Effect of a geriatric consultation service on management of patients in an acute care hospital.

Elderly patients present particular management challenges. We conducted a randomized clinical trial of the effect of a geriatric consultation service on the management of elderly patients in an acute care hospital. A total of 113 patients aged 75 years or more who met certain criteria were assigned to either receive (57 patients) or not receive (56) care by the service. At the end of their hospital stay the patients were assessed with regard to predetermined outcomes. The patients were followed up for 1 year after discharge to determine death rates and direct health care expenditures. The intervention group showed significantly greater improvement in mental status (p less than 0.01), were receiving fewer medications at discharge (p less than 0.05) and had lower short-term death rates (p less than 0.05) than the control group. A geriatric consultation service can improve the hospital care and health of the elderly.     

Nursing dependency in registered nursing homes and long term care geriatric wards in Edinburgh.

There has been growing interest and public investment in registered nursing homes, apparently based on the assumption that these homes are the private equivalent of hospital long term care. We have tested this hypothesis in a survey comparing 400 patients in 18 registered nursing homes with 217 patients in 11 geriatric long term care wards in Edinburgh. The nursing home patients formed a distinct and separate group: 362 (92%) were women, 392 (98%) were single or widowed, and 358 (90%) were self financing, whereas in the geriatric long term care group 148 (68%) were women and 35 (16%) were still married. Patients in nursing homes were also far less dependent than those in geriatric long term care wards (p less than 0.005). This study suggests that there may be large differences between the patients in these two types of institution, particularly with regard to nursing dependency. This finding has important implications in the future planning of long term places for the dependent elderly.     

Psychogeriatric Ward for Mentally Disturbed Elderly Patients

The operation is described of a special psychogeriatric ward of 23 beds set up in 1967 to provide treatment for mentally disturbed elderly patients who could not be kept in a general ward or at home. The unit is in a predominantly geriatric hospital which serves a population of 340,000 and in the four and a half years reviewed 600 patients were admitted. Half of the admissions were emergencies. A consultant geriatrician was in charge and the nursing staff were general trained. The number of beds was found to be adequate for the demand. Few patients had to be transferred to a psychiatric hospital, but, since the mental disturbance was often associated with severe illness and the patients were old, the death rate was high. The nursing staff have found the work interesting and stimulating.     

Domiciliary consultations: some facts and questions.

The domiciliary consultation scheme introduced at the start of the NHS enables joint consultation between a consultant and general practitioner in a patient''s home when the patient cannot attend hospital on medical grounds. Consultants claim a fee from the NHS, general practitioners do not. Data from the Department of Health and Social Security on domiciliary consultations in England and Wales during 1981-6 were analysed. The number of domiciliary consultations fell during 1981-6 from 429,759 in 1981 to 387,394 in 1986, a fall of 10%, whereas the numbers of consultants and general practitioners increased by 1404 (12%) and 2400 (10%), respectively. The yearly rate of domiciliary consultation per consultant fell by 19% from 36 in 1981 to 29 in 1986 and that per general practitioner by 18% from 18 to 15. In 1986 geriatric medicine had the highest rate of domiciliary consultation per consultant (187) followed by psychiatry (89), general medicine (52), dermatology (49), rheumatology (42), general surgery (36), gastroenterology (35), thoracic medicine (34), and orthopaedics (30). In 1986 all specialties apart from clinical pharmacology and therapeutics and clinical genetics showed a decrease in the yearly rate of domiciliary consultation when compared with the rate for 1981. Domiciliary consultation seems to have become a domiciliary visit by the consultant alone. At an estimated cost of about 20m pounds for 1988 the scheme needs critical evaluation.     

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

doi: 10.1111/j.1741‐2358.2011.00529.x 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.     

Care of the diabetic child in the community.

Brief admission of the new diabetic child and of a parent to an enlightened hospital for stabilisation, preliminary education, and familiarisation with hospital and community staff is well worth while. The greater the demand for constant control of the highest quality, the greater the need for a close understanding of the psychosocial factors concerned and for clinical skill. The nature of the home and the family relationships should in theory be available from the child''s general practitioner at the time of the first referral since he has so much information about the whole family. With the virtual disappearance, however, of mutual consultation in the patient''s home in many places, the opportunity for oral communication has declined, and availability on the telephone is not always easy. The busy general practitioner (far less an unknown physician from a deputising service without access to the records) has little time to write a comprehensive letter. In practice a relatively small hospital-based mobile team of specially experienced sisters who are keen to communicate in the home, the GP''s surgery, and the school makes a major contribution to the diabetic care of a young population vulnerable to major handicap in what should be the prime of life. Their cost effectiveness may be difficult to prove but it is not at all in doubt--especially when the sisters as in this area deal in the community with a wider range of chronic illnesses and handicaps in children.     

Facilitating care of patients with HIV infection by hospital and primary care teams.

To complement the role of primary care teams working with patients with HIV disease and AIDS within greater London and to ease the load on the special hospital units a home support team was developed. It comprises six specialist nurses, a general practitioner trained medical officer, and a receptionist and is funded from regional and district sources and charities. A nurse is available for out of hours and emergency weekend calls, with support from the patient''s general practitioner or the attached medical officer. During the first 18 months 249 patients were seen; the mean duration of care was five months. Nearly a third (18/50, 30%) of patients who were terminally ill died at home. The team''s activities included practical nursing care, emotional support for carers and patients, and advice and guidance to primary care teams. Problems in providing care in patients'' homes included issues relating to confidentiality and 24 hour cover. With the increasing incidence of HIV infection the home support team may be a useful model for care of large numbers of patients with symptomatic HIV disease, especially in large urban areas.     

Effectiveness of geriatric rehabilitative care after fractures of the proximal femur in elderly women: a randomised clinical trial.

OBJECTIVE--To compare postoperative collaborative care between orthopaedic surgeons and physicians in geriatric medicine with routine orthopaedic care in elderly women with proximal femoral fracture. DESIGN--Exclusion of patients dying before fit enough to enter trial, those with pathological fractures, those likely to be discharged within seven days of entering the trial, and those remaining unfit for transfer to a peripheral hospital. Remainder allocated to two groups: treatment group and control group. SETTING--District hospital acute admission ward and rehabilitation ward. PATIENTS--144 sequentially admitted elderly women with proximal fracture of the femur; 36 excluded on above criteria and remainder entered into trial. INTERVENTION--Both treatment and control groups (n = 54 in each) received physiotherapy and other services. The treatment group also received thrice weekly supervision by a geriatrician. END POINTS--Physical independence, residence after discharge, and length of hospital stay. MEASUREMENTS AND MAIN RESULTS--At discharge significantly more patients in treatment group were independent in terms of activities of daily living than controls (41 v 25) and their median stay was 24 days (range 8-197) compared with 41 (9-365) (95% confidence intervals for difference 2 to 25). Significantly fewer treatment patients were discharged to institutional care (10% v 32%; 95% confidence interval for difference 6% to 37%) and more to their own homes (63% v 38%; 95% confidence interval for difference 6% to 44%). These beneficial effects were consistent across a range of ages and mental state. CONCLUSIONS--Both hospital and patient benefited when postoperative rehabilitation was provided in a setting specialising in such care for elderly patients with trauma.     

The Yad Sarah geriatric dental clinic, a different model

Introduction: There are not sufficient dental services for elderly people around the world. Yad Sarah is an Israel‐wide network of volunteers aiding sick, elderly, isolated and housebound people with an array of services aimed at making home care possible. It provides medical and social services to more than 380 000 elderly persons per year and in addition, lends medical equipment free of charge, has day rehabilitation centres, legal aid council for seniors, provides transportation for the disabled, meal deliveries and geriatric dental services. Materials and methods: The latter are equipped with five dental units (one mobile unit) and a dental laboratory. During the 5 years from 2000 to 2004 the dental services provided dental care for 3890 elderly patients with the main clinic located in Jerusalem. Patients pay an average of 70% of the cost price of their dental care, with the difference being subsidised by Yad Sarah. Of the 515 patients who applied for treatment in 2004, 54% possessed natural teeth in both jaws, 28% were fully edentulous, 12% were edentulous in the maxilla and 6% were edentulous in the mandible. Females applied for dental treatment more often than the male population. Older patients (75–101 years old) required oral care at their homes or at old age residences, more frequently than the younger age groups (60–74 years old). Conclusion: Dental treatment was administered by 70 volunteer dental surgeons, two certified dental hygienists and dental hygienist students. The clinical staff was provided with a comprehensive in‐service training in geriatric dentistry during the 3‐year service learning period. A survey in 2004 showed that 83% of the selected patients were satisfied, compared with 14% who were not. The reasons for satisfaction were, mainly, the personal relationship with the attending staff (41%) and the professional ability of the dental team (46%).     

Teaching and training in geriatric medicine in the European Union

In 1993 about 20% of the population in the 15 'old' member countries of the European Union (EU) was over 60 years of age and this percentage will increase to more than 25% in 2020. These developments play a key role for the investments in education and training to meet societies needs for health care services. In 2002 about 25% of the medical students in the 'old' EU did not receive any education in geriatric medicine. A question is who will provide the services for older people in related areas, like social care, community care, acute care in the hospitals, long-term care, permanent care and care for psychiatric patients? Geriatric medicine has been recognized as an independent specialty in 8 of the 15 member countries of the 'old' EU. In all EU member states the governments are autonomous regarding all aspects of health care services, including the recognition of specialties and specialist training programmes. A two years training in internal medicine has been recommended in the EU, followed by another four years of training in geriatric medicine. The specialist training has a hospital oriented character, however, it includes also community care and other institutionalised care like nursing homes. The curriculum should contain: biological, social, psychological and medical aspects of common diseases and disturbances in older people. A problem in many EU countries is the shortage of well trained researchers and leading persons for academic positions for geriatric medicine. In a number of countries chairs at the universities remain vacant for long periods of time or even disappear. Good services in the health care for older people need a high quality curriculum and training programme.     

The post-infarction nurse practitioner project

Objectives To confirm the feasibility of nurse practitioner interventionin non-high-risk patients with recent myocardial infarction (MI). Design Observational study. Setting Acute coronary care unit in a teaching hospital. Methods We performed an open-label feasibility study to identify non-high-risk MI patients and evaluate the outcome of a new nurse practitioner intervention programme. The initial pilot phase served to identify the non-high-risk population. In the subsequent confirmation phase, 500 consecutive non-high-risk post-MI patients with preserved LV function without heart failure were included to receive nurse practitioner management. The nurse practitioner intervention started on transfer from the coronary care unit to the cardiology ward and continued thereafter for up to 30 days. Main outcome measures Time to first event analysis of death from all causes or repeat myocardial infarction. Results 500 Patients without signs of heart failure or depressed LV function were identified as nonhigh- risk and eligible for inclusion in the nurse practitioner intervention programme. In the implementation phase, none of the patients died and 0.9% developed a repeat myocardial infarction after 30 days of follow-up. Compared with the pilot phase, patients in the implementation phase spent fewer days in hospital (mean 11.1 versus 6.2 days; p<0.001). Conclusion It is feasible to identify non-high-risk post-MI patients, who can be managed adequately by a nurse practitioner. Embedding experienced nurse practitioners within critical care pathways may result in significant decreases in length of hospital stay. (Neth Heart J 2009;17:61-7.)     

Undergraduate geriatric education through community service learning

doi: 10.1111/j.1741‐2358.2010.00444.x Undergraduate geriatric education through community service learning Introduction: Despite the exponential growth of the elderly population worldwide, geriatric education has been a formal component of only a few dental schools’ curricula. Objective: To describe the geriatric community service learning (CSL) component of the professionalism and community service (PACS) module, and to explore a CSL project carried out by a group of first year dental students at a long‐term care facility. Methods: A literature review was performed to present and describe the CSL component of the PACS module. Students’ personal reflections were used to illustrate some of the joys and challenges of experiencing a long‐term care facility environment. Results: The newly developed PACS module combines community service learning with the long‐term care experience. Students develop, apply and evaluate an educational health promotion activity in a long‐term care facility. Conclusions: The PACS module has encouraged students to acquire comprehensive knowledge and awareness of the needs and dynamics of a long‐term care as they collaboratively interacted with personnel from the facility to develop their projects. The authors would like to engage other schools in discussing the need to integrate community‐based geriatric education into their dental curricula.     

Psychiatric consultation in the nursing home. An inquiry among Amsterdam nursing home physicians

Psychiatric disorders are common among nursing home residents. However, little is known about psychiatric consultation in Dutch nursing homes. As an exploration of the topic, Amsterdam-based nursing home physicians were asked to rate a number of aspects of psychiatric consultation as performed in their nursing home. Striking differences are reported between 14 participating nursing homes with regard to the intensity of psychiatric consultation and the number of consultation requests, which seems low compared with the perceived psychiatric problems. Somatically ill and psychogeriatric residents are estimated to generate an equal number of consultation requests. Psychiatric consultation appears to be characterized by diagnostic clarification, medication recommendations and behavioral management advice whereas staff-directed activities are scarce. Physicians report shortcomings in psychiatric skills among care staff. Research is necessary concerning the psychiatric care delivered to nursing home residents, as well as with regard to the optimal model for psychiatric consultation services. Integration of psychiatric care in nursing homes with mental health care services appears to be desirable.     

Outcomes of a Geriatric Liaison Intervention to Prevent the Development of Postoperative Delirium in Frail Elderly Cancer Patients: Report on a Multicentre,Randomized, Controlled Trial

Background

Delirium is a serious and common postoperative complication, especially in frail elderly patients. The aim of this study was to evaluate the effect of a geriatric liaison intervention in comparison with standard care on the incidence of postoperative delirium in frail elderly cancer patients treated with an elective surgical procedure for a solid tumour.

Methods

Patients over 65 years of age who were undergoing elective surgery for a solid tumour were recruited to a multicentre, prospective, randomized, controlled trial. The patients were randomized to standard treatment versus a geriatric liaison intervention. The intervention consisted of a preoperative geriatric consultation, an individual treatment plan targeted at risk factors for delirium, daily visits by a geriatric nurse during the hospital stay and advice on managing any problems encountered. The primary outcome was the incidence of postoperative delirium. The secondary outcome measures were the severity of delirium, length of hospital stay, complications, mortality, care dependency, quality of life, return to an independent preoperative living situation and additional care at home.

Results

In total, the data of 260 patients were analysed. Delirium occurred in 31 patients (11.9%), and there was no significant difference between the incidence of delirium in the intervention group and the usual-care group (9.4% vs. 14.3%, OR: 0.63, 95% CI: 0.29–1.35).

Conclusions

Within this study, a geriatric liaison intervention based on frailty for the prevention of postoperative delirium in frail elderly cancer patients undergoing elective surgery for a solid tumour has not proven to be effective.

Trial Registration

Nederlands Trial Register Trial ID NTR 823     

Understanding the psychology of geriatric edentulous patients

doi: 10.1111/j.1741‐2358.2011.00496.x Understanding the psychology of geriatric edentulous patients Objective: This article focuses on understanding our older patients who require complete prosthodontic care. By breaking down the patient psychology to its component parts, it is easier to obtain a clear picture of this special cohort of patients. Considering the increase in number of geriatric edentulous patients, this knowledge will help the dentist serve the geriatric population better. Background: The role of psychology and personality in complete denture treatment is well documented. The geriatric patient who needs complete dentures has a psychological aspect that needs consideration. Although significant, these aspects may sometimes be ignored or considered irrelevant. Materials and methods: A review of relevant literature was carried out to obtain data on the psychology and personality of geriatric, complete denture patients and their behavioural changes. The obtained data was filtered and condensed to provide a short but comprehensive look at the geriatric edentulous patient’s psychology. Conclusion: When handling geriatric edentulous patients, the dentist must be confident of addressing and managing the psychology of these patients. A thorough understanding of the geriatric mental state thus becomes important and significant for the clinician.     

Contribution from geriatric medicine within acute medical wards.

In 1977 a scheme of attachment to acute medical wards of consultants in geriatric medicine and associated junior medical staff was instituted in a large Edinburgh teaching hospital. The effect on admissions of patients aged 65 and over was examined for comparable periods before and during this arrangement. Mean and median stays were reduced for both sexes but more noticeably for women. The mean stay for all women aged over 65 was reduced from 25 to 16 days and for women aged over 85 from 50 to 19 days. The proportion staying under two weeks was significantly increased in both sexes, and the proportion discharged home also increased, correspondingly fewer patients being transferred to convalescent wards. These changes were not accompanied by increased transfers to the geriatric department, and probably the skills and extra resources available to the geriatric service were the factors mainly responsible for the changes in performance.     

An evaluation of home visiting of patients by physicians in geriatric medicine

The practice of preadmission home visiting of patients referred to geriatric medicine units has in recent years been criticised as being unnecessary on the grounds that if there is no waiting list there is no need for allocation of priority for admission; as being wasteful of doctors'' time; as being resented by general practitioners; and as failing to provide adequate clinical information. The geriatric medicine department at the City Hospital with no waiting list for patients referred by general practitioners has retained home visits for most referrals because of the advantages in terms of acceptability to general practitioners (98-100%); the quantity and quality of information obtained; the usefulness of this information in deciding appropriate management and in planning discharge from hospital; and the provision of a unique teaching opportunity, which is highly valued by students and teachers alike.     

The impact of a new geriatric program in a hospital for the chronically ill.

Reports of the rapidly increasing proportion of persons aged 65 years and more in Canada and the resultant need for changes in the country''s health care system prompted experimental changes in the operation and training procedures at St. Mary''s of the Lake Hospital, Kingston, Ont. Aimed at better patient care and at better education of medical house staff in geriatrics and long-term care, the revised program is permeated with the philosophy of rehabilitation. It includes full-time staff, a geriatric outpatient clinic, a day hospital, a team approach to patient care (with regular team audits), problem-oriented medical records, a formal physical medicine section with a district inpatient unit, and an intensive inservice education program. After the first year of the program patient outcome had improved and more efficient use was being made of continuing care beds because of larger numbers of patinets being discharged home after shorter stays. This may be one avenue for deceleration of our country''s dismal rate of institutionalization.