Residence and quality of life determinants for adults with tetraplegia of traumatic spinal cord injury etiology.

STUDY DESIGN: Cross-sectional analysis of individual interviews with a convenience sample of persons living with tetraplegia. OBJECTIVES: To describe patterns of residence among persons living with tetraplegia following discharge from initial acute medical care after spinal cord injury, decision-making process for each residence move and quality of life determinants at different residence types. SETTING: California and Minnesota, United States. METHODS: A total of 22 adults with traumatic spinal cord injury tetraplegia were interviewed about their residence histories, the residence decision-making process for each move, and positive and negative features at each residence at which they had lived. RESULTS: Information, money, insurance, accessibility, intimate relationships and personal assistants had the strongest influence over residence location, with insufficient information and finances demonstrating particularly strong influences. Participants frequently viewed parents' homes as an 'only option,' 'place of refuge' or 'stunting' environment. They viewed own homes as 'only options' or ways to achieve quality of life improvements, and other institutions as 'only options' or 'stepping-stones' to independent living. CONCLUSION: Further research is needed to examine decision-making across multiple moves over the course of the lives of persons living with tetraplegia, particularly examining the roles of inadequate information and finances as inhibitors of freedom of choice.

Identifying hospitalized older patients at varying risk for physical performance decline: a new approach.

OBJECTIVE: A classification tree analysis identifies patient groups at varying risk for decline in physical performance 1 year after hospitalization. DESIGN: Prospective cohort study. SETTING: Tertiary care VAMC. PARTICIPANTS: A total of 507 acutely ill hospitalized male veterans aged 65 years and older. MEASUREMENTS: Eighteen admission characteristics were considered as potential predictors: demographic data, medical diagnoses, functional status (e.g., ADL and IADL), geriatric conditions (e.g., incontinence, vision impairment, weight change), mental status, depression, and physical functioning (measured by self-report (MOS-PFR) and the Physical Performance and Mobility Examination (PPME)). Outcome measure was change in PPME status at 12-months post-admission. RESULTS: Patients with the greatest risk for decline had both high baseline physical performance (PPME > or = 9) and at least moderate self-report limitations on physical functioning (MOS-PFR < or = 36, mean = 30.8). Patients with the lowest risk of decline had impaired baseline physical performance (PPME < or = 8) but fewer self-report limitations on physical functioning (MOS-PFR > or = 31, mean = 37.4) and two or less geriatric conditions. CONCLUSIONS: The predictive role of self-report functioning suggests that perception of the impact of health on one's own physical functioning is associated with future performance. The number of geriatric conditions is also an important predictor of physical performance change. By identifying patient risk groups based on geriatric conditions, physical performance, and self-report physical functioning, future targeting strategies may improve physical performance outcomes for hospitalized older adults.

Geriatric targeting criteria as predictors of survival and health care utilization.

OBJECTIVE: To assess the utility of geriatric targeting criteria in predicting survival and health care utilization in a cohort of hospitalized older veterans. DESIGN: A prospective cohort study assessing geriatric targeting criteria, e.g., polypharmacy, falls, or confusion, with respect to adverse outcomes at 12 months. SETTING: A Tertiary Care VA Medical Center. PATIENTS: 507 acutely hospitalized male veterans aged 65 years or more. MAIN OUTCOME MEASURES: Survival status, nursing home placement, and total hospital days during 12 months following hospital admission. RESULTS: Patients who had a higher number of targeting criteria at admission showed a significantly increasing trend toward death (P < or = .001), nursing home placement (P < or = .01), and longer hospital stays (P < or = .01) at 12 months. In univariate analyses, weight loss (relative hazard 3.8, 95% CI 2.4, 5.9), appetite loss (relative hazard 3.3, 95% CI 1.9, 5.8), depression (relative hazard 2.5, 95% CI 1.4, 4.5), falls (relative hazard 2.2, 95% CI 1.2, 4.1), confusion (relative hazard 2.2, 95% CI 1.2, 4.0), and socioeconomic problems (relative hazard 1.6, 95% CI 1.0, 2.5) predicted death. Polypharmacy (OR 3.4, 95% CI 1.3, 8.8), confusion (OR 4.4, 95% CI 1.5, 13.0), and prolonged bedrest (OR 7.6, 95% CI 1.5, 39.3) predicted nursing home placement. Confusion (Beta 12.0, 95% CI 2.9, 21.3), falls (Beta 14.2, 95% CI 4.2, 24.3), and prolonged bedrest (Beta 22.4, 95% CI 3.9, 41.0) predicted total hospital days. In multivariate analyses, weight loss, depression, and socioeconomic problems predicted death; confusion and polypharmacy predicted nursing home placements; and falls predicted total hospital days. CONCLUSION: This prospective cohort study of hospitalized older veterans demonstrated geriatric targeting criteria as predictors of adverse hospital outcomes. Our findings suggest screening acutely hospitalized patients using chart abstracted geriatric targeting criteria is useful in identifying patients at risk for adverse outcomes of hospitalization.

Functional outcomes of acute medical illness and hospitalization in older persons.

BACKGROUND: Short-stay hospitalization in older patients is frequently associated with a loss of function, which can lead to a need for postdischarge assistance and longer-term institutionalization. Because little is known about this adverse outcome of hospitalization, this study was conducted to (1) determine the discharge and 3-month postdischarge functional outcomes for a large cohort of older persons hospitalized for medical illness, (2) determine the extent to which patients were able to recover to preadmission levels of functioning after hospital discharge, and (3) identify the patient factors associated with an increased risk of developing disability associated with acute illness and hospitalization. METHODS: A total of 1279 community-dwelling patients, aged 70 years and older, hospitalized for acute medical illness were enrolled in this multicenter, prospective cohort study. Functional measurements obtained at discharge (Activities of Daily Living) and at 3 months after discharge (Activities of Daily Living and Instrumental Activities of Daily Living) were compared with a preadmission baseline level of functioning to document loss and recovery of functioning. RESULTS: At discharge, 59% of the study population reported no change, 10% improved, and 31% declined in Activities of Daily Living when compared with the preadmission baseline. At the 3-month follow-up, 51% of the original study population, for whom postdischarge data were available (n=1206), were found to have died (11%) or to report new Activities of Daily Living and/or Instrumental Activities of Daily Living disabilities (40%) when compared with the preadmission baseline. Among survivors, 19% reported a new Activities of Daily Living and 40% reported a new Instrumental Activities of Daily Living disability at follow-up. The 3-month outcomes were the result of the loss of function during the index hospitalization, the failure of many patients to recover after discharge, and the development of new postdischarge disabilities. Patients at greatest risk of adverse functional outcomes at follow-up were older, had preadmission Instrumental Activities of Daily Living disabilities and lower mental status scores on admission, and had been rehospitalized. CONCLUSION: This study documents a high incidence of functional decline after hospitalization for acute medial illness. Although there are several potential explanations for these findings, this study suggests a need to reexamine current inpatient and postdischarge practices that might influence the functioning of older patients.

Hospital admission risk profile (HARP): identifying older patients at risk for functional decline following acute medical illness and hospitalization.

OBJECTIVES: To develop and validate an instrument for stratifying older patients at the time of hospital admission according to their risk of developing new disabilities in activities of daily living (ADL) following acute medical illness and hospitalization. DESIGN: Multi-center prospective cohort study. SETTING: Four university and two private non-federal acute care hospitals. PATIENTS: The development cohort consists of 448 patients and the validation cohort consists of 379 patients who were aged 70 and older and who were hospitalized for acute medical illness between 1989 and 1992. MEASUREMENTS: All patients were evaluated on hospital admission to identify baseline demographic and functional characteristics and were then assessed at discharge and 3 months after discharge to determine decline in ADL functioning. RESULTS: Logistic regression analysis identified three patient characteristics that were independent predictors of functional decline in the development cohort: increasing age, lower admission Mini-Mental Status Exam scores, and lower preadmission IADL function. A scoring system was developed for each predictor variable and patients were assigned to low, intermediate, and high risk categories. The rates of ADL decline at discharge for the low, intermediate, and high risk categories were 17%, 28%, and 56% in the development cohort and 19%, 31%, and 55% in the validation cohort, respectively. Patients in the low risk category were significantly more likely to recover ADL function and to avoid nursing home placement during the 3 months after discharge. CONCLUSION: Hospital Admission Risk Profile (HARP) is a simple instrument that can be used to identify patients at risk of functional decline following hospitalization. HARP can be used to identify patients who might benefit from comprehensive discharge planning, specialized geriatric care, and experimental interventions designed to prevent/reduce the development of disability in hospitalized older populations.

Development of a physical performance and mobility examination.

OBJECTIVE: To develop and validate the Physical Performance and Mobility Examination (PPME), an observer-administered, performance-based instrument assessing 6 domains of physical functioning and mobility for hospitalized elderly. DESIGN: Development of a pass-fail and 3-level scoring system and training manuals for the PPME instrument for use in both clinical and research settings. Two patient samples were used to assess construct validity and interrater reliability of the PPME. A third sample was selected to assess the test-retest reliability of the instrument. SETTING/PATIENTS: (1) 146 subjects > or = 65 years of age with impaired mobility admitted to Medical Units of Stanford University Hospital. (2) 352 subjects > or = 65 admitted to acute Medical and Surgical Services of the Palo Alto VA Medical Center. Patient samples were obtained during hospitalization and followed until 3 months post-discharge. To study test-retest reliability, 50 additional patients, whose clinical condition was stable, were selected from both settings. METHODS: An expert panel selected 6 mobility tasks integral to daily life: bed mobility, transfer skills, multiple stands from chair, standing balance, step-up, and ambulation. Tasks were piloted with frail hospitalized subjects for appropriateness and safety. Test-retest and interrater reliability and construct validity were evaluated. Construct validity was tested using the Folstein Mini-Mental State Examination, Activities of Daily Living (ADL), Instrumental Activities of Daily Living (IADL), Geriatric Depression Scale, and modified Medical Outcomes Study Measure of Physical Functioning (MOS-PFR). Two scoring schema were developed for each task: (1) dichotomous pass-fail and (2) 3-level high pass, low pass, and fail. A summary scale was developed for each method of scoring. MAIN RESULTS: High interrater reliability and intrarater reliability were demonstrated for individual tasks. The mean percent agreement (interrater) for each pass/fail task ranged from 96 to 100% and from 90 to 100% for the 3 pairs of raters for each task using the 3-level scoring. Kappas for individual pairs of raters ranged from .80 to 1.0 for pass-fail scoring and from .75 to 1.0 for 3-level scoring (all P < 0.01). Intraclass correlation coefficients for 3-level scoring by pairs of raters ranged from .66 to 1.0. For summary scales, the mean intraclass correlation was .99 for both scoring schema. Test-retest reliability for summary scales using kappa coefficients was .99 for both pass-fail and 3-level scoring, and .99 and .98, respectively, using Pearson Product Moment Correlation. Correlations of PPME with other instruments (construct validity) suggest that the PPME adds a unique dimension of mobility beyond that measured by self-reported ADLS and physical functioning, and it is not greatly influenced by mood or mental status (r = 0.70 (ADL), r = 0.43 (IADL), r = 0.36 (MMSE), r = 0.71 (MOS-PFR), r = 0.23 (GDS)). The 3-level summary scale was sensitive to the variability in the patient population and exhibited neither ceiling nor floor effects. CONCLUSIONS: The PPME is a reliable and valid performance-based instrument measuring physical functioning and mobility in hospitalized and frail elderly.

Psychoactive medications in the long-term care setting: differing perspectives among physicians, nursing staff, and patients.

Differences in perceptions among nursing home patients, nursing staff, and physicians were compared in this preliminary study regarding nighttime disorders and psychoactive medications. Nighttime disorders, including both insomnia and behavior problems, are prevalent among institutionalized elderly and are frequently managed with psychoactive medications. All nursing home patients receiving psychoactive medications, the nursing staff, and the physicians involved in their care were interviewed regarding the description, etiology, management, and impact of the nighttime disorder including side effects of the prescribed medications. Overall, the differences in responses among the three groups ranged from 47% to 63%. While both physicians and nurses reported problems more often than did the patients, nurses reported problems more frequently than did physicians. This preliminary study suggests that patients, nursing staff, and physicians perceive nighttime disorders and their management differently. These differences point to the need for improved methods of communication and education to mutually identify the targeted disorder and develop appropriate management.

A negative trial of inpatient geriatric consultation. Lessons learned and recommendations for future research.

PURPOSE: To determine the effectiveness of inpatient interdisciplinary geriatric consultation provided during hospitalization to frail, elderly subjects. SUBJECTS AND SITE: Admission cohort of 197 men admitted from 1985 through 1989, aged 65 years or more, meeting proxy criteria for frailty, living within follow-up area, without terminal illness, and without prolonged nursing home residence. METHODS AND MEASURES: Randomized controlled trial of inpatient geriatric consultation at a tertiary care Veterans Affairs hospital. Differences were determined between groups in the Physical Self-Maintenance Scale, Instrumental Activities of Daily Living, Mini-Mental State Examination, Morale Scale, and nursing home and health care utilization. RESULTS: No differences were seen between groups in any measure after the intervention or during 1 year of follow-up. Intervention implementation may have been incomplete due to compliance and resource availability. CONCLUSIONS: This trial is not definitive in determining whether geriatric consultation is effective or ineffective. Lessons learned from this research indicate that future studies should target frail subjects, include intervention-specific measures, and be conducted with direct control of comprehensive resources.

Fluoxetine in elderly patients: is there cause for concern?

OBJECTIVE: To assess whether fluoxetine use is associated with significant weight loss or other side effects in depressed elderly patients with concomitant medical illness. DESIGN: A retrospective chart review. SETTING: A tertiary care VA hospital. PATIENTS: Five groups of outpatients were studied: (1) patients greater than 75 years old receiving fluoxetine (n = 15); (2) patients 60 to 71 years old receiving fluoxetine (n = 20); (3) patients greater than 75 years old receiving nortryptiline or desipramine (n = 20); (4) patients greater than 75 years old with a history of depression but on no antidepressant medication (n = 20); and (5) patients greater than 75 years old with no history of depression (n = 28). MEASUREMENTS: Mortality, change in weight, reports of anorexia or nausea, and serum sodium and glucose measurements. MAIN RESULTS: Patients greater than 75 years of age taking fluoxetine experienced significantly greater weight loss (average 4.6 kilograms, P = 0.0062) than the other groups. Both groups of patients taking fluoxetine were significantly more likely to report nausea (P = 0.0095) and anorexia (P = 0.0009). No significant differences were noted in mortality or the frequency of hypoglycemia or hyponatremia between groups. CONCLUSION: The frequency and degree of weight loss noted here in medically ill elderly receiving fluoxetine warrants further investigation.

Clinic-based primary care of frail older patients in California.

We surveyed medical directors of primary care clinics in California to learn how those clinics cared for their frail older patients. Of 143 questionnaires sent, 127 (89%) were returned. A median of 30% of all patient encounters were with persons aged 65 or older, and a median of 20% of older patients were considered frail. A total of 20% of the clinics routinely provided house calls to homebound elderly patients. Of clinics involved in training medical students of physicians (teaching clinics), 70% had at least one physician with an interest in geriatrics, compared with 42% of nonteaching clinics (P less than .005). For frail patients, 40% of the clinics routinely performed functional assessment, while 20% routinely did an interdisciplinary evaluation. Continuing education in geriatrics emerged as a significant independent correlate of both functional assessment and interdisciplinary evaluation. Among the 94 clinics with a standard appointment length for the history and physical examination, only 11 (12%) allotted more than 60 minutes for frail patients. The data suggest that certain geriatric approaches are being incorporated into clinic-based primary care in California but do not provide insight into their content or clinical effects.

Durable power of attorney for health care. Are we ready for it?

Health care professionals need to be well informed about advance directives for medical care in the event a patient becomes incapacitated. The Patient Self-Determination Act requires that all patients be advised of their options at the time of hospital admission. Hospitals and health care professionals will need to work together to plan for implementing this law. We surveyed 215 physicians, nurses, and social workers at a Veterans Affairs Medical Center about the California advance directive, the Durable Power of Attorney for Health Care. Attitudes were generally positive. All of the social workers had heard of the durable power of attorney directive, but 36% of physicians and nurses had never heard of it and an additional 20% had no experience with one. For respondents who had heard of the directive, the mean knowledge score was 6.35 of a possible 10 (5 predicted by chance). Respondents brought up the issue of durable power of attorney with patients before a crisis only 19% of the time and determined whether one had been signed for only 16% of older patients in hospital. The most commonly cited reasons for failure to discuss this with patients were lack of proper forms, pamphlets, or a place to refer a patient. Of those who had ever seen such a document in use, 42% were aware of a problem with it at some time. Whereas attitudes toward advance directives are positive, many physicians and nurses had little knowledge of the Durable Power of Attorney for Health Care and were poorly equipped to discuss it with patients. We encourage educating hospital staff to prepare for the enactment of the Patient Self-Determination Act. We also recommend that the concerns raised by professionals about the use of a durable power of attorney be addressed.

Medicare reimbursement for geriatric assessment: report of the American Geriatrics Society Ad Hoc Committee on Geriatrics Assessment.

This ad hoc committee report from the American Geriatrics Society proposes the prompt initiation of Medicare reimbursement for geriatric assessment (GA) services (also termed comprehensive geriatric assessment or geriatric evaluation and management services). Despite an extensive body of literature documenting the effectiveness of GA for improving health care outcomes in many settings for identifiable groups of frail elderly patients, no explicit Medicare reimbursement mechanisms currently exist to cover GA services provided by either hospital or physician. We believe that new physician reimbursement codes specific for geriatric assessment should be established in the Current Procedural Technology (CPT-4) manual and that reimbursement for GA should be specifically provided under Part B of Medicare. Further, we believe that hospital reimbursement within the Medicare prospective payment system should be modified to encourage GA during inpatient stays for appropriate patients. This paper summarizes the background for these recommendations. It defines the major content of GA at three levels of intensity--screening, intermediate, and comprehensive. It describes the major sites for conducting GA--hospital, office, home, nursing home. Finally, it proposes criteria for targeting patients most likely to benefit from GA.

Targeting strategies: an overview of criteria and outcomes.

Researchers generally agree that Geriatric Evaluation and Management (GEM) Units are effective only when they are targeted at a specific group of frail, elderly patients who are most likely to benefit. Such patients are those who are neither too sick (eg, severely demented or moribund) nor too well. Various strategies for identifying such patients have been employed by investigators with little consensus on the most efficient targeting criteria. Criteria most often use for inclusion in GEM programs are various combinations of patient age, degree of functional impairment, presence of geriatric conditions (eg falls, incontinence, confusion), particular diagnostic conditions (eg, multiple disorders), and psychosocial conditions (eg, living alone, recent bereavement, low income). Commonly used exclusion factors are severe dementia, inevitable nursing home placement, and terminal illness. Outcome studies suggest that beneficial effects of GEM care are most apparent when patients are selected using specific clinical criteria. Future research on targeting should address the potential need for differing criteria in different settings (eg, inpatient vs outpatient GEM units), simplifications of criteria for greatest ease of application, and prospective evaluation of which criteria best predict functional improvement, longer survival, and reduced health care expenditures in response to GEM care.

Working group recommendations: targeting criteria for geriatric evaluation and management research.

To maximize the cost effectiveness of geriatric evaluation and management (GEM) programs, criteria need to be established for selecting patients most likely to benefit. A working group was convened to define appropriate patient selection (targeting) criteria for each type of GEM program and to consider research questions for future targeting studies. The group outlined targeting criteria for the spectrum of GEM program types and locations. GEM program types included: inpatient GEM units; hospital geriatric consultation service; GEM programs in nursing homes; outpatient GEM programs for functionally impaired persons; and geriatric community outreach/screening programs for functionally independent elders. For each program type, the group outlined targeting criteria based on current literature and experience. Because research has not yet established the effectiveness of many of these patient targeting strategies, the group drafted a set of research questions, pertinent to targeting, that require attention: (1) For each identifiable population of elderly people, who are most likely to benefit from GEM? (2) How should these people best be identified/targeted? (3) What criteria should be used for targeting? (4) How and how often should population screening be performed to identify persons in need of GEM?

Screening for frailty: criteria and predictors of outcomes.

OBJECTIVE: To determine the reliability of rapid screening by clinically derived geriatric criteria in predicting outcomes of elderly hospitalized patients. DESIGN: Prospective cohort study of 985 patients screened at the time of hospital admission and followed for 1 year with respect to the outcomes of mortality, hospital readmission, and nursing home utilization. SETTING: Palo Alto Veterans Affairs Medical Center, a tertiary care teaching hospital. SUBJECTS: Male patients 65 years of age and older admitted to the Medical and Surgical services during the period from October 1, 1985 through September 30, 1986. RESULTS: Patients were grouped by specific screening criteria into three groups of increasing frailty: Independent, Frail, and Severely Impaired. Each criterion focused on a geriatric condition and was designed to serve as a marker for frailty. Increasing frailty was significantly correlated with increasing length of hospital stay (P less than 0.0001), nursing home utilization (P less than 0.0001), and mortality (P less than 0.0001). Multivariate analyses revealed that the clinical groups were more predictive of mortality and nursing home utilization than were age or Diagnosis-Related Groups (DRGs). Rehospitalization was unrelated to age, clinical group, or DRG, suggesting that utilization may not be driven by the clinical factors measured in this study. CONCLUSIONS: Rapid clinical screening using specific geriatric criteria is effective in identifying frail older subjects at risk for mortality and nursing home utilization. Our findings suggest that geriatric syndromes are more predictive of adverse outcomes than diagnosis per se. This well operationalized screening process is inexpensive as well as effective and could easily be introduced into other hospital settings.