Carol Hutner Winograd

The Natural History of Functional Morbidity in Hospitalized Older Patients

This study provides data on changes in the functional status of older patients that are associated with acute hospitalization. Seventy‐one patients over the age of 74 admitted to the medical service of Stanford University Hospital between February and May 1987 received functional assessments covering seven domains: mobility, transfer, toileting, incontinence, feeding, grooming, and mental status. Assessments were obtained by report from the patients caregiver (or the patient when he or she lived alone) for 2 weeks before admission; from the patients nurse on day 2 of hospitalization and on the day before discharge; and again from the caregiver (or patient) 1 week after discharge. The sample had a mean age of 84, covered 37 Diagnostic Related Groups, and had a median length of stay of 8 days. Between baseline and day 2, statistically significant deteriorations occurred for the overall functional score and for the individual scores for mobility, transfer, toileting, feeding, and grooming. None of these scores improved significantly by discharge. In the case of mobility, 65% of the patients experienced a decline in score between baseline and day 2. Between day 2 and discharge, 67°/o showed no improvement, and another 10% deteriorated further. These data suggest that older patients may experience a burden of new and worsened functional impairment during hospitalization that improves at a much slower rate than the acute illness. An awareness of delayed functional recovery should influence discharge planning for older patients. Greater efforts to prevent functional decline in the hospitalized older patient may be warranted.

Screening for frailty : criteria and predictors of outcomes

To determine the reliability of rapid screening by clinically derived geriatric criteria in predicting outcomes of elderly hospitalized patients.

Hospital Admission Risk Profile (HARP): Identifying Older Patients at Risk for Functional Decline Following Acute Medical Illness and Hospitalization

OBJECTIVES: To develop and validate an instrument for stratifying older patients at the time of hospital admission according to their risk of developing new disabilities in activities of daily living (ADL) following acute medical illness and hospitalization.

Development of a Physical Performance and Mobility Examination

OBJECTIVE: To develop and validate the Physical Performance and Mobility Examination (PPME), an observer‐administered, performance‐based instrument assessing 6 domains of physical functioning and mobility for hospitalized elderly.

Geriatric Targeting Criteria as Predictors of Survival and Health Care Utilization

OBJECTIVE: To assess the utility of geriatric targeting criteria in predicting survival and health care utilization in a cohort of hospitalized older veterans.

Targeting Strategies: An Overview of Criteria and Outcomes

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

Targeting the Hospitalized Elderly for Geriatric Consultation

This empirical study reports the proportion of hospitalized elderly patients who were identified as frail. As a part of a randomized controlled trial, standardized criteria were developed to target the frail hospitalized elderly for geriatric consultation. Twelve‐hundred patients aged 65 years and older admitted to the medical and surgical services at the Palo Alto Veterans Administration Medical Center were screened. Because of administrative exclusions of the randomized controlled trial (eg, short stay, lived too far away), 749 (62%) were excluded from the clinical screening process. The remaining 451 patients received clinical screening. Of these patients, almost two thirds (64%) were considered “too independent” to benefit from geriatric consultation (ie, independent in activities of daily living with short term illness), while 12% were judged “too impaired” to benefit (ie, had severe dementia or terminal cancer). Only 24% of those clinically screened (9% of the entire sample) were considered appropriate for geriatric consultation. Strikingly, over 42% of those patients aged 76 or older, were judged “too independent.”

Fluoxetine in Elderly Patients: Is There Cause for Concern?

To assess whether fluoxetine use is associated with significant weight loss or other side effects in depressed elderly patients with concomitant medical illness.

Impact of prospective payment and discharge location on the outcome of hip fracture

Objective:To determine the impact of prospective payment by diagnosis-related groups (DRGs) on length of stay in the hospital, ambulatory status, and level of post-hospital care needed for patients hospitalized with hip fracture.Design:Retrospective chart review of a consecutive series of cases before and after the reference date of implementation of the prospective payment system (PPS).Setting:Academic, tertiary-care hospital.Patients/participants:181 patients 69 years of age or older admitted with International Classification of Diseases (ICD) or DRG codes for hip fracture.Results:Length of stay was shorter by 1.37 days in the post-PPS era (p=0.05). Poorer discharge ambulation was found in the post-PPS group (p=0.089). At one year, differences in ambulation and nursing home residence were found to be related not to the implementation of PPS, but rather to the nursing home to which the patient was discharged. Patients discharged to a facility with active physical rehabilitation were less likely to remain institutionalized (p=0.0025) than those in “ordinary” nursing homes and ambulated more independently (p=0.05).Conclusions:The PPS did not have a significant long-term impact on hip fracture outcome. Post-hospital care may be of crucial importance to the future quality of life of hip fracture patients.

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

To maximize the cost effectiveness of geriatric evaluation and management (GEM) programs, criteria need to be established for selecting patients most likely to benefit. A working group was convened to define appropriate patient selection (targeting) criteria for each type of GEM program and to consider research questions for future targeting studies. The group outlined targeting criteria for the spectrum of GEM program types and locations. GEM program types included: inpatient GEM units; hospital geriatric consultation services; GEM programs in nursing homes; outpatient GEM programs for functionally impaired persons; and geriatric community outreach/screening programs for functionally independent elders. For each program type, the group outlined targeting criteria based on current literature and experience.