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.

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.