Effectiveness of preventive in-home geriatric assessment in well functioning, community-dwelling older people: secondary analysis of a randomized trial.

OBJECTIVES: To determine whether preventive in-home comprehensive geriatric assessment (CGA) prevents functional decline in community-dwelling older persons with different baseline functional status: (1) without any basic activities of daily living (BADL) dependency at baseline; and (2) without any instrumental ADL (IADL) and basic ADL dependency at baseline. DESIGN: Subgroup analyses of a 3-year randomized controlled trial. SETTING: The city of Santa Monica, California. PARTICIPANTS: Participants came from the original population (n = 414) of community-living older persons aged 75 years and older who participated in a trial testing the effectiveness of annual preventive in-home CGA. For the first subgroup analysis, we excluded subjects (n = 27) who were dependent in one or more BADL before randomization (final sample size, n = 387); for the second subgroup analysis, we excluded 93 additional subjects who were dependent in one or more IADL before randomization (final sample size, n = 294). INTERVENTION: Annual preventive in-home CGA, with quarterly home visits by gerontologic nurse practitioners, for 3 years. MEASUREMENTS: Functional status data were collected through yearly in-home interviews by independent observers. Subjects were classified as (1) independent in both BADL and IADL, (2) dependent in IADL but independent in BADL, or (3) dependent in both IADL and BADL. RESULTS: In both subgroup analyses, there was no difference in survival between intervention and control subjects. In the subgroup with no BADL impairment at baseline, intervention subjects spent significantly fewer days dependent in both BADL and IADL during each year of the study (5 days vs 14 days, P = .022; 13 vs 33, P = .016; and 19 vs 44, P = .014 for years 1, 2, and 3, respectively) and over all 3 years combined (36 days vs 92 days, P = .016) in bivariate analyses. In multivariate analyses, the intervention reduced time spent in complete (BADL and IADL) dependency (P = .028). In the subgroup of subjects without any IADL or BADL impairment at baseline, no significant differences were apparent in the number of days spent in complete independence and days spent in complete dependency. Intervention group subjects spent more days in partial dependency during Year 1 (24 days vs 9 days, P = .021), but the difference was not significant during Year 2 (47 vs 29, P = .088), Year 3 (49 vs 41, P = .370), and over all 3 years combined (120 vs 79, P = .123) as well as in multivariate analysis (P = .062). CONCLUSION: These findings support the hypothesis that in-home preventive visits delay the onset of disability in people without initial BADL impairment. Further studies in larger samples are needed to determine optimal intervention strategies and effectiveness among well functioning older people.

The association between chronic illness and functional change among participants in a comprehensive geriatric assessment program.

OBJECTIVE: To examine the association between chronic illness and functional status change during a 3-year period in older people enrolled in an in-home comprehensive geriatric assessment (CGA) and preventive care program. DESIGN: Secondary analysis of data from a longitudinal cohort study. SETTING: Santa Monica, California. PARTICIPANTS: Two hundred two community-dwelling older persons (mean age at baseline was 81 years, 70% were women, and 72% reported good health) randomized to the intervention group in a trial of in-home comprehensive geriatric assessment and preventive care. MEASUREMENTS: We studied 13 common chronic illnesses/conditions determined clinically from an annual comprehensive evaluation by gerontologic nurse practitioners (GNPs) in consultation with study geriatricians. These target conditions included hypertension, osteoarthritis, coronary artery disease, obesity, undernutrition, urinary incontinence, sleep disorders, falls, gait/balance disorders, hearing and vision deficits, depression, and unsafe home environment. The dependent variable was functional change as measured by instrumental activities of daily living (IADL) and basic activities of daily living (BADL) assessed at baseline and annually for 3 years by independent research personnel. Potential confounding variables, including comorbid conditions and other subject characteristics, were controlled for in the analyses. RESULTS: Although functional status was similar at baseline, the presence of certain target conditions in this sample was associated significantly with functional decline in IADL and BADL during the 3-year period. Four conditions (gait/balance disorders, depression, unsafe home environment, and coronary artery disease) were associated with significant declines in IADL, and four conditions (gait/balance disorders, depression, hypertension, and urinary incontinence) were associated with significant declines in BADL. Conversely, subjects with obesity had no significant change in IADL or BADL throughout the study period and had less decline in IADL compared with nonobese subjects. CONCLUSIONS: Certain chronic conditions, particularly gait/balance disorders and depression, are associated with significant decline in functional status in older persons who receive CGA. These findings may help identify older persons at risk for greatest functional decline despite participation in CGA and may also suggest the need for more effective intervention strategies in these individuals.

The process of care in preventive in-home comprehensive geriatric assessment.

OBJECTIVES: To describe the process of care of a program of in-home comprehensive geriatric assessment (CGA) and to determine: (1) if there are major findings in all domains of CGA (medical, functional, mental health, and social/ environmental), (2) if there is a continued clinical yield when CGA is repeated annually, and (3) factors that affect patient adherence with recommendations from CGA. DESIGN: Descriptive prospective study of subjects allocated to the intervention group of a 3-year randomized trial of preventive in-home CGA. SETTING: Homes of participants living in an urban setting. PARTICIPANTS: Persons aged 75 years or older and living at home who received the intervention (N = 202 subjects, mean age 80.8 years, 70% female, 95% white, 64% living alone). INTERVENTION: Annual in-home CGA and quarterly home visits by gerontologic nurse practitioners for 3 years. MEASUREMENTS: Detailed data were collected prospectively on clinical problems detected by CGA, and specific recommendations were made for these problems using an instrument developed explicitly for this project to study the CGA process. Subject adherence with these recommendations was also recorded. RESULTS: Major problems were identified in all domains of CGA; the most common problems were medical. In the first year, 76.7% of subjects had at least one major problem identified that was either previously unknown or suboptimally treated. One-third of subjects had additional major problems identified during the second and third years. A constant number of therapeutic and preventive recommendations was made each year (11.5 per subject annually). Subject adherence varied by type of recommendation (ANOVA, F = 108.4, P < .001); adherence was better for referrals to a physician than for referrals to a non-physician professional or community service or for recommendations involving self-care activities (Scheffe's test, P < .001). CONCLUSION: In these community-dwelling older people, there was a continued yield of problems identified and recommendations made when CGA was repeated annually for 3 years, supporting the practice of repeat CGA in older people in the community. Subject adherence with recommendations from CGA varied by type of recommendation, but further work is needed to determine additional factors that affect this adherence and to determine the association between the yield of CGA (i.e., problems identified, recommendations given and adherence with these recommendations) and important clinical outcomes.

Measuring psychosocial aspects of well-being in older community residents: performance of four short scales.

Given that the assessment of multiple dimensions of health/well-being can create respondent burden, assessment scales that are both effective and brief hold great attraction. In this study, we used Cronbach's alpha and correlational methods, including factor analysis, to evaluate the performance of four short scales measuring psychosocial aspects of well-being (depression, quality of life, sense of coherence, social support) in two samples of community-dwelling persons aged 75 and over (n = 414, n = 50). All four scales exhibited good range, high internal consistency, strong temporal reliability, and reasonable levels of construct validity. We conclude that they are practical contributors to measuring health in community-based older adults.

A trial of annual in-home comprehensive geriatric assessments for elderly people living in the community.

BACKGROUND AND METHODS: The prevention of disability in elderly people poses a challenge for health care and social services. We conducted a three-year, randomized, controlled trial of the effect of annual in-home comprehensive geriatric assessment and follow-up for people living in the community who were 75 years of age or older. The 215 people in the intervention group were seen at home by gerontologic nurse practitioners who, in collaboration with geriatricians, evaluated problems and risk factors for disability, gave specific recommendations, and provided health education. The 199 people in the control group received their regular medical care. The main outcome measures were the prevention of disability, defined as the need for assistance in performing the basic activities of daily living (bathing, dressing, feeding, grooming, transferring from bed to chair, and moving around inside the house) or the instrumental activities of daily living (e.g., cooking, handling finances and medication, housekeeping, and shopping), and the prevention of nursing home admissions. RESULTS: At three years, 20 people in the intervention group (12 percent of 170 surviving participants) and 32 in the control group (22 percent of 147 surviving participants) required assistance in performing the basic activities of daily living (adjusted odds ratio, 0.4; 95 percent confidence interval, 0.2 to 0.8; P = 0.02). The number of persons who were dependent on assistance in performing the instrumental activities of daily living but not the basic activities did not differ significantly between the two groups. Nine people in the intervention group (4 percent) and 20 in the control group (10 percent) were permanently admitted to nursing homes (P = 0.02). Acute care hospital admissions and short-term nursing home admissions did not differ significantly between the two groups. In the second and third years of the study, there were significantly more visits to physicians among the participants in the intervention group than among those in the control group (mean number of visits per month, 1.41 in year 2 and 1.27 in year 3 in the intervention group, as compared with 1.11 and 0.92 visits, respectively, in the control group; P = 0.007 and P = 0.001, respectively). The cost of the intervention for each year of disability-free life gained was about $46,000. CONCLUSIONS: A program of in-home comprehensive geriatric assessments can delay the development of disability and reduce permanent nursing home stays among elderly people living at home.

Community physicians' cooperation with a program of in-home comprehensive geriatric assessment.

OBJECTIVES: To study the cooperation of primary care physicians with a community-based prevention and health promotion program for older persons, to study physician factors related to cooperation, and to determine any relationship between physician cooperation and patient adherence to program recommendations and patient satisfaction with health care. DESIGN AND SETTING: A survey administered in subjects' homes and physicians' offices in Santa Monica, California. PARTICIPANTS: Patients (n = 81) were intervention group subjects in a 3-year, randomized, controlled trial of in-home comprehensive geriatric assessment paired with prevention and health promotion. Physicians (n = 50) were selected if they had been contacted at least once by a study nurse practitioner about one of these patients. MEASUREMENTS: Physician cooperation was rated by study nurse practitioners. Physicians were interviewed to identify factors associated with cooperation. Patients' satisfaction with health care and adherence were measured prospectively throughout the 3-year program. MAIN RESULTS: Physicians exhibiting better cooperation had fewer years in practice (P = .03) and were more likely to discuss the program with their patients (P = .005), see benefit for their patients from the program (P = .02), and rate program information as useful (P = .002). Higher physician cooperation did not predict higher patient satisfaction (P = .23) but did predict higher patient adherence to program recommendations (P = .02). CONCLUSIONS: Physicians rated as cooperative were more likely to have a positive appraisal of the program, and their patients had higher adherence to program recommendations. These findings suggest that strategies for increasing primary care physician cooperation might improve effectiveness of similar community-based prevention and health promotion programs.

Inappropriate medication use in community-residing older persons.

BACKGROUND: Elderly patients taking inappropriate drugs are at increased risk for adverse outcomes. We investigated the prevalence of inappropriate drug use and its predisposing factors in community-residing older persons. METHODS: We conducted in-home interviews with 414 subjects aged 75 years and older living in the community of Santa Monica, Calif. Inappropriate medication use was evaluated using explicit criteria developed through a modified Delphi consensus process. These criteria identified drugs that should generally be avoided in elderly community-residing subjects regardless of dosage, duration of therapy, or clinical circumstances. RESULTS: Based on these conservative criteria, 14.0% of the subjects were using at least one inappropriate drug. The most common examples were long-acting benzodiazepines, persantine, amitriptyline, and chlorpropamide. Subjects using three or more prescription drugs, compared with one or two, were more likely to be taking an inappropriate medication (odds ratio, 3.9; 95% confidence interval, 1.9 to 7.9). Furthermore, subjects with depressive symptoms had a higher risk of receiving inappropriate medications than nondepressive subjects (odds ratio, 2.2; 95% confidence interval, 1.1 to 4.1). CONCLUSIONS: Inappropriate drug use is a common problem in community-residing older persons. The risk of inappropriate drug use is increased in patients taking multiple medications and in patients with depressive symptoms.

A home-based geriatric assessment, follow-up and health promotion program: design, methods, and baseline findings from a 3-year randomized clinical trial.

Controlled trials in a number of countries have documented benefits from different types of in-home assessment and treatment programs for various subgroups of elderly persons. We have developed a program to test, using a randomized controlled design, the concepts of in-home comprehensive geriatric assessment (CGA) coupled with follow-up, health education, and preventive care in an urban United States community. The intervention includes yearly in-home CGA by geriatric nurse practitioners (GNPs), who provide, following discussions with physician geriatricians, lists of specific recommendations for health and well-being enhancement. The GNPs provide follow-up visits quarterly and regular telephone contacts to improve compliance. We recruited for our trial 414 home-living subjects aged 75 years and over, 215 randomized to the intervention group and 199 to the control group. Subjects were generally representative of the overall elderly population of the city of Santa Monica, a seaside suburb of Los Angeles. Extensive baseline data (medical, functional, psychosocial and environmental) were collected from subjects prior to randomization, using validated instruments whenever possible. Follow-up data were collected from each subject every 4 months by trained research assistants throughout the 3-year intervention follow-up period. Our study was designed to assess effects of the intervention on the hypothesized outcomes of health status, functional status, psychosocial parameters, and service utilization. Careful documentation of the intervention will enhance our ability to make process-outcome comparisons. Preliminary analysis reveals that the in-home CGA uncovered many important health deficits for most subjects resulting in a number of substantial recommendations. We are confident that when it is completed, this study will succeed in answering important remaining questions about the feasibility and effectiveness of establishing a geriatric in-home prevention and health promotion program in the United States based on principles of CGA.

Flaws in mortality data. The hazards of ignoring comorbid disease.

Recent public releases of hospital mortality data have sparked debate over methods to identify poor-quality care. We examined variations among hospitals in patient characteristics known independently to affect the risk of adverse outcomes and focused on patient comorbidity, defined as the state of health at admission apart from the primary diagnosis. Data from a study of 2935 incident cancer patients treated in seven Southern California hospitals revealed substantial variations among hospitals in age, cancer stage, and the burden of comorbid conditions. In the highest-ranked hospital, 17.9% of patients had high levels of comorbidity, compared with 9.3% in the lowest-ranked hospital. The three hospitals with the highest comorbidity were also identified as high-mortality outliers in a recent California report on hospital mortality rates. We conclude that comorbidity must be considered in any hospital quality assessment method based on patient outcome. If it is not considered, variations in referral and admission patterns may be misinterpreted as differences in hospital quality.