Anne Ekdahl

Are elderly people with co-morbidities involved adequately in medical decision making when hospitalised? A cross-sectional survey

BackgroundMedical decision making has long been in focus, but little is known of the preferences and conditions for elderly people with co-morbidities to participate in medical decision making. The main objective of the present study was to investigate the preferred and the actual degree of control, i.e. the role elderly people with co-morbidities wish to assume and actually had with regard to information and participation in medical decision making during their last stay in hospital.This study was a cross-sectional survey including three Swedish hospitals with acute admittance. The participants were patients aged 75 years and above with three or more diagnoses according to the International Classification of Diseases (ICD-10) and three or more hospitalisations during the last year.MethodsWe used a questionnaire combined with a telephone interview, using the Control Preference Scale to measure each participants preferred and actual role in medical decision making during their last stay in hospital. Additional questions were asked about barriers to participation in decision making and preferred information seeking role. The results are presented with descriptive statistics with kappa weights.ResultsOf the 297 elderly patients identified, 52.5% responded (n = 156, 46.5% male). Mean age was 83.1 years. Of the respondents, 42 of 153 patients said that they were not asked for their opinion (i.e. no shared decision making). Among the other 111 patients, 49 had their exact preferred level of participation, 37 had less participation than they would have preferred, and 23 had more responsibility than they would have preferred. Kappa statistics showed a moderate agreement between preferred and actual role (κw = 0.57; 95% CI: 0.45-0.69). Most patients wanted to be given more information without having to ask. There was no correlation between age, gender, or education and preferred role. 35% of the patients agreed that they experienced some of the various barriers to decision making that they were asked about: 1) the severity of their illness, 2) doctors with different treatment strategies, 3) difficulty understanding the medical information, and 4) difficulty understanding doctors who did not speak the patients own language.ConclusionsPhysicians are not fully responsive to patient preferences regarding either the degree of communication or the patients participation in decision making. Barriers to participation can be a problem, and should be taken into account more often when dealing with hospitalised elderly people.

Long-Term Evaluation of the Ambulatory Geriatric Assessment: A Frailty Intervention Trial (AGe-FIT): Clinical Outcomes and Total Costs After 36 Months

OBJECTIVE To compare the effects of care based on comprehensive geriatric assessment (CGA) as a complement to usual care in an outpatient setting with those of usual care alone. The assessment was performed 36 months after study inclusion. DESIGN Randomized, controlled, assessor-blinded, single-center trial. SETTING A geriatric ambulatory unit in a municipality in the southeast of Sweden. PARTICIPANTS Community-dwelling individuals aged ≥ 75 years who had received inpatient hospital care 3 or more times in the past 12 months and had 3 or more concomitant medical diagnoses were eligible for study inclusion. Participants were randomized to the intervention group (IG) or control group (CG). INTERVENTION Participants in the IG received CGA-based care for 24 to 31 months at the geriatric ambulatory unit in addition to usual care. OUTCOME MEASURES Mortality, transfer to nursing home, days in hospital, and total costs of health and social care after 36 months. RESULTS Mean age (SD) of participants was 82.5 (4.9) years. Participants in the IG (n = 208) lived 69 days longer than did those in the CG (n = 174); 27.9% (n = 58) of participants in the IG and 38.5% (n = 67) in the CG died (hazard ratio 1.49, 95% confidence interval 1.05-2.12, P = .026). The mean number of inpatient days was lower in the IG (15.1 [SD 18.4]) than in the CG (21.0 [SD 25.0], P = .01). Mean overall costs during the 36-month period did not differ between the IG and CG (USD 71,905 [SD 85,560] and USD 65,626 [SD 66,338], P = .43). CONCLUSIONS CGA-based care resulted in longer survival and fewer days in hospital, without significantly higher cost, at 3 years after baseline. These findings add to the evidence of CGAs superiority over usual care in outpatient settings. As CGA-based care leads to important positive outcomes, this method should be used more extensively in the treatment of older people to meet their needs.

‘Are decisions about discharge of elderly hospital patients mainly about freeing blocked beds?’ A qualitative observational study

Objective To explore the interactions concerning the frail and elderly patients having to do with discharge from acute hospital wards and their participation in medical decision-making. The views of the patients and the medical staff were both investigated. Design A qualitative observational and interview study using the grounded theory. Setting and participants The setting was three hospitals in rural and urban areas of two counties in Sweden of which one was a teaching hospital. The data comprised observations, healthcare staff interviews and patient interviews. The selected patients were all about to be informed that they were going to be discharged. Results The patients were seldom invited to participate in the decision-making regarding discharge. Generally, most communications regarding discharge were between the doctor and the nurse, after which the patient was simply informed about the decision. It was observed that the discharge information was often given in an indirect way as if other, albeit absent, people were responsible for the decision. Interviews with the healthcare staff revealed their preoccupation with the need to free up beds: ‘thinking about discharge planning all the time’ was the core category. This focus not only failed to fulfil the complex needs of elderly patients, it also generated feelings of frustration and guilt in the staff, and made the patients feel unwelcome. Conclusions Frail elderly patients often did not participate in the medical decision-making regarding their discharge from hospital. The staff was highly focused on patients getting rapidly discharged, which made it difficult to fulfil the complex needs of these patients.

Living unnoticed: Cognitive impairment in older people with multimorbidity

ObjectivesTo investigate the correlation between MMSE ≤ 23 and the presence of a diagnosis of dementia in the medical record in a population with multimorbidity.Design, setting, and participantsThis cross-sectional study was part of the Ambulatory Geriatric Assessment – a Frailty Intervention Trial (AGe-FIT; N = 382). Participants were community dwelling, aged ≥ 75 years, had received inpatient hospital care at least three times during the past 12 months, and had three or more concomitant diagnoses according to the International Classification of Diseases, 10th revision.MeasurementsThe Mini Mental State Examination (MMSE) was administered at baseline. Medical records of participants with MMSE scores < 24 were examined for the presence of dementia diagnoses and two years ahead.ResultsFifty-three (16%) of 337 participants with a measure of MMSE had a MMSE scores < 24. Six of these 53 (11%) participants had diagnoses of dementia (vascular dementia, n = 4; unspecified dementia, n = 1; Alzheimers disease, n = 1) according to medical records; 89% did not.ConclusionsA MMSE-score < 24 is not well correlated to a diagnosis of dementia in the medical record in a population of elderly with multimorbidity. This could imply that cognitive decline and the diagnosis of dementia remain undetected in older people with multimorbidity. Proactive care of older people with multimorbidity should focus on cognitive decline to detect cognitive impairment and to provide necessary help and support to this very vulnerable group.

Standard set of health outcome measures for older persons

BackgroundThe International Consortium for Health Outcomes Measurement (ICHOM) was founded in 2012 to propose consensus-based measurement tools and documentation for different conditions and populations.This article describes how the ICHOM Older Person Working Group followed a consensus-driven modified Delphi technique to develop multiple global outcome measures in older persons.The standard set of outcome measures developed by this group will support the ability of healthcare systems to improve their care pathways and quality of care. An additional benefit will be the opportunity to compare variations in outcomes which encourages and supports learning between different health care systems that drives quality improvement. These outcome measures were not developed for use in research. They are aimed at non researchers in healthcare provision and those who pay for these services.MethodsA modified Delphi technique utilising a value based healthcare framework was applied by an international panel to arrive at consensus decisions.To inform the panel meetings, information was sought from literature reviews, longitudinal ageing surveys and a focus group.ResultsThe outcome measures developed and recommended were participation in decision making, autonomy and control, mood and emotional health, loneliness and isolation, pain, activities of daily living, frailty, time spent in hospital, overall survival, carer burden, polypharmacy, falls and place of death mapped to a three tier value based healthcare framework.ConclusionsThe first global health standard set of outcome measures in older persons has been developed to enable health care systems improve the quality of care provided to older persons.

O3.03: Caring for elderly with multimorbidity: Evaluation of ambulatory geriatric unit (AGU) (the AGe-FIT-study) – a randomized controlled trial

Importance: The care of older persons with multimorbidity is a future challenge for the welfare sector in many countries in terms of organization of care and provision of sufficient health care resources. Objective: To determine whether an alternative with an ambulatory geriatric unit (AGU) additional to usual care based on Comprehensive Geriatric Assessment (CGA) is more effective than usual care (UC) only. Design: Randomized, controlled, assessor blinded, single center trial of community dwelling patients ≥75 years, hospitalized at least three times during the past 12 months, having at least three concomitant diagnoses [intervention (AGU) n = 208, control group (UC) n = 175]. Outcomes: Hospitalizations, mortality, health related quality of life (HRQoL) and costs of care. Results: After 24 months there was no difference in number of hospitalizations (2.1 in AGU versus 2.4 in CG (P = 0.19). However, patients in AGU had less inpatient days (11.1) compared to the UC (15.2) (P = 0.03). Further, the UC had 54% higher mortality rate than the IG (HR = 1.54 (95% CI: 1.01-2.34), P = 0.046). The cost of care was € 19,941 in the AGU and € 17,730 in the UC group. There was no difference in HRQoL between the groups. Conclusion: The superiority of the alternative with AGU in important findings such as decreased inpatient days and mortality, but to slightly higher total cost after 24 months follow up. This finding is important knowledge when organizing the care for the elderly. (Less)

Primary and Community Care

Care of older persons in community and primary care differs substantially between European countries, but most countries pursue the concept of “ageing in place”, meaning that most older people do not live in institutions. More and more older people are living alone. Relatives still play an important role in the care of older people, but it differs substantially within Europe, and will probably remain the case even in the future. Care of older people with complex needs requires corresponding complex teams to be able to provide adequate and good quality of care, which means that there must be geriatric skills to diagnose, treat, and comprehensively follow up people with common geriatric diseases, including dementia, within primary and community care.

Effectiveness of Intensive Primary Care

Dear Editor, I read with great interest the recent review in JGIM by Dr. Edwards et al. on the BEffectiveness of Intensive Primary Care Interventions.^ Our group published one of the articles included in Dr. Edwards’ review and we are concerned about several discrepancies between our findings and those reported in the review. First, they report that we had 252 patients followed for 2 years. While we experienced losses to followup and only included 252 patients in our 2-year analysis of several clinical assessed outcomes, we originally enrolled 382 subjects, and for our 2-year outcomes of death and hospitalization, we included all originally randomized 382 subjects in an intention-to-treat analysis. A second concern is that the article states in Table 2 that we had NR (no report) on the outcomes of hospital admissions and average hospital length of stay. However, we provide extractable data for both outcomes; while we found was no difference between our intervention and control groups for hospital admission rates (2.1 vs. 2.5, p = 0.212), our intervention significantly reduced the average length of stay (11.1 vs. 15.2 days, p = 0.035). Finally, the review states that they searched throughMarch of 2017 for pertinent articles. However, we published a 3-year follow-up data on our original study cohort in 2016 and in that report, we found that the reduction in average length of stay for hospitalization persisted in our intervention group, the difference in mortality was now significant (27.9%vs. 38.5%, p = 0.026), and there was a trend towards a decrease in rates of hospitalization (2.8 vs. 3.4, p = 0.06). W up study was not included in their syste I am concerned, saddened actually, view lists these BNR^ results from the A that clinicians and policy makers will rel of our data and that future readers ma misled about our findings by this article

Is care based on comprehensive geriatric assessment with mobile teams better than usual care? A study protocol of a randomised controlled trial (The GerMoT study)

Introduction Comprehensive geriatric assessment (CGA) is a multidimensional, interdisciplinary diagnostic process used to determine the medical, psychological and functional capabilities of frail older people. The primary aim of our current study is to confirm whether CGA-based outpatient care is superior than usual care in terms of health-related outcomes, resource use and costs. Methods and analysis The Geriatric Mobile Team trial is designed as a single-centre randomised, controlled, assessor-blinded (at baseline) trial. All participants will be identified via local healthcare registries with the following inclusion criteria: age ≥75 years, ≥3 different diagnoses and ≥3 visits to the emergency care unit (with or without admittance to hospital) during the past 18 months. Nursing home residency will be an exclusion criterion. Baseline assessments will be done before the 1:1 randomisation. Participants in the intervention group will, after an initial CGA, have access to care given by a geriatric team in addition to usual care. The control group receives usual care only. The primary outcome is the total number of inpatient days during the follow-up period. Assessments of the outcomes: mortality, quality of life, health care use, physical functional level, frailty, dependence and cognition will be performed 12 and 24 months after inclusion. Both descriptive and analytical statistics will be used, in order to compare groups and for analyses of outcomes over time including changes therein. The primary outcome will be analysed using analysis of variance, including in-transformed values if needed to achieve normal distribution of the residuals. Ethics and dissemination Ethical approval has been obtained and the results will be disseminated in national and international journals and to health care leaders and stakeholders. Protocol amendments will be published in ClinicalTrials.gov as amendments to the initial registration NCT02923843. In case of success, the study will promote the implementation of CGA in outpatient care settings and thereby contribute to an improved care of older people with multimorbidity through dissemination of the results through scientific articles, information to politicians and to the public. Trial registration number NCT02923843; Pre-results.

The importance of studying personality traits and pain in the oldest adults

In this issue of the Scandinavian Journal of Pain Lena SandinWranker and coworkers [1] report on the influence of differentpersonality traits on the perception of pain with focus on olderadults and also differences between the two genders with regardto personality trait and pain.Older people often suffer from symptoms such as depression[2], fatigue [3], sleep disorder [4], and pain [5] which is the focus ofthis paper. Community-dwelling older people have reported painprevalence of between 20% and 79% [6,7], and pain causes olderpeople a considerable amount of suffering. Sandin Wranker andco-workers invited 2312 persons between 60 and 96 years of age,and of the 1403 who responded, 65% of women and 36% of menanswered yestothequestiononwhethertheyhadhadanyacheorpain duringthelast4weeks.Painwasmoderateorseverein86%ofwomen and 79% of men who responded “yes” to this question [1].Earlier studies described pain as underdiagnosed and under-treated [6,8] and found that independent of clinical diagnosis, 25%of older people did not receive analgesic treatment for pain, andpeople olderthan85wereevenlesslikelytoreceiveanalgesics[8].It is therefore very important to do research on older people andpain, as this is an area with a marked potency for significant andmuch needed clinical improvement.In their study they found that of the five components of theFive