Geriatric assessment for oncologists: rationale and future directions

Sixty percent of all cancer occurrences and seventy percent of cancer mortalities occur in people over the age of 65. As the population ages, there is an emerging need to develop a means for oncologists to characterize the "functional age" of older patients with cancer in order to tailor treatment decisions and stratify outcomes based on factors other than chronological age and to develop interventions to optimize cancer treatment. In this paper, we discuss the formulation of a geriatric assessment for older patients with cancer. The measures included in this assessment were chosen based on their validity, reliability, brevity, adaptability for self-administration, and ability to prognosticate risk for morbidity or mortality in an older patient. The proposed geriatric assessment covers the essential domains of assessment predictive of survival in the geriatric population, is primarily self-administered, and limited personnel time is required. Our eventual goal is to determine if this geriatric assessment measure can identify factors independent of age that predict cancer treatment morbidity and mortality and result in rationale interventions to optimize oncologic care.     

The Columbia Cooperative Aging Program: an interdisciplinary and interdepartmental approach to geriatric education for medical interns

Although there is a critical need to prepare physicians to care for the growing population of older adults, many academic medical centers lack the geriatric-trained faculty and dedicated resources needed to support comprehensive residency training programs in geriatrics. Because of this challenge at Columbia University, the Columbia Cooperative Aging Program was developed to foster geriatric training for medical interns. For approximately 60 interns each year completing their month-long geriatric rotations, an integral part of this training now involves conducting comprehensive assessments with "well" older people, supervised by an interdisciplinary team of preceptors from various disciplines, including cardiology, internal medicine, occupational therapy, geriatric nursing, psychiatry, education, public health, social work, and medical anthropology. Interns explore individual behaviors and social supports that promote health in older people; older people's strengths, vulnerabilities, and risk for functional decline; and strategies for maintaining quality of life and independence. In addition, a structured "narrative medicine" writing assignment is used to promote the interns' reflections on the assessment process, the data gathered, and their clinical reasoning throughout. Preliminary measures of the program's effect have shown significant improvements in attitudes toward, and knowledge of, older adults as patients, as well as in interns' self-assessed clinical skills. For academic medical centers, where certified geriatric providers are scarce, this approach may be an effective model for fostering residency geriatric education among interns.     

Could Self‐Neglect in Older Adults Be a Geriatric Syndrome?

Self-neglect in older adults is a complex phenomenon characterized by inattention to health and hygiene, typically stemming from an inability or unwillingness to access potentially remediating services. Some aspects of self-neglect clinically resemble geriatric syndromes (e.g., falling, incontinence). The literature on self-neglect was comprehensively reviewed and its quality evaluated in the context of considering its candidacy for a geriatric syndrome. MEDLINE (1966-2004) was searched using self-neglect as a keyword. Using a "snowball" sampling strategy, associated terms (e.g., Diogenes' syndrome) were combined, selecting relevant papers and frequently cited references, assessing each one using specific criteria. Its candidacy for consideration for a geriatric syndrome was assessed based on the quality of data in four domains: multifactorial etiology, shared risk factors with other geriatric syndromes, association with functional decline, and association with increased mortality. The 54 articles reviewed included 24 case series, 13 theoretical articles, 11 observational studies, and six reviews; these were of highly variable methodological quality. The strongest evidence that self-neglect may be a geriatric syndrome includes its often multifactorial etiology, its clear independent association with increased mortality, and the fact that two other geriatric syndromes (cognitive impairment and depression) are risk factors for self-neglect. Self-neglect in older adults is a prevalent problem that appears to have at least some features of a geriatric syndrome. Insofar as the concept of geriatric syndrome has been a useful clinical and research paradigm to create interventions for vulnerable older adults, and no such strategies are available for this vexing and understudied clinical problem, future research is warranted in this area.     

Utilization of comprehensive geriatric assessment in cancer patients

A growing and diverse aging population, recent advances in research on aging and cancer, and the fact that a disproportional burden of cancer still occurs in people aged 65 years and older have generated great interest in delivering better cancer care for older adults. This is particularly true as more survivors of cancer live to experience cancer as a chronic disease. Cancer and its treatment precipitate classic geriatric syndromes such as falls, malnutrition, delirium, and urinary incontinence. Comprehensive Geriatric Assessment (CGA), by taking all patient's needs into account and by incorporating patient's wishes for the level of aggressiveness of treatment, offers a model of integrating medical care with social support services. It holds the promise of controlling health care costs while improving quality of care by providing a better match of services to patient needs. Three decades after the CGA was initially developed in England, oncologists have begun taking notice on the potential benefits that CGA might bring to the field of geriatric oncology. This article describes the utilization of the CGA in cancer patients with an eye toward promoting interdisciplinary care for older cancer patients. To set an initial context, a search of computerized databases took place, using "comprehensive geriatric assessment" and "cancer" as keywords. A selection of literature from between 1980 and 2003 was reviewed. Additional articles were identified through the bibliography of relevant articles.     

Geriatric assessment in family practice--results of concerted action by 7 European countries

General practitioners are faced with the complex medical care of an increasing number of older people. Traditional demand led care is not able to provide optimal management for this age group, since it has been shown that many important health problems remain unknown or not optimally treated. Preventive geriatric assessment offers primary health care providers new opportunities to focus their management on the particular health problems of older people. A European concerted action involving seven countries formed to develop a "standard assessment for elderly people in primary care (STEP)". The aim was threefold: 1) to identify important and preventable health problems in old age, 2) to supply health care planners and providers with scientific evidence of the corresponding preventive procedures, and 3) to initiate a practical assessment framework for use in European primary care practices. Using a strict methodological protocol, 33 health problems were identified that potentially improve health outcomes in preventive programs for older people. A summary of the evidence is given for each of the included health areas. Taking the best available evidence, patients' preferences, and practice conditions into account, a preventive assessment program was developed containing validated and accepted instruments. The approach is algorithmic with a simple problem identification level and a further diagnostic stage. All recommended procedures are harmonized for common European use. An evidence-based preventive assessment program is expected not only to prevent disease and minimize disability and handicap, but it also offers health care planners a European data set of older peoples' needs for optimized resource allocation.     

Defining the domain of geriatric medicine in an urban public health system affiliated with an academic medical center

The American Geriatrics Society has recommended a reexamination of the roles and deployment of providers with expertise in geriatric medicine. Healthcare systems use a variety of strategies to maximize their geriatric expertise. In general, these health systems tend to focus geriatric medicine resources on a group of older adults that are locally defined as the most in need. This article describes a model of care within an academic urban public health system and describes how local characteristics interact to define the domain of geriatric medicine. This domain is defined using 4 years of data from an electronic medical record combined with data collected from clinical trials. From January 2002 to December 2005, 31,443 adults aged 65 and older were seen at any clinical site within this healthcare system. The mean age was 75 (range 65-105); 61% were women; 35% African American, and 2% Hispanic. The payer mix was 80% Medicare and 17% Medicaid. The local geriatric medicine program includes sites of care in inpatient, ambulatory, nursing home, and home-based settings. By design, this geriatric medicine clinical practice complements the care provided to older adults by the primary care practice. Primary care physicians tend to cede care to geriatric medicine for older adults with advanced disability or geriatric syndromes. This is most apparent for older adults in nursing facilities or those requiring home-based care. There is a dynamic interplay between design features, reputation, and capacity that modulates volume, location, and type of patients seen by geriatrics.     

Standards of medical care for nursing home residents in Europe

ObjectiveNursing home inhabitants represent the most vulnerable and frail group of older people. They have more complex medical backgrounds and more significant care requirements. With an ever-ageing European population, the number of people requiring nursing home care will only increase. It is important then that we optimise the medical care of older people living in nursing homes.MethodsFormalized care standards are essential to optimal care but we feel that such guidelines are lacking. We decided to investigate this by means of a survey on nursing home care standards sent to the geriatric medicine societies around Europe.ResultsOnly five of 25 (20%) health services have a requirement for specific training in geriatric medicine for doctors in nursing homes, while only three of 25 (12%) countries have written medical care standards applicable to nursing home care provided by professional organizations. Four of 25 (16%) had a nursing home doctor society and one of these, The Netherlands, provided written medical care standards for nursing homes which were also adopted by the relevant general practitioner society.DiscussionThe Europe-wide deficiency of documented care standards for nursing homes is alarming. It should be a prerequisite that physicians dealing with these complex patients have undertaken some level of specific training in geriatric medicine. It is important that geriatricians, old age psychiatrists and family doctors across European countries engage more formally on the development of appropriate models for both developing care standards and specifying appropriate training and support for doctors working in nursing homes.     

Identifying Barriers to Care for Older Adults with Substance Use Disorders and Cognitive Impairments

Some substance use disorders in older adults may be better conceptualized as hazardous use that is sometimes unintentional and affected by other mental health conditions, including dementia. This study identified (1) the types of substances older adults are abusing, (2) how the disorders are linked to dementia and other mental health issues, and (3) barriers to screening and treatment. Focus groups with inpatient and outpatient treatment teams and a review of medical records were completed. Screenings for substance use disorders and other geriatric syndromes (e.g., depression, dementia) are not widely done and is an area in which improvements can be made.     

Development of a home visitation programme for the early detection of health problems in potentially frail community-dwelling older people by general practices

The integration within existing health care systems of preventive initiatives to maintain independent living among older people is increasingly emphasized. This article describes the development and refinement of the [G]OLD home visitation programme: an eight-step programme, including a comprehensive geriatric assessment, for the early detection of health and well-being problems among older people (≥75 years) by general practices. A single group post-test study using a mixed model design is performed to evaluate (a) the feasibility of the home visitation programme in general practice, (b) the practical usefulness of the geriatric assessment instrument, and (c) programme implementation with respect to reinventions introduced by general practitioners (GPs) and practice nurses (PNs). Within 3 months time, 22 PNs of 18 participating general practices visited 240 community-dwelling older people (mean age = 82.0 years; SD 4.2) who had not been in contact with their general practice for more than 6 months. Mean time investment of the programme per older person was 118.1 min (SD 27.0) for GPs and PNs combined. Evaluation meetings revealed that GPs and PNs considered the home visitation programme to be feasible in daily practice. They judged the geriatric assessment to be useful, although minor adjustments are needed (e.g., lay-out, substitution of tests). PNs often failed to register follow-up actions for detected problems in a care and treatment plan. Future training for PNs should address this issue. No reinventions were introduced that threatened fidelity of implementation. The findings are used to improve the home visitation programme before its evaluation in a large-scale controlled trial.     

Caring for Older Americans: The Future of Geriatric Medicine

In response to the needs and demands of an aging population, geriatric medicine has grown rapidly during the past 3 decades. The discipline has defined its core values as well as the knowledge base and clinical skills needed to improve the health, functioning, and well-being of older persons and to provide appropriate palliative care. Geriatric medicine has developed new models of care, advanced the treatment of common geriatric conditions, and advocated for the health and health care of older persons. Nevertheless, at the beginning of the 21st century, the health care of older persons is at a crossroads. Despite the substantial progress that geriatric medicine has made, much more remains to be done to meet the healthcare needs of our aging population. The clinical, educational, and research approaches of the 20th century are unable to keep pace and require major revisions. Maintaining the status quo will mean falling further and further behind. The healthcare delivery and financing systems need fundamental redesign to improve quality and eliminate waste.
The American Geriatrics Society (AGS) Task Force on the Future of Geriatric Medicine has identified five goals aimed at optimizing the health of older persons:

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  To ensure that every older person receives high-quality, patient-centered health care

       
  
  

Older HIV patients require special considerations

HIV is a socially unacceptable disease in America, especially with older patients. Older people with HIV often have psychosocial health issues that are not seen in other populations. Health care providers are counseled to direct patients toward HIV support groups so that they do not become isolated by the disease. In addition, doctors should differentiate between geriatric and HIV symptoms while treating both, and to be aware of drug interactions in this population. Suggestions for older HIV patients are given by HIV experts and older people infected by the virus.     

Socioeconomic status and health among older adults in rural and urban China

Objective: The association between socioeconomic status (SES) and health, which has proven to be quite robust, is rarely tested in societies where levels of economic development and systems of stratification differ from those in Western developed countries. This article examines associations in rural and urban China. Method: Techniques include logit equation estimates of separate and pooled samples. The latter employ interaction terms to test rural and urban effects. Socioeconomic indicators include those more customarily used in these types of studies (e.g., education) and several that are less traditional (e.g., pension eligibility). Results: Results indicate associations exist in China. Bank savings is the strongest predictor. Some unexpected results are also found, including a positive association between socioeconomic status and chronic conditions (e.g., cardiovascular disease) among older adults in urban China. Discussion: Use and access to a health care professional might explain part of this anomaly.     

On the significance of geriatric medicine departments in Italy

The aging of population has been characteristic for the industrial countries during the last years. It is essentially due to two factors: the increase of life span and the decrease of births. Today the health conditions of the older population are better than in the past, but in octagenarians morbidity and disability globally increased. Therefore, aging of the population involves also more expenses for all the health care services, i.e., both for each older patient's family, and for the community. In departments of geriatric medicine it is right to consider two kinds of patients: older patient and geriatric patient. Multidimensional assessment and global intervention performed by a multidisciplinary team can obtain much better results for the geriatric patients, than the traditional medical strategies. Several reviews show also that departments of geriatric medicine achieve better results, than of the common internal medicine. Geriatric medicine departments have different aspects not only in the treatment of diseases, but also in supporting a global assistance, which aim also at rehabilitating the patient. Because of this central role and indispensability of the geriatric specialists, their work in the network of services should be obligatory, since only a continuous and global care can guarantee significant results for the geriatric patients.     

Health care for older people in Ireland

Despite a low level of popular advocacy for older people, specialist medical and psychiatric services for older people have developed rapidly in Ireland, and geriatric medicine has become the largest medical specialty in hospital practice. Official policy has incorporated significant recognition of the special needs of older people, but implementation of these policies has been variable and inadequate. No significant transfer of funding has accompanied advances in specialist medical manpower, and there are deficiencies in the full complement of rehabilitation therapists available in the hospitals and the community. Community and long-term care services are relatively underdeveloped; it may require legislative initiatives similar to the Older Americans Act to prompt the profound improvement required in these areas.     

Intensive care-management at home: an alternative to institutional care?

BACKGROUND: Care management and assessment of need are the cornerstones of the community care reforms in the UK. Although much of the research base has been on highly vulnerable older people, in practice, care management has been implemented for a wider group. OBJECTIVE: To examine how intensive care-management at home has developed. DESIGN: Postal survey of all local authority social services departments in England. METHOD: We used an overview questionnaire (85% response) and an old-age services questionnaire (77% response). We classified local authorities according to the presence or absence of seven indicators of intensive care management at home. RESULTS: 97% of social services departments had a goal of providing a community-based alternative to residential and nursing-home care. However, only 5% had specialist intensive care-management services for older people. Other key indicators of intensive care-management, such as devolved budgets, health service care managers, small caseloads and clear eligibility criteria, were uncommon. CONCLUSIONS: There was little evidence of intensive care-management at home in older peoples' services. This is of concern, given the move towards community-based provision for frail older people. Closer links between secondary health-care services (such as geriatric medicine) and intensive care-management at home may promote more effective care at home for those who are most vulnerable.     

Intermediate care--a challenge to specialty of geriatric medicine or its renaissance?

The specialism of geriatric medicine has developed considerably in the last half of the twentieth century. In Great Britain it has emerged from its sombre beginnings in Victorian poor law institutions to become one of the largest specialities in medicine encompassing a wide range of disciplines and interests. More recently, there has been a parallel development in "intermediate care" a sweeping phrase that encompasses a wide diversity of practices in a plethora of venues. Although there is considerable attraction in minimising the duration of hospital stay by older people, there is a real risk of intermediate care being used as a euphemism for indeterminate neglect. For older people to benefit from appropriate treatment and care, the lessons learnt by earlier generations of geriatricians, and supported by the international evidence base should not be disregarded. Elderly people need a full multi-disciplinary assessment (comprehensive geriatric assessment) and continued involvement of skilled and trained personnel in their continuing care (geriatric evaluation and management). The recommendations of the British Geriatrics Society on intermediate care are commended and should be adhered to by all planners and providers of intermediate care. There is considerable logic in developing ways in which the two developments can be integrated to build upon the best features of both.     

Health system reforms and the needs of the ageing population—an analysis of recent policy paths and reform trends in Finland and Sweden

Population ageing with an increasing number of people experiencing complex health and social care needs challenges health systems. We explore whether and how health system reforms and policy measures adopted during the past two decades in Finland and Sweden reflect and address the needs of the older people. We discuss health system characteristics that are important to meet the care needs of older people and analyse how health policy agendas have highlighted these aspects in Finland and Sweden. The analysis is based on “most similar cases”. The two countries have rather similar health systems and are facing similar challenges. However, the policy paths to address these challenges are different. The Swedish health system is better resourced, and the affordability of care better ensured, but choice and market-oriented competition reforms do not address the needs of the people with complex health and social care needs, rather it has led to increased fragmentation. In Finland, the level of public funding is lower which may have negative impacts on people who need multiple services. However, in terms of integration and care coordination, Finland seems to follow a path which may pave the way for improved coordination of care for people with multiple care needs. Intensified monitoring and analysis of patterns of health care utilization among older people are warranted in both countries to ensure that care is provided equitably.     

Effects on health care use and associated cost of a home visiting program for older people with poor health status: a randomized clinical trial in the Netherlands

BACKGROUND: Home visiting programs have been developed to improve the functional abilities of older people and subsequently to reduce the use of institutional care services. The results of trials have been inconsistent and their cost-effectiveness uncertain. Home visits for a high-risk population rather than the general population seems a promising approach. We therefore studied the effects of a home visiting program for older people with poor health. This article describes the effects on health care use and associated cost. METHODS: We conducted a randomized clinical trial among 330 community-dwelling citizens, aged 70-84 years, in the Netherlands. Participants in the intervention group (n = 160) received eight home visits by a trained home nurse over an 18-month period; a multidimensional geriatric assessment of problems was included. The main outcomes are: admissions to hospital, nursing home, and home for older persons; contacts with medical specialists, general practitioners, and paramedics; and hours of home care help. The data on health care use were mostly obtained from computerized databases of various medical administration offices; the follow-up period was 24 months. RESULTS: Inpatient and outpatient health care use was similar for both groups, with the exception of a higher distribution of aids and in-home modifications in favor of the intervention group. No differences were found between the intervention and control group in health care cost. CONCLUSION: The home visiting program did not appear to have any effect on the health care use of older people with poor health and had a low chance of being cost-effective. We conclude that these visits are probably not beneficial for such persons within the health care setting in the Netherlands or comparable settings in other Western countries.