The effectiveness of a comprehensive geriatric assessment intervention program for frailty in community-dwelling older people: a randomized,controlled trial

This randomized, controlled trial assessed the effectiveness of comprehensive geriatric assessment (CGA) and subsequent intervention in pre-frail and frail community-dwelling elderly based on the Fried Frailty Criteria (FFC) and the Barthel Index (BI) A total of 310 pre-frail or frail elderly from a single community were identified using the FFC. Of these, 152 were randomly assigned to the intervention group for CGA and appropriate intervention by medication adjustment, exercise instruction, nutrition support, physical rehabilitation, social worker consultation, and specialty referral. Clinical outcome was re-evaluated by the FFC and BI 6 months later. Compared to the control group, the intervention group tended to have a better outcome, with an odds ratio (OR) = 1.19, 95% confidence interval (95% CI) = 0.48–3.04, p = 0.71) and 3.29 (95% CI = 0.65–16.64, p = 0.15), respectively, and were less likely to deteriorate, with an OR = 0.78 (95% CI = 0.34–1.79, p = 0.57) and 0.94 (95% CI = 0.42–2.12, p = 0.88), respectively. Although no significant differences were observed, the CGA and subsequent intervention showed a favorable outcome in frail and pre-frail elderly based on the frailty status and BI. Inability to complete the CGA and poor compliance with the intervention program appear to be the main reasons for unfavorable outcomes.     

A randomized trial of in-home visits for disability prevention in community-dwelling older people at low and high risk for nursing home admission

BACKGROUND: In-home preventive visits with multidimensional geriatric assessments can delay the onset of disabilities in older people. METHODS: This was a stratified randomized trial. There were 791 participants, community-dwelling people in Bern, Switzerland, older than 75 years. The participants' risk status was based on 6 baseline predictors of functional deterioration. The intervention consisted of annual multidimensional assessments and quarterly follow-up in-home visits by 3 public health nurses (nurses A, B, and C), who, in collaboration with geriatricians, evaluated problems, gave recommendations, facilitated adherence with recommendations, and provided health education. Each nurse was responsible for conducting the home visits in 1 ZIP code area. RESULTS: After 3 years, surviving participants at low baseline risk in the intervention group were less dependent in instrumental activities of daily living (ADL) compared with controls (odds ratio, 0.6; 95% confidence interval, 0.3-1.0; P = .04). Among subjects at high baseline risk, there were no favorable intervention effects on ADL and an unfavorable increase in nursing home admissions (P= .02). Despite the similar health status of subjects, nurse C identified fewer problems in the subjects who were visited compared with those assessed by nurses A and B. Subgroup analysis revealed that among low-risk subjects visited by nurses A and B, the intervention had favorable effects on instrumental ADL (P = .005) and basic ADL (P = .009), reduced nursing home admissions (P = .004), and resulted in net cost savings in the third year (US $1403 per person per year). Among low-risk subjects visited by nurse C, the intervention had no favorable effects. CONCLUSIONS: These data suggest that this intervention can reduce disabilities among elderly people at low risk but not among those at high risk for functional impairment, and that these effects are likely related to the home visitor's performance in conducting the visits.     

In-home preventive comprehensive geriatric assessment (CGA) reduces mortality-A randomized controlled trial

The study should prove the effectiveness of a preventive in-home CGA regarding mortality and time able to stay in the community. We performed a randomized controlled trial with a mean follow-up of 6.2 years. The home visits were performed in Germany. 1620 community-living persons aged 70 years and older (n=630 intervention; 990 controls) from 20 general practitioner surgeries were visited. The intervention was performed by trained medical students it included a CGA using the STEP-tool (standardized assessment of elderly people in primary care in Europe; a combination of a structured questionnaire and a structured physical examination) and additional tests, followed by recommendations for the general practitioner. The controls received usual general practitioner care. Follow-up visit was made at mean 6.2 years after randomization. The main outcome parameters were mortality and time able to stay at home. Follow-up-rate was 75%. In COX-regression-analyses, a 20% reduction of mortality and a 22% lower risk of nursing-home admission were shown in the intervention group at the follow up. Despite the main limitations of the study (general practitioners volunteered to participate, follow-up-rate <80%, possible performance of geriatric assessments also in the control group, intervention group had poorer health status than the control group, adherence to recommendations from the assessment was not verified) we conclude that the implementation of a preventive geriatric assessment into primary care in Germany seems to be reasonable.     

Environmental interventions to prevent falls in community-dwelling older people: a meta-analysis of randomized trials

Objective. This study seeks to determine the efficacy of environmental interventions in reducing falls in community-dwelling older people. Method. A systematic review and meta-analysis of randomized trials was performed. Results. Pooled analysis of six trials (N = 3,298) demonstrated a 21% reduction in falls risk (relative risk [RR] = 0.79; 0.65 to 0.97). Heterogeneity was attributable to the large treatment effect of one trial. Analysis of a subgroup of studies with participants at high risk of falls (four trials, n = 570) demonstrated a clinically significant 39% reduction of falls (RR = 0.61; 0.47 to 0.79), an absolute risk difference of 26% for a number needed to treat four people. Discussion. Home assessment interventions that are comprehensive, are well focused, and incorporate an environmental-fit perspective with adequate follow-up can be successful in reducing falls with significant effects. The highest effects are associated with interventions that are conducted with high-risk groups.     

An in-home nurse-administered geriatric assessment for hypoalbuminemic older persons: development and preliminary experience.

BACKGROUND: Although malnutrition in older persons is a common, potentially treatable condition, few data indicate that treatments for this disorder can be effective. OBJECTIVE: To develop and preliminarily evaluate a two-component intervention that includes a nurse-administered, in-home assessment to identify potentially remediable causes of hypoalbuminemia and protocols to treat these problems. DESIGN: A pre-test post-test case-series. SETTING: An academic geriatrics practice. PARTICIPANTS: Seventeen persons aged 65 and older with serum albumin levels < or = 3.8 g/dL; eight of the participants received pre-and post-test outcome measures. INTERVENTION: Nurse-administered standardized assessment and intervention protocols. MEASUREMENTS: Serum albumin, Medical Outcome Study (MOS) SF-36, serum IL-1a and b, TNF alpha, IL-6, and lymphocyte markers of immune function. RESULTS: The assessment took 87 minutes, on average, and generated a mean 4.2 recommendations. Among the eight subjects with pre- and post-test measures, serum albumin increased by 0.2 g/dL (P = .035). Compared with baseline, two T cell markers of immune function demonstrated changes consistent with better function. CONCLUSIONS: These preliminary data support the potential benefit of a nurse-administered assessment coupled with protocols to address remediable contributors to hypoalbuminemia.     

Effects of exercise training on frailty in community-dwelling older adults: results of a randomized,controlled trial

OBJECTIVES: Although deficits in skeletal muscle strength, gait, balance, and oxygen uptake are potentially reversible causes of frailty, the efficacy of exercise in reversing frailty in community-dwelling older adults has not been proven. The aim of this study was to determine the effects of intensive exercise training (ET) on measures of physical frailty in older community-dwelling men and women. DESIGN: Randomized controlled trial. SETTING: Medical school research center. PARTICIPANTS: One hundred fifteen sedentary men and women (mean age +/- standard deviation = 83 +/- 4) with mild to moderate physical frailty, as defined by two of the following three criteria: Modified Physical Performance Test (modified PPT) score between 18 and 32, peak oxygen uptake (VO2 peak) between 10 and 18 mL/kg/min, and self-report of difficulty or assistance with one basic activity of daily living (ADL), or two instrumental ADLs. INTERVENTION: Participants were randomly assigned to a control group that performed a 9-month low-intensity home exercise program (control) or an exercise-training program (ET). The control intervention primarily consisted of flexibility exercises. ET began with 3 months of flexibility, light-resistance, and balance training. During the next 3 months, resistance training was added, and, during the next 3 months, endurance training was added. MEASUREMENTS: Modified PPT score, VO2 peak, performance of ADLs as measured by the Older Americans Resources and Services instrument, and the Functional Status Questionnaire (FSQ). RESULTS: ET resulted in significantly greater improvements than home exercise in three of the four primary outcome measures. Adjusted 95% confidence bounds on the magnitude of improvement in the ET group compared with the control group were 1.0 to 5.2 points for the modified PPT score, 0.9 to 3.6 mL/kg/min for VO2 peak, and 1.6 to 4.9 points for the FSQ score. CONCLUSIONS: Our results show that intensive ET can improve measures of physical function and preclinical disability in older adults who have impairments in physical performance and oxygen uptake and are not taking hormone replacement therapy better than a low-intensity home exercise program.     

Preventing falls in community-dwelling frail older people using a home intervention team (HIT): results from the randomized Falls-HIT trial

OBJECTIVES: To evaluate the effect of an intervention by a multidisciplinary team to reduce falls in older people's homes. DESIGN: Randomized, controlled trial with follow-up of subjects for 1 year. SETTING: University-affiliated geriatric hospital and older patients' homes. PARTICIPANTS: Three hundred sixty subjects (mean age +/- standard deviation = 81.5 +/- 6.4) admitted from home to a geriatric hospital and showing functional decline, especially in mobility. INTERVENTION: The participants were randomly assigned to receive a comprehensive geriatric assessment followed by a diagnostic home visit and home intervention or a comprehensive geriatric assessment with recommendations and usual care at home. The home intervention included a diagnostic home visit, assessing the home for environmental hazards, advice about possible changes, offer of facilities for any necessary home modifications, and training in the use of technical and mobility aids. An additional home visit was made after 3 months to reinforce the recommendations. After 12 months of follow-up, a home visit was made to all study participants. MEASUREMENTS: Number of falls, type of recommended home modifications, and compliance with recommendations. RESULTS: After 1 year, there were 163 falls in the intervention group and 204 falls in the control group. The intervention group had 31% fewer falls than the control group (incidence rate ratio (IRR) = 0.69, 95% confidence interval (CI) = 0.51-0.97). The intervention was most effective in a subgroup of participants who reported having had two or more falls during the year before recruitment into the study. In this subgroup, the proportion of frequent fallers and the rate of falls was significantly reduced for the intervention group compared with the control group (21 vs 36 subjects with recurrent falls, P =.009; IRR = 0.63, 95% CI = 0.43-0.94). The compliance rate varied with the type of change recommended from 83% to 33% after 12 months of follow-up. CONCLUSION: Home intervention based on home visits to assess the home for environmental hazards, providing information about possible changes, facilitating any necessary modifications, and training in the use of technical and mobility aids was effective in a selected group of frail older subjects with a history of recurrent falling.     

Postacute care for older people in community hospitals: a multicenter randomized, controlled trial

OBJECTIVES: To compare the effects of community hospital care on independence for older people needing rehabilitation with that of general hospital care.
DESIGN: Randomized, controlled trial.
SETTING: Seven community hospitals and five general hospitals in the midlands and north of England.
PARTICIPANTS: Four hundred ninety patients needing rehabilitation after hospital admission with an acute illness.
INTERVENTION: Multidisciplinary team care for older people in community hospitals.
MEASUREMENTS: The primary outcome was the Nottingham extended activities of daily living scale (NEADL); secondary outcomes were the Barthel Index, Nottingham Health Profile, Hospital Anxiety and Depression Scale, mortality, discharge destination, 6-month residence status, and satisfaction with services.
RESULTS: Loss of independence at 6 months was significantly less likely in the community hospital group (mean adjusted NEADL change score group difference 3.27; 95% confidence interval 0.26–6.28; P =.03). The results for the secondary outcome measures were similar for the two groups.
CONCLUSION: Postacute community hospital rehabilitation care for older people is associated with greater independence.     

The effect of group exercise on physical functioning and falls in frail older people living in retirement villages: a randomized, controlled trial

OBJECTIVES: To determine whether a 12-month program of group exercise can improve physical functioning and reduce the rate of falling in frail older people. DESIGN: Cluster randomized, controlled trial of 12 months duration. SETTING: Retirement villages in Sydney and Wollongong, Australia. PARTICIPANTS: Five hundred fifty-one people aged 62 to 95 (mean+/-standard deviation=79.5+/-6.4) who were living in self- and intermediate-care retirement villages. MEASUREMENTS: Accidental falls, choice stepping reaction time, 6-minute walk distance postural sway, leaning balance, simple reaction time, and lower-limb muscle strength. RESULTS: Two hundred eighty subjects were randomized to the weight-bearing group exercise (GE) intervention that was designed to improve the ability of subjects to undertake activities for daily living. Subjects randomized to the control arm (n=271) attended flexibility and relaxation (FR) classes (n=90) or did not participate in a group activity (n=181). In spite of the reduced precision of cluster randomization, there were few differences in the baseline characteristics of the GE and combined control (CC) subjects, although the mean age of the GE group was higher than that of the CC group, and there were fewer men in the GE group. The mean number of classes attended was 39.4+/-28.7 for the GE subjects and 31.5+/-25.2 for the FR subjects. After adjusting for age and sex, there were 22% fewer falls during the trial in the GE group than in the CC group (incident rate ratio=0.78, 95% confidence interval (CI)=0.62-0.99), and 31% fewer falls in the 173 subjects who had fallen in the past year (incident rate ratio=0.69, 95% CI=0.48-0.99). At 6-month retest, the GE group performed significantly better than the CC group in tests of choice stepping reaction time, 6-minute walking distance, and simple reaction time requiring a hand press. The groups did not differ at retest in tests of strength, sway, or leaning balance. CONCLUSION: These findings show that group exercise can prevent falls and maintain physical functioning in frail older people.     

Preventing falls in older people: outcome evaluation of a randomized controlled trial

OBJECTIVES: To evaluate the outcome of an intervention to reduce hazards in the home on the rate of falls in seniors. DESIGN: Randomized controlled trial, with follow-up of subjects for 1 year. SETTING: Community-based study in Perth, Western Australia. PARTICIPANTS: People age 70 and older. INTERVENTION: One thousand eight hundred seventy-nine subjects were recruited and randomly allocated by household to the intervention and control groups in the ratio 1:2. Because of early withdrawals, 1,737 subjects commenced the study. All members of both groups received a single home visit from a research nurse. Intervention subjects (n = 570) were offered a home hazard assessment, information on hazard reduction, and the installation of safety devices, whereas control subjects (n = 1,167) received no safety devices or information on home hazard reduction. MEASUREMENTS: Both groups recorded falls on a daily calendar. Reported falls were confirmed by a semistructured telephone interview and were assigned to one of three overlapping categories: all falls, falls inside the home, and falls involving environmental hazards in the home. Analysis was by multivariate modelling of rate ratios and odds ratios for falls, corrected for household clustering, using Poisson regression and logistic regression with robust variance estimation. RESULTS: Overall, 86% of study subjects completed the 1 year of follow-up. The intervention was not associated with any significant reduction in falls or fall-related injuries. There was no significant reduction in the intervention group in the incidence rate of falls involving environmental hazards inside the home (adjusted rate ratio, 1.11; 95% CI = 0.82-1.50), or the proportion of the intervention group who fell because of hazards inside the home (adjusted odds ratio, 0.97; 95% CI = 0.74-1.28). No reduction was seen in the rate of all falls (adjusted rate ratio, 1.02; 95% CI = 0.83-1.27) or the rate of falls inside the home (adjusted rate ratio, 1.17; 95% CI = 0.85-1.60). There was no significant reduction in the rate of injurious falls in intervention subjects (adjusted rate ratio, 0.92; 95% CI = 0.73-1.14). CONCLUSIONS: The intervention failed to achieve a reduction in the occurrence of falls. This was most likely because the intervention strategies had a limited effect on the number of hazards in the homes of intervention subjects. The study provides evidence that a one-time intervention program of education, hazard assessment, and home modification to reduce fall hazards in the homes of healthy older people is not an effective strategy for the prevention of falls in seniors.     

Improving vision to prevent falls in frail older people: a randomized trial

OBJECTIVES: To determine the efficacy of vision and eye examinations, with subsequent treatment of vision problems, for preventing falls and fractures in frail older people. DESIGN: Randomized, controlled trial. SETTING: Community in Sydney, Australia. PARTICIPANTS: Six hundred sixteen men and women aged 70 and older (mean age 81) recruited mainly from people attending outpatient aged care services. INTERVENTIONS: The intervention group received comprehensive vision and eye examinations conducted by a study optometrist. The optometrist arranged for new eyeglasses for 92 subjects and referred 24 for a home visit with an occupational therapist, 17 for glaucoma management, and 15 for cataract surgery. The control group received usual care. MEASUREMENTS: Falls and fractures during 12 months of follow-up were ascertained according to self-report using a monthly postcard system. RESULTS: Fifty-seven percent of subjects fell at least once during follow-up. Falls occurred more frequently in the group randomized to receive the vision intervention (65% fell at least once; 758 falls in total) than in the control group (50% fell at least once; 516 falls in total). The falls rate ratio using the negative binomial model was 1.57 (95% confidence interval (CI)=1.20-2.05, P=.001). Fractures were also more frequent in the intervention group (31 fractures) than the control group (18 fractures; relative risk from proportional hazards model 1.74, 95% CI=0.97-3.11, P=.06). CONCLUSION: In frail older people, comprehensive vision and eye assessment, with appropriate treatment, does not reduce, and may even increase, the risk of falls and fractures.     

Efficacy of a comprehensive geriatric intervention in older patients hospitalized for hip fracture: a randomized, controlled trial

OBJECTIVES: To evaluate whether an early multidisciplinary geriatric intervention in elderly patients with hip fracture reduced length of stay, morbidity, and mortality and improved functional evolution. DESIGN: Randomized, controlled intervention trial. SETTING: Orthopedic ward in a university hospital. PARTICIPANTS: Three hundred nineteen patients aged 65 and older hospitalized for hip fracture surgery. INTERVENTION: Participants were randomly assigned to a daily multidisciplinary geriatric intervention (n=155) or usual care (n=164) during hospitalization in the acute phase of hip fracture. MEASUREMENTS: Primary endpoints were in-hospital length of stay and incidence of death or major medical complications. Secondary endpoints were the rate of recovery of previous activities of daily living and ambulation ability at 3, 6, and 12 months. RESULTS: Median length of stay was 16 days in the geriatric intervention group and 18 days in the usual care group (P=.06). Patients assigned to the geriatric intervention showed a lower in-hospital mortality (0.6% vs 5.8%, P=.03) and major medical complications rate (45.2% vs 61.7%, P=.003). After adjustment for confounding variables, geriatric intervention was associated with a 45% lower probability of death or major complications (95% confidence interval=7-68%). More patients in the geriatric intervention group achieved a partial recovery at 3 months (57% vs 44%, P=.03), but there were no differences between the groups at 6 and 12 months. CONCLUSION: Early multidisciplinary daily geriatric care reduces in-hospital mortality and medical complications in elderly patients with hip fracture, but there is not a significant effect on length of hospital stay or long-term functional recovery.     

Efficacy of a nurse-led multidimensional preventive programme for older people at risk of functional decline. A randomized controlled trial

OBJECTIVE: To verify the efficacy of a multidimensional preventive programme on functional decline of older people. DESIGN: Randomized controlled trial. SETTING: Community of Sherbrooke City, Quebec, Canada. SUBJECTS: A representative sample of individuals aged over 75 living at home and identified to be at risk of functional decline by postal questionnaire (n = 503). INTERVENTION: Subjects randomized to the study group (n = 250) were assessed at home by a nurse on 12 dimensions (including medication, depressive mood, risk of falls, hearing). A report of the assessment was sent to the general practitioner with recommendations for interventions. A monthly telephone contact was carried out by the nurse for surveillance and to verify if the recommendations had been applied. METHODS: The primary outcome--functional decline--was defined as either death, admission to an institution or increase of > or = 5 points on the disability score of the Functional Autonomy Measurement System (SMAF) scale during the reference year. Secondary outcomes were functional autonomy (on the SMAF), well-being (General Well-being Schedule), perceived social support (Social Provisions Scale) and use of health care services. RESULTS: Of the 494 subjects who completed the study, 48 (19.6%) of 245 in the study group and 49 (19.7%) of 249 in the control group had functional decline (relative risk 1.00; 95% confidence interval 0.82-1.23). There were no differences between the groups in all secondary outcomes. CONCLUSIONS: This study confirms the inefficacy of multidimensional programmes for preventing functional decline in the older population. More effort should be devoted to improving the efficacy of specific interventions for conditions causing functional decline.     

Multidimensional preventive home visit programs for community-dwelling older adults: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND: Multidimensional preventive home visit programs aim at maintaining health and autonomy of older adults and preventing disability and subsequent nursing home admission, but results of randomized controlled trials (RCTs) have been inconsistent. Our objective was to systematically review RCTs examining the effect of home visit programs on mortality, nursing home admissions, and functional status decline. METHODS: Data sources were MEDLINE, EMBASE, Cochrane CENTRAL database, and references. Studies were reviewed to identify RCTs that compared outcome data of older participants in preventive home visit programs with control group outcome data. Publications reporting 21 trials were included. Data on study population, intervention characteristics, outcomes, and trial quality were double-extracted. We conducted random effects meta-analyses. RESULTS: Pooled effects estimates revealed statistically nonsignificant favorable, and heterogeneous effects on mortality (odds ratio [OR] 0.92, 95% confidence interval [CI], 0.80-1.05), functional status decline (OR 0.89, 95% CI, 0.77-1.03), and nursing home admission (OR 0.86, 95% CI, 0.68-1.10). A beneficial effect on mortality was seen in younger study populations (OR 0.74, 95% CI, 0.58-0.94) but not in older populations (OR 1.14, 95% CI, 0.90-1.43). Functional decline was reduced in programs including a clinical examination in the initial assessment (OR 0.64, 95% CI, 0.48-0.87) but not in other trials (OR 1.00, 95% CI, 0.88-1.14). There was no single factor explaining the heterogenous effects of trials on nursing home admissions. CONCLUSION: Multidimensional preventive home visits have the potential to reduce disability burden among older adults when based on multidimensional assessment with clinical examination. Effects on nursing home admissions are heterogeneous and likely depend on multiple factors including population factors, program characteristics, and health care setting.     

Effectiveness of a falls-and-fracture nurse coordinator to reduce falls: a randomized, controlled trial of at-risk older adults

OBJECTIVES: To assess the effectiveness of a community‐based falls‐and‐fracture nurse coordinator and multifactorial intervention in reducing falls in older people. DESIGN: Randomized, controlled trial. SETTING: Screening for previous falls in family practice followed by community‐based intervention. PARTICIPANTS: Three hundred twelve community‐living people aged 75 and older who had fallen in the previous year. INTERVENTION: Home‐based nurse assessment of falls‐and‐fracture risk factors and home hazards, referral to appropriate community interventions, and strength and balance exercise program. Control group received usual care and social visits. MEASUREMENTS: Primary outcome was rate of falls over 12 months. Secondary outcomes were muscle strength and balance, falls efficacy, activities of daily living, self‐reported physical activity level, and quality of life (Medical Outcomes Study 36‐item Short Form Questionnaire). RESULTS: Of the 3,434 older adults screened for falls, 312 (9%) from 19 family practices were enrolled and randomized. The average age was 81±5, and 69% (215/312) were women. The incidence rate ratio for falls for the intervention group compared with the control group was 0.96 (95% confidence interval=0.70–1.34). There were no significant differences in secondary outcomes between the two groups. CONCLUSION: This nurse‐led intervention was not effective in reducing falls in older people who had fallen previously. Implementation and adherence to the fall‐prevention measures was dependent on referral to other health professionals working in their usual clinical practice. This may have limited the effectiveness of the interventions.     

Effectiveness of geriatric evaluation and care. One-year results of a multicenter randomized clinical trial

The aim of this study was to demonstrate the effectiveness of outpatient elderly care based on Comprehensive Geriatric Assessment (CGA). Eleven hospital Geriatric Evaluation and Management units (GEMs) systematically screened 1386 inpatients over a 10-month period, using the same uniform selection plan which included 15 programmed exclusion-inclusion criteria and a standard CGA. At the end of this screening, 152 eligible frail elderly patients were randomized to either a comprehensive outpatient GEMs program (intervention group: N=79) or to usual care by their family doctors (control group: N=73). We did not find any statistically significant difference between the two groups at entry. During the one-year follow-up period, 6 GEMs patients (7.6%) and 12 controls (17.1%) died, without significant differences between the two survival curves. Only three patients (all controls) ultimately dropped out, and eight (3 unit patients and 5 controls) entered a nursing home. GEMs patients were significantly more likely to have individual improvement in mental status (p=0.006), morale (p=0.024) and functional level (p=0.023), compared to controls. Even though intervention participants spent fewer days in hospital and nursing home (p<0.05), they received much more home care and day-hospital assistance (p<0.001), which explains why total expenditure on health care was the same in the two groups. We conclude that: 1) a standardized selection plan may contribute to identify the older inpatients in need of CGA; and 2) CGA-based outpatient care may be clinical- and cost-effective if directly managed by GEMs, and may provide targeted older patients with more substantial benefits than standard care, without inflating health care expenses.