwelling patients aged ≥65 years diagnosed with MCI in the previous year. The protocol included 30 twice-weekly 90-min sessions with a full neurocognitive evaluation prior to the intervention (v1), at its conclusion (v2), and half a year later (v3). RESULTS: Nine of the 15 recruited participants completed the study. The mean age was 76.2 years. Compared to v1 and v2, the only significant improvements found at v3 were in the "visual perception" subtest of the NeuroTrax test and the total score of the MOCA test (p = 0.048 and 0.028, respectively). The effect size was >0.7 (r = 0.7), indicating a moderate-to-high clinical significance. The results of the qualitative questionnaire were consistent with the positive effect of the group on the fostering of social ties, the motivation to learn, the cognitive contribution, and the development of a sense of self-efficacy. CONCLUSION: The study findings support the conclusion that an intervention with a focus on cognitive exercising can promote a feeling of self-efficacy and preserve some cognitive skills.

The Results of a Crossover Placebo-Controlled Study of the Effect of Lavender Oil on Behavioral and Psychological Symptoms of Dementia.

Studies of the effect of aromatherapy on patients with behavioral and psychological symptoms of dementia (BPSD) have yielded contradictory results. One possible explanation for this lack of consistent results is the site of application of the oil. The aim of the study was to evaluate the effect of lavender oil on the rate of BPSD when applied close to and away from the olfactory system. A crossover placebo-controlled study was conducted in the two psychogeriatric long term care departments. Patients in Department A received lavender oil on their face during the first month and on their foot in the second month, sunflower seed oil on their foot in the third month and on their face in the fourth month. Patients in Department B received sunflower seed oil on their face during the first month and on their foot in the second month, and lavender oil on their foot in the third month and on their face in the fourth month. Forty-two patients completed the study. Their mean age was 76.1 ± 11.2 years. After 4 months of treatment, the mean Neuropsychiatric Inventory score in Department A dropped from 13.1 ± 8.3 (median 12.0) to 3.5 ± 3.8 (median 2.0; p < 0.0001) and in Department B it dropped from 9.7 ± 9.6 (median 6.0) to 1.4 ± 2.5 (median 0; p < 0.0001). This reduction was not associated with the type of oil or the site of application. Based on these results, lavender oil has no advantage over sunflower seed oil in the reduction of BPSD, regardless of the place of application.

Doctors' Knowledge and Attitudes Regarding Enteral Feeding and Eating Problems in Advanced Dementia.

BACKGROUND: The use of feeding tubes (FTs) in patients with advanced dementia does not yield positive health outcomes and can have a negative effect. METHODS: A cross-sectional study assessed the knowledge and attitudes of physicians on the use of FTs for patients with advanced dementia. RESULTS: 201 of 240 doctors (83.8%) participated in the study; 61.7% of the doctors claimed that FTs prevent aspiration, 51.7% that they prevent pneumonia, and 38.8% that they prevent weight gain. Almost one-third (32.3%) said that the decision to use FTs could be taken by a hospitalist or a primary physician (28.9%). CONCLUSION: We found large gaps in knowledge among doctors about the use of FTs and consequences in patients with advanced dementia.

Orthostatic hypotension and overall mortality in 1050 older patients of the outpatient comprehensive geriatric assessment unit.

AIM: Orthostatic hypotension is a common problem in individuals aged ≥65 years. Its association with mortality is not clear. The aim of the present study was to evaluate associations between orthostatic hypotension and overall mortality in a sample of individuals aged ≥65 years who were seen at the Outpatient Comprehensive Geriatric Assessment Unit, Clalit Health Services, Beer-Sheva, Israel. METHODS: Individuals who were evaluated in the Outpatient Comprehensive Geriatric Assessment Unit between January 2005 and December 2015, and who had data on orthostatic hypotension were included in the study. The database included sociodemographic characteristics, body mass index, functional and cognitive state, geriatric syndromes reached over the course of the assessment, and comorbidity. Data on mortality were also collected. RESULTS: The study sample included 1050 people, of whom 626 underwent comprehensive geriatric assessment and 424 underwent geriatric consultation. The mean age was 77.3 ± 5.4 years and 35.7% were men. Orthostatic hypotension was diagnosed in 294 patients (28.0%). In univariate analysis, orthostatic hypotension was associated with overall mortality only in patients aged 65-75 years (HR 1.5, 95% CI 1.07-2.2), but in the multivariate model this association disappeared. CONCLUSIONS: In older frail patients, orthostatic hypotension was not an independent risk factor for overall mortality. Geriatr Gerontol Int 2018; 18: 1009-1017.

The association between subjectively impaired sleep and symptoms of depression and anxiety in a frail elderly population.

BACKGROUND: Most previous studies showed an association between sleep impairment in the elderly and symptoms of depression and anxiety. Majority of these studies were conducted in "strong", community-dwelling elderly. AIM: To assess the association between subjective sleep impairment and its affective disturbances among frail elderly patients. METHODS: The retrospective study included patients 65 years old and above. Data included socio-demographic characteristics, the mini-mental state examination, the short anxiety screening test, the 15-item Geriatric Depression Scale, and the Patient Health Questionnaire. The patients were asked about sleep complaints. RESULTS: The study population consisted of 496 patients. The mean age was 83.7 ± 6.2 years, and only 7 (1.4%) did not report any sleep disturbance. After adjustment, depression symptoms were associated only with decreased overall sleep satisfaction (OR 2.62, 95% CI 1.18-5.81), while anxiety symptoms were associated with decreased overall sleep satisfaction (OR 3.17, 96% CI 1.71-5.88), difficulty falling asleep (OR 3.58, 95% CI 1.96-6.52), waking up during the night (OR 3.16, 95% CI 1.63-6.1), morning weakness (OR 2.68, 95% CI 1.44-5.0) and daytime drowsiness (OR 2.39, 95% CI 1.21-4.69). DISCUSSION: Sleep impairment is very prevalent among frail elderly and associated much more with anxiety than with depression. CONCLUSION: The findings of the present study provide further evidence for the importance in taking a detailed history of sleep habits during the course of the geriatric assessment in frail elderly patients.

Can home care for homebound patients with chronic heart failure reduce hospitalizations and costs?

BACKGROUND: Congestive heart failure (CHF), a common problem in adults, is associated with multiple hospitalizations, high mortality rates and high costs. PURPOSE: To evaluate whether home care for homebound patients with CHF reduces healthcare service utilization and overall costs. METHODS: A retrospective study of healthcare utilization among homebound patients who received home care for CHF from 2012-1015. The outcome measures were number of hospital admissions per month, total number of hospitalization days and days for CHF only, emergency room visits, and overall costs. A comparison was conducted between the 6-month period prior to entry into home care and the time in home care. RESULTS: Over the study period 196 patients were treated by home care for CHF with a mean age of 79.4±9.5 years. 113 (57.7%) were women. Compared to the six months prior to home care, there were statistically significant decreases in hospitalizations (46.3%), in the number of total in-hospital days (28.7%), in the number of in-hospital days for CHF (66.7%), in emergency room visits (47%), and in overall costs (23.9%). CONCLUSION: Home care for homebound adults with CHF can reduce healthcare utilization and healthcare costs.

[SYNDROME OF OBSTRUCTIVE SLEEP APNEA IN THE ELDERLY POPULATION - PREVALENCE, CLINICAL CHARACTERISTICS AND TREATMENT STRATEGY].

INTRODUCTION: Obstructive sleep apnea syndrome - a common problem among old people, reduces the quality of life and is accompanied by increased morbidity and mortality. There are tests that enable early detection and diagnosis of this condition and there are effective treatments. This review will focus on the following topics: • The importance of the problem • Review of diagnostic tools • Treatment guidelines • How to improve adherence of patients to treatment.

Which factors affect the implementation of geriatric recommendations by primary care physicians?

BACKGROUND: The overall implementation rate for outpatient comprehensive geriatric assessment (OCGAU) recommendations ranges from 48.6 to 71%. The purpose of the study was to identify factors that reduce the implementation rate of geriatric recommendations. METHODS: The medical records of patients who were assessed in the comprehensive geriatric assessment unit over an 8 year study period were surveyed. Data collected included patient's characteristics (socio-demographic, functional, cognitive, and affective condition, co-morbidity), number of recommendations, the identity of the geriatrician, and data related to the primary physician (age, sex, seniority, number of patients referred for geriatric assessment). RESULTS: Three thousand four hundred thirty-four recommendations were made for 488 patients (mean age 83.6 ± 0.6 years) of which 1,634 (47.6%) were implemented by their primary physician. In univariate analyses patients with an implementation rate < 25%, compared to patients with implementation rate ≥75%, had a higher Charlson Comorbidity Index Total Score (CCITS) (2.5 ± 1.9 vs. 1.8 ± 1.7, P < 0.05), a lower Barthel Index (82.8 ± 16.2 vs. 87.0 ± 15.3, P < 0.05), and a lower Instrumental Activity of Daily Living score (7.2 ± 3.5 vs. 8.2 ± 3.7, P < 0.05). There were no differences between these groups in other patient characteristics or the number of recommendations made during the assessment. Similarly, there were no differences in the identity of the geriatrician or the primary physician's characteristics. In the multivariate analysis only higher CCITS was associated with a lower rate of recommendation implementation by primary physicians. CONCLUSIONS: There is a need to increase the implementation rate by primary physicians by increasing and strengthening the link with them and by further training in the field of geriatrics medicine. TRIAL REGISTRATION: The Helsinki committee of the Meir Medical Center approved the study (Approval #024/2015 [k]).

A Comparative Study of Models of Geriatric Assessment and the Implementation of Recommendations by Primary Care Physicians.

The aim of the present study was to compare implementation rates by primary care physicians of geriatric assessment recommendations given in various assessment settings. We compared Model "OCGAU," an outpatient comprehensive geriatric assessment unit where there was no direct contact between the geriatrician and the primary care physician with three "Clinic" models of in-clinic geriatric assessment: Model "Clinic A-2007" in which the primary care physician participated in the assessment, Model "Clinic A-2013" where there was no contact with the primary care physician, and Model "Clinics B-2013" where the primary care physician participated in a staff meeting with the geriatrician in the clinic. Subgroups of "OCGAU" model were composed of patients referred to the geriatric unit by primary care physicians of patients included in three "Clinic" models. Model "OCGAU" included 240 patients, Model "Clinic A-2007" 107, Model "Clinic A-2013" 127, and Model "Clinics B-2013" 133. The patients in Model "OCGAU" were older (mean age 83.2 ± 6.2 years) than in "Clinic" models where the mean age was 79.7 ± 6.5, 81.5 ± 6.1, and 80.7 ± 6.5, p < 0.001. More recommendations were given per patient (6.4) in the Model OCGAU than in the "Clinic" models (range 1.9-3.9, p < 0.05), but the implementation of recommendations by primary care physicians was lower in Model OCGAU (48.9%) than in "Clinic" models (range 56.9%-71.8%, p < 0.005). Although more recommendations were made in the geriatric unit, the implementation rate was lower. This indicates the need for organizational changes, in particular, improving communication between the geriatric staff and primary care physicians.

Out of sight, out of mind? Does terminating the physical presence of a geriatric consultant in the community clinic reduce the implementation rate for geriatric recommendations.

AIM: To assess the effect of moving the geriatric consultation from the primary care clinic to another setting, on the rate of implementation of geriatric recommendations by family physicians. METHODS: A retrospective review of the computerized medical records of elderly patients in four primary care clinics. The rate of implementation of geriatric recommendations was compared between clinics in which a geriatric consultant was physically present (control clinics) and a clinic where the consultation took place elsewhere (study clinic). In addition, the results of the present study were compared to a previous study in which the geriatric consultation was carried out in the study clinic and the family doctor was an active participant. RESULTS: 127 computerized files were reviewed in the study clinic and 133 in the control clinics. The mean age of the patients was 81.1±6.3 years and 63.1% were women. The overall implementation of geriatric recommendations by family doctors in the study clinic was 55.9%, a statistically significant decrease compared to the previous study where the rate was 73.9% (p<0.0001). In contrast, there was no change in the implementation rate in the control clinics at 65.0% in the present study and 59.9% in the previous one (p=0.205). CONCLUSIONS: Direct, person-to-person contact between the geriatric consultant and the family doctor has a beneficial effect on the implementation of geriatric recommendations. This should be considered by healthcare policy makers when planning geriatric services in the community.