Responsiveness of outcome measures used in an antidementia drug trial.

The responsiveness of outcome measures used in antidementia drug trials has had little formal analysis, but it can be crucial to the interpretation of a medication's effectiveness. The authors report the responsiveness of outcome measures from the Canadian trial of linopirdine, a novel phenylinodolinone, estimated using an effect size statistic. The effect sizes ranged from 0.10-0.26, with the cognitive and functional measures yielding estimates greater than 0.20, a level held to be clinically detectable. All of the standard measures used in this trial, save one, performed better than the global clinical measure. The global clinical measure used in this study may have been too insensitive to detect minimal clinical change.

A clinimetric evaluation of specialized geriatric care for rural dwelling, frail older people.

OBJECTIVE: To test Comprehensive Geriatric Assessment (CGA) as an adjunct to usual care. DESIGN: A randomized controlled trial with 3, 6, and 12 months follow-up. SETTING: Rural communities. PATIENTS: A total of 182 of 265 frail older patients (52 refused, 2 withdrawn, 27 ineligible, 2 deaths) referred by family practitioners with allocation to intervention (n = 95) or usual care (n = 87). INTERVENTION: Three-month implementation of CGA recommendations by a Mobile Geriatric Assessment Team (MGAT) with follow-up assessments at 3, 6, and 12 months. Geriatric nurse assessors, blinded to group assignment, performed each assessment. MAIN OUTCOME MEASURE: Goal Attainment Scaling (GAS). RESULTS: Baseline characteristics were comparable between groups. At 3 months, the intervention group was more likely to attain their goals (GAS total: chi = 46.4 +/- 5.9; GAS outcome chi = 48.0 +/- 6.6) compared with controls (total: chi = 38.7 +/- 4.1; outcome chi = 40.8 +/- 5.6) (P < .001). Standard assessments of function (Barthel index, instrumental activities of daily living), cognition (Mini-Mental State Examination), and quality of life (modified Spitzer quality of life index) showed no difference over 12 months. No difference in survival (intervention: chi = 320 days, SE = 6; control: chi = 294 days, SE = 6; P = .257) or time to institutionalization (intervention: 340 days, SE = 9; control: 342 days, SE = 8; log rank = 0.661; P = .416) were observed. CONCLUSIONS: A MGAT can target rural dwelling, frail older persons, perform in-home CGA, and develop an intervention strategy. Although the intervention did not prolong life or delay institutionalization, clinically important benefits were observed.

Development and validation of an improving prescribing in the elderly tool.

OBJECTIVE: To apply recently published consensus panel guidelines to a series of hospital inpatient charts to develop and validate a brief screening tool for potentially inappropriate prescriptions in the elderly. SETTING: A 400-bed acute care hospital in London, Ontario. METHODS: Three hundred and sixty-one consecutive inpatient charts, 185 from a clinical teaching unit (CTU) and 176 from a geriatric assessment unit (GAU) were examined for potentially inappropriate prescriptions as listed by McLeod et al. The potentially inappropriate prescribing practices detected were used to develop the Improving Prescribing in the Elderly Tool (IPET). Construct validity was examined by looking for a predicted difference in the rate of potentially inappropriate prescriptions between the CTU and the GAU. Interrater reliability was determined by applying the IPET to a new series of 100 charts. RESULTS: Forty-two of 361 individuals (12.5%) had 45 potentially inappropriate prescriptions representing 14 different potential drug/disease interactions; these were used to construct the IPET. A demonstrated difference in the rate of potentially inappropriate prescriptions between the CTU and GAU indicated construct validity. The interrater reliability of the IPET (kappa) when applied to a new series of 100 charts was 1.0. INTERPRETATION: The IPET is a brief, reliable and valid tool based on the published literature that may be used to screen for potentially inappropriate prescriptions in the elderly.

Improving a system of care for elderly persons in rural areas.

This article describes a community initiative to improve the care of elders in largely rural areas. An organization development framework guided pilot projects in two communities, with support from a regional geriatric program. Two interdisciplinary teams, representing primary service agencies in the communities, have been trained to serve as local resources in geriatric assessment and intervention. Through the resource teams, the communities are developing a more integrated and coordinated approach to care for the elderly population. The process has yielded valuable insights into the implementation of system change.

The application of goal attainment scaling in chronic pain settings.

Although the multidimensional nature of chronic pain has been recognized since the 1960s, pain management continues to reflect a biomedical model for many chronic pain patients. The application of a biopsychosocial approach would be aided by measurement tools that reflect the multidimensional nature of pain, facilitate interdisciplinary care planning, and focus treatment on the consequences of pain that are important to patients. Goal Attainment Scaling (GAS) is an individualized health outcome measure that is suitable for health problems that warrant a multidimensional and individualized approach to treatment planning and outcome measurement. This paper describes the use of GAS as a treatment and research tool in cancer pain, pediatric pain, work-related nonmalignant pain, and geriatric pain. Unlike the typical process where goals are not explicitly stated, GAS allows goals to be stated in a systematic measurable manner that is relevant and meaningful for each patient, and that can guide individual treatment planning. GAS is an appropriate technique for guiding and monitoring the treatment of individual chronic pain patients, and may provide a useful tool for evaluating chronic pain programs.

An individualized approach to outcome measurement in geriatric rehabilitation.

BACKGROUND: The heterogeneity of health problems experienced by frail elderly patients makes it difficult to use a single standard measure to evaluate multiple outcomes of geriatric rehabilitation. Commonly, several measures are used, but an alternative is to use an individualized measure such as Goal Attainment Scaling (GAS). This study investigated the reliability, validity, and responsiveness of GAS as an outcome measure in geriatric rehabilitation. METHODS: We studied 173 consecutive admissions (mean age 81; 77% female; mean length of stay 33 days) to a geriatric rehabilitation unit. Assessment instruments were completed at admission and discharge. Individualized treatment goals were identified for each patient by using GAS; standardized measures included self-rated health, a global clinical assessment, the Barthel Index, the OARS IADL scale, the Folstein Mini-Mental State Examination (MMSE), and the Nottingham Health Profile (NHP). RESULTS: Mobility, future care arrangements, and functional impairment were the most commonly identified GAS goal areas. The interrater reliability of the GAS discharge score was 0.93. The GAS discharge score correlated strongly (r> or =0.50) with the standardized measures, except for self-rated health, the MMSE, and the NHP (r> or =0.31). GAS was more responsive to change than any of the standardized measures. The GAS score was used to derive receiver operating characteristic curves for other measures; this can provide insight into the interpretation of clinically important outcomes. CONCLUSIONS: GAS appears to be a feasible, reliable, valid, and responsive approach to outcome measurement in geriatric rehabilitation.

Clinical experience with Goal Attainment Scaling in geriatric care.

OBJECTIVES: This article presents a qualitative evaluation of the utility of Goal Attainment Scaling (GAS) in geriatric care. GAS is an individualized outcome measure particularly suited for clients with multiple complex problems, such as are commonly served by geriatric programs. METHODS: Semistructured interviews were completed with 24 clinicians in four hospital or community-based geriatric services where GAS has been used. An inductive analysis was used to identify themes. RESULTS: GAS was described as resulting in shorter lengths of stay, more focused care, and improved team functioning. GAS was perceived as having greater use for functional (versus medical) goals, when clinicians had more direct control over treatments, when patients were involved in goal-setting, and when goals were set by an interdisciplinary team. DISCUSSION: GAS has affected both care practices and patient outcomes. This study illustrates the clinical impacts an outcome measure can have, as well as the use of qualitative methods for this type of research.

Use of goal attainment scaling in measuring clinically important change in cognitive rehabilitation patients.

Measuring the effectiveness of cognitive rehabilitation programs poses both conceptual and practical challenges. We compared several standardized outcome measures with goal attainment scaling (GAS) to assess their sensitivity to changes in health status in patients undergoing cognitive rehabilitation. GAS is a measurement approach that accommodates multiple individual patient goals, and has a scoring system which allows for comparisons between patients. Forty-four patients were evaluated. GAS yielded a mean 4.4 goals per patient. The mean gain in the GAS score was compared with the change in the Rappaport Disability Rating Scale, the Kohlman Evaluation of Daily Living Skills, the Milwaukee Evaluation of Daily Living, the Klein-Bell elimination scale and mobility scale, the Instrumental Activities of Daily Living Scale, and the Spitzer Quality of Life Index. Using a relative efficiency statistic, GAS proved more responsive than any other measure. The effect size statistic also demonstrated greater responsiveness to change with GAS compared with standard measures. GAS shows promise as a responsive measure in cognitive rehabilitation. This study replicates a similar study of GAS in frail elderly patients, suggesting that individualized measures may have broad merit in evaluating rehabilitation programs.

Cross-validation of the Delirium Rating Scale in older patients.

OBJECTIVE: To cross-validate the Delirium Rating Scale (DRS). DESIGN: Cross-sectional. SETTING: Geriatric medicine and geriatric psychiatry assessment units and consultation services. PARTICIPANTS: A total of 104 older patients on the above services. MEASUREMENTS: Mini-Mental State Examination (MMSE) score, Barthel Index score, DRS score, Blessed Dementia Scale score, clinical diagnoses using DSM-III-R criteria. MAIN RESULTS: The mean DRS score was highest in the delirium group. Cronbach's alpha was .90, and inter-rater reliability of total scores was .91 (intra-class correlation). Receiver Operating Characteristic curve analysis showed that the area under the curve for the DRS was significantly higher than the MMSE as a test for delirium. At its published cutpoint of 10, the sensitivity of the DRS is .82 and the specificity is 94. The value at which the sensitivity of the DRS is .90 is 8, at which specificity is .82. CONCLUSIONS: The DRS appears to a feasible instrument. In a sample with a high proportion of delirious patients, it has acceptable measurement properties when used by expert observers.

Factors associated with institutionalization of older people in Canada: testing a multifactorial definition of frailty.

OBJECTIVES: To test a model of frailty by examining factors associated with institutionalization of older people in Canada; to assess whether diagnostic data provided information about risk beyond that provided by data on functional capacity and demographic variables. METHODS: Cross-sectional study of 1258 institutional subjects and 9113 community-dwelling older adults from the Canadian Study of Health and Aging. RESULTS: Multiple logistic regression analysis showed that female gender, being unmarried, absence of a caregiver, presence of cognitive impairment (including all types of dementia), functional impairment, diabetes mellitus, stroke, and Parkinson's disease were independently associated with being in a long-term care facility. CONCLUSION: Frailty appears to be a multidimensional construct, and not simply a synonym for dependence in Activities of Daily Living. Studies of health outcomes in older people should include diagnostic data as well as demographic information and data on functional capacity.

A community development and outreach program in geriatric mental health: four years' experience.

OBJECTIVES: To describe a geriatric mental health outreach program based on a community development model and to review 4 years of experience with this program. DESIGN: Program model and description of implementation experience. SETTINGS: A geriatric mental health outreach program of a regional psychiatric hospital, serving a primarily non-urban area, with offices in the community it serves. PARTICIPANTS: The program targets community-dwelling or institutionalized older persons with late-onset mental health problems and/or behavioral disturbances, persons with long-standing psychiatric disorders with age-related changes, and their caregivers. INTERVENTION: The program is a geriatric mental health outreach and consultation service that emphasizes community development and caregiver education. Program components include an interprofessional consultation team, a specialized information and resource service, educational service initiatives, and an ongoing role in planning and coordination activity in the local health care system. MEASUREMENTS: Program monitoring, including a patient database and a description of program activities. RESULTS: Cognitive impairment, behavioral disturbance, physical/medical problems and depression are the most common reasons for referral to the outreach program. Referred patients (mean age 78; 65% female) have usually (almost 90% of cases) been managed at a similar or lower level of care. Program activities have included focused educational initiatives in community and institutional settings and have emphasized the involvement and development of community caregivers and other local resources. CONCLUSION: The program is a multifaceted effort to make efficient use of scarce specialized resources in a manner that is sensitive and responsive to local circumstances and needs. Experience to date has shown evidence of the feasibility and potential benefits of a comprehensive approach to community development and outreach in geriatric mental health.

Use of Goal Attainment Scaling to measure treatment effects in an anti-dementia drug trial.

We report data on the validity and responsiveness (i.e. sensitivity to change) of assessment instruments including Goal Attainment Scaling (GAS), at a single site in a multicentre trial of the experimental therapeutic agent linopirdine. Fifteen people (11 women) were evaluated. GAS yielded a mean 3.7 goals per patient (range 2-6). The mean gain in the GAS scores, 2.7 +/- 16.4, was compared to changes in the Alzheimer's Disease Assessment Scale-Cognitive Section, the Global Deterioration Scale, Clinical Global Impression and the Mini-Mental State Exam. GAS had the largest relative efficiency (0.47) when compared to the standard. GAS also had the largest effect size (0.61). The data suggest that an individualized approach may have merit as an outcome measure and as a means to better understanding treatment effects. Qualitative analysis revealed consistent goal setting in self-care, behaviour, cognition and leisure, suggesting that these areas should routinely be evaluated.

Illness presentation in elderly patients.

BACKGROUND: Atypical disease presentations, such as delirium, are associated with adverse health outcomes. They are also markers of frailty in elderly people, which is itself associated with adverse hospital outcomes. We investigated the relationship between frailty and atypical disease presentation in predicting adverse hospital outcomes and complications of the hospital course of elderly patients admitted to general medical services. METHODS: We conducted a cohort study in a large (800 beds) tertiary care university hospital. The prevalence of atypical disease presentations and the incidence of adverse hospital outcomes (death, nursing home admission, prolonged hospital stay, and failure to regain premorbid functional status) were studied in previously well and previously frail elderly patients. RESULTS: Patients were classified as being well or frail on the basis of the premorbid Barthel Index (well, score of > or = 95 [n = 76]; frail, score of < 95 [n = 117]). Frail elderly were older (80 vs 76 years), more often female (62% vs 46%), and less likely to be community dwelling (89% vs 99%). Atypical disease presentation was more common in the frail elderly (59% vs 25%; P < .001). Of those who presented atypically, the frail most often presented with delirium (61%) and the well presented with falls (37%) and delirium (32%). Of the frail elderly with atypical symptoms, 60% had adverse hospital outcomes compared with 32% of the well elderly who presented typically (P < .05). Logistic regression analysis showed that premorbid functional dependence (odds ratio, 2.48; 95% confidence interval, 1.17 to 5.22), atypical disease presentation (odds ratio, 2.37; 95% confidence interval, 1.20 to 4.67), and functional decline at admission (odds ratio, 5.64; 95% confidence interval, 2.37 to 13.44) were all independently predictive of poor hospital outcomes. By contrast, severity of disease, age, and sex did not confer an increased risk of adverse events. CONCLUSIONS: Premorbid functional dependency, atypical disease presentation, and functional decline on admission have independent impacts on adverse hospital outcomes. Assessment of each should be incorporated into the routine care of elderly patients.

Geriatric psychiatry consultation in the community.

While increasing emphasis is being placed on geriatric psychiatry consultation and outreach services, there is considerable variation in terms of the composition and direction of these programs. Programs vary in terms of their objectives, location, target population, use of health professions and other resources and their method of consultation. The purposes of this paper are to review the characteristics of existing programs, to review the needs of the targets of consultation and to consider theoretical and methodological approaches which have been found to be useful in mental health/psychiatric consultation, in continuing medical education, and in program evaluation. On the basis of this review, future directions for effective approaches to consultative outreach in geriatric psychiatry will then be proposed.

Increasing the recognition of delirium in elderly patients.

OBJECTIVE: To determine if an educational intervention aimed at house staff will increase knowledge about and recognition of delirium. DESIGN: Before/after study, with blinding of participants to the intent of the study. SETTING: University hospital in Halifax, Nova Scotia. PATIENTS: One hundred eighty-seven control patients, seen as consecutive admissions of elderly patients (65 + years) to the General Medicine services of the Victoria General Hospital prior to the educational intervention, and 247 patients seen thereafter. INTERVENTION: Educational intervention at grand rounds, housestaff rounds, sign-in rounds, and bedside teaching. MEASUREMENTS: Recognition of delirium in the admitting history or progress notes, Confusion Assessment Method (CAM) as recorded by nurses, diagnosis of delirium by independent study physicians using DSM-IIIR criteria and the Trzepacz Delirium Symptom Rating Scale. RESULTS: Prior to the intervention, delirium or acute confusion was diagnosed in 3% of patients; after the intervention, delirium or acute confusion was diagnosed in 9% of patients (P < 0.01). Other abnormalities in mental state were noted in 8.5% of admissions prior to the intervention, and 15.6% of admissions after the intervention. After the intervention there was a significant difference in the proportion of patients in whom a mental status questionnaire had been carried out and in whom there was formal comment on various aspects of the mental state. The nursing CAM had a sensitivity of 0.68 and a specificity of 0.97. CONCLUSIONS: A simple educational intervention aimed at house staff appears to be effective in changing house staff behavior. Improved recognition of delirium may lead to better patient outcomes.

Use of goal attainment scaling in measuring clinically important change in the frail elderly.

The selection of appropriate outcome measures is important in evaluating specialized geriatric programs, but how the various measures compare, and which are most appropriate, are matters still largely unexplored. We compared several outcome measures, including goal attainment scaling, to assess their sensitivity to changes in the health status of frail elderly patients admitted to two geriatric medicine wards. GAS is a measurement approach which accommodates multiple individual patient goals, and has a scoring system which allows for comparisons between patients. Forty-five patients (mean age 81 years, 30 females) received comprehensive assessments. GAS yielded a mean 5 goals per patient. The mean gain in the GAS score was 22 points (SD = 7) which was compared with the change in the Barthel Index (r = 0.59), the Functional Independence Measure (r = 0.45), the Physical Self-Maintenance Scale (r = 0.54), the Katz Activities of Daily Living Index (r = 0.49) and the Spitzer Quality of Life Index (r = 0.38). The inter-rater reliability of scoring the GAS follow-up guides was 0.91. Using a relative efficiency statistic, GAS proved more efficient than any other measure. The effect size statistic also demonstrated an increased responsiveness to change of GAS compared with standard measures. GAS is an individualized measurement approach which shows promise as a responsive measure in frail elderly patients.

The use of goal attainment scaling in a geriatric care setting.

OBJECTIVE: Goal attainment scaling (GAS) is a measurement approach used extensively in mental health. It accommodates multiple individual patient goals, yet retains mathematical properties allowing comparisons between patients. This study was carried out to investigate the feasibility and measurement properties of GAS in a geriatric care setting. DESIGN: Prospective descriptive study. SETTING: The geriatric restorative care service and geriatric assessment unit at Camp Hill Hospital, a 350-bed tertiary care facility in Halifax, Canada. PATIENTS: Fifteen patients aged 65 to 94 who were consecutively admitted to the two geriatric services (mean age 79 years, mean length of stay 37 days, 9 females). INTERVENTION: Goal Attainment follow-up guides were developed independently for each patient by two geriatricians after a comprehensive assessment of the patient. These guides were later compared to assess level of agreement in goal setting and scale development. A single goal attainment follow-up guide was then developed for each patient by consensus of the two geriatricians. At the end of the follow-up, the guides were scored independently for each patient by one of the geriatricians and by the patient's primary care nurse. MAIN OUTCOME MEASURES: GAS scores were determined on admission and discharge. Each patient also received admission and discharge ratings on the Barthel Index as well as a global rating of outcome (on a subjective 10-point scale) by a geriatrician who was blinded to the Goal Attainment follow-up score. RESULTS: GAS proved feasible, requiring 15-20 minutes to scale an average of six goals per patient. GAS also appears reliable. Of 87 goals, 71 (82%) were identified independently by two geriatricians, and the remainder were determined by consensus. This is also a measure of content validity. The physician-nurse inter-rater reliability was 0.87 (intraclass correlation). Concurrent validity was assessed by correlation with the Barthel Index (r = 0.86) and the global clinical outcome rating (r = 0.82). Content validity was also assessed by comparing our goal areas with those identified in recent consensus reports on geriatric assessment. Of these 13 assessment areas, 12 appeared to be reasonably well covered while one assessment area (sexual problems) was not identified for any of the 15 patients. CONCLUSIONS: GAS appears to be a feasible method of goal setting and outcome evaluation in geriatric care settings, with promising reliability and validity.

Outcomes of admission to a psychogeriatric service.

There is an increasing demand in Canada for improved care of elderly patients with psychiatric disorders. We report one year's experience, with a one year follow-up, of 130 consecutive admissions to the psychogeriatric service at Alberta Hospital, Edmonton. Approximately one-half of the patients came from the community and one-half from long term care institutions; 3 % were admitted via an acute care hospital. The median age was 76 years (range from 43 to 92). Aggression (45%) and wandering (29%) were the most common problems. Dementia was diagnosed in 58% and depression in 19% of patients; 17% had medical problems which precipitated or exacerbated the presenting symptoms. The median length of stay was 92 days (range from one to 365 days); patients admitted from long term care facilities were hospitalized for a longer period of time than those admitted from the community. The mortality rate was 16% in the hospital and five percent at one year follow-up. Approximately one-half of the patients were discharged back to their original residence. These results suggest that even very severely disturbed behaviour can be managed successfully and that a close link between medical diagnostic and treatment services is important. Innovations between these services and long term care facilities may reduce the need for prolonged hospitalization.

The prevalence of cognitive impairment in an elderly Canadian population.

We investigated cognitive impairment in a study of the health of the elderly population of Saskatchewan. Surveys of elderly persons living at home (n = 1267) and living in long-term care facilities (n = 990) were conducted in 1981. Cognitive impairment was assessed by a short 10-item mental status questionnaire previously validated against a clinical diagnosis of dementia in an elderly Canadian population. The prevalence of clinically significant cognitive impairment was found to increase with age and with dependence level in long-term care facilities. We estimate that 7.8% of the elderly population have cognitive impairment consistent with a clinical diagnosis of dementia. Our estimates are compared with those derived from other studies. These findings affirm the importance of dementia as a cause of dependence in the elderly and the need for long-term care facilities to deal with dementia and its consequences. Also, since at least as many persons with cognitive impairment live at home as in long-term care facilities, health care planners must direct attention to the elderly with dementia at home.