Kenneth Brummel-Smith

National Institutes of Health Consensus Development Conference Statement: Geriatric Assessment Methods for Clinical Decision‐making

he population of elderly persons in the developed nations is growing with extraordinary rapidity. Although the majority enjoy good T health, many older people suffer from multiple illnesses and significant disability. Comprehensive assessment methodologies, while not solely applicable to frail elderly persons, are believed to be particularly suited to their situation. These individuals tend to exhibit great medical complexity and vulnerability; have illnesses with atypical and obscure presentations; suffer major cognitive, affective, and functional problems; are especially vulnerable to iatrogenesis; are often socially isolated and economically deprived; and are at high risk for premature or inappropriate institutionalization. To deal with the exceedingly difficult health care issues posed by frail elderly persons, health professionals need to collect, organize, and use a vast array of clinically relevant information. This process, compre-

Assessment of Pain in Cognitively Impaired Older Adults: A Comparison of Pain Assessment Tools and Their Use by Nonprofessional Caregivers

OBJECTIVES: To compare self‐reporting of pain by cognitively impaired (CI) older adults living in the community with reports of their caregivers; to identify the factors associated with differences in agreement; and to identify those pain assessment tools that are most useful to nonprofessional caregivers.

Decreasing the burden in families caring for a relative with a dementing illness. A controlled study.

The purpose of this study was to investigate the efficacy of a specifically designed group support program for relatives of patients with Alzheimers disease and related disorders. The group program included educational/supportive activities and used basic principles of the cognitive‐behavioral approach. Twenty‐two subjects participated in an eight‐session program. Eighteen control subjects received no treatment. Measures of family burden, levels of depression, and knowledge of dementia were obtained. Experimental subjects showed a significant decrease in total family burden, whereas control subjects actually showed a significant increase, experimental subjects also showed reduction in their levels of depression. Experimental subjects showed a significantly greater improvement than did control subjects on knowledge of dementia. The acquisition of new knowledge was an important ingredient in reducing perception of burden and levels of depression, but other facets of the intervention also accounted for the improvement. Results indicated that a relatively short but intensive support experience can have a positive effect in reducing some of the burden and depression associated with the care of a demented relative.

Physician Orders for Life-Sustaining Treatment (POLST): Outcomes in a PACE Program

OBJECTIVES: To evaluate whether terminal care was consistent with Physician Orders for Life‐Sustaining Treatment (POLST), a preprinted and signed doctors order specifying treatment instructions in the event of serious illness for CPR, levels of medical intervention, antibiotics, IV fluids, and feeding tubes.

Best Paper of the 1980s: National Institutes of Health Consensus Development Conference Statement: Geriatric Assessment Methods for Clinical Decision‐Making

The population of elderly persons in developed nations is growing with extraordinary rapidity. Although the majority enjoy good health, many older people suffer from multiple illnesses and significant disability. Comprehensive assessment methodologies, while not solely applicable to frail elderly persons, are believed to be particularly suited for their situation. These individuals tend to exhibit great medical complexity in vulnerability; have illnesses with atypical and obscure presentations; suffer major cognitive, affective, and functional problems; are especially vulnerable to iatrogenesis; are often socially isolated and economically deprived; and are at high risk for premature or inappropriate institutionalization. To deal with exceedingly difficult health care issues posed by frail elderly persons, health professionals need to collect, organize, and use a vast array of clinically relevant information. The process, comprehensive geriatric assessment, is defined as a multidisciplinary evaluation in which the multiple problems of older persons are uncovered, described, and explained, if possible, and in which the resources and strengths of the person are catalogued, need for services assessed, and a coordinated care plan developed to focus interventions on the person’s problems. Comprehensive geriatric assessment generally includes evaluation of the patient in several domains, most commonly the physical, mental, social, economic, functional, and environmental. The term ‘‘functional’’ is used here in a narrow sense: It means the ability to function in the arena of everyday living. The panel recognizes that the same word has been used in the much broader sense of the whole range of functions we have listed just above. In other words, some use ‘‘functional assessment’’ to mean what we have termed ‘‘comprehensive geriatric assessment’’. When applied to clinical decisionmaking, comprehensive geriatric assessment involves clinicians from the many healthcare professions who are necessarily involved in good geriatric care. Comprehensive geriatric assessment is only one component of general geriatric care. Appropriate geriatric care involves some level of assessment of the multiple domains just cited, but comprehensive geriatric assessment tends to be applied only to a subset of older persons who are frail and considered most likely to benefit (see question 3). It has been suggested that a new form of comprehensive assessment could be developed to evaluate physical fitness for purposes of monitoring health promotion and disease prevention in well older persons and another form to guide the humane care of irreversibly disabled and terminally ill older persons. Between 1973 and 1987, reports have appeared on a significant number of true experiments exploring the elements and effectiveness of various approaches to geriatric assessment. The data from these studies, coupled with the growing numbers of frail elderly individuals, the high cost of their health care, the intensity of their distress and discomfort, and the great uncertainty as to the best route to wise clinical decision-making, led to the current conference. The National Institute on Aging and Office of Medical Applications of Research of the National Institutes of Health, in conjunction with the National Institute of Mental Health, the Veterans Administration, and the Henry J. Kaiser Family Foundation, convened the Consensus Development Conference on Geriatric Assessment Methods for Clinical Decision-making on October 19–21, 1987.

Health needs of the Hispanic elderly.

This paper presents results of a study concerning the health care needs of the Hispanic elderly population of Los Angeles County. By use of the Comprehensive Assessment and Referral Evaluation (CARE) instrument, data on a sample of 704 subjects were employed to compute the scores for 22 Likert‐type scales measuring the prevalence of numerous psychiatric, medical, and social problems. The data indicate that older Hispanics were affected by cognitive impairment (13.8 per cent), depression/demoralization (30.8 per cent), heart disorders (12.8 per cent), stroke effects (11.5 per cent), arthritis (28.3 per cent), hypertension (23.7 per cent), financial hardship (28.0 per cent), fear of crime (38.4 per cent), ambulation problems (17.2 per cent), or activity limitation (24.7 per cent); they also needed assistance (19.3 per cent) or used social services (22.0 per cent). Further analysis revealed that the prevalence of many of these problems varies significantly according to the age, sex, language, and income of respondents. The indicators of health care needs used in the study differed substantially from the more traditional measures based on the persons own perception of his or her health.

The First Certifying Examination in Geriatric Medicine

On April 22, 1988, the first Certifying Examination in Geriatric Medicine was administered jointly by the American Board of Internal Medicine and the American Board of Family Practice to 4,282 diplomates (ABIM = 2,202; ABFP = 2,080). This paper addresses both an analysis of the examination and the relationship between performance on that examination and a group of characteristics of the examinees, collected as part of the registration process. The pass rate was 56%. Performance on the examination was positively correlated with scores on the general certifying examinations and with training in geriatric medicine. Data provided by the candidates in an addendum to the application were also available for analysis and were used to derive correlations with groups of questions. The performance of candidates was positively correlated with seeing large numbers of elderly in hospitals, nursing homes, or home settings, working in a University Hospital, teaching and research, and the size of the community in which the candidate practiced. Physicians from long‐term care settings did exceptionally well. Working in a solo practice setting was negatively correlated with performance on the examination as was working in a for‐profit setting.

GERIATRICS IN MANAGED CARE*: Essential Components of Geriatric Care Provided Through Health Maintenance Organizations The HMO Workgroup on Care Management

The rapid growth in the number of older adults enrolling in health maintenance organizations (HMO) presents a number of opportunities and challenges. Older HMO enrollees have needs that differ from those of younger enrollees, such as the medical conditions they face, their likelihood of having functional deficits, and differences in their living arrangements. In addition, their health‐related needs often extend beyond medical care and may include relationships with families, caregivers, and community agencies. This article describes the types of services that should realistically be available to older adults who are enrolled in an HMO with a Medicare risk contract in order to meet the goals of geriatric care: to promote health, independence, and optimal functioning, to prevent avoidable decline in health status, and to enhance quality of life. The findings are based on deliberations during the past year by the HMO Workgroup on Care Management, which was convened under the auspices of The Robert Wood Johnson Foundations national program, “Chronic Care Initiatives in HMOs.”

Assistive Technologies in the Home

Assistive technologies are critical to elders maintaining independence in the home. Adequate assessment of the patients needs, the appropriateness of the device to that need, and the patients motivation to use of a device is required for successful outcomes. A team approach is needed to ensure that devices are correctly prescribed, and the patient is taught how to use it effectively. A wide range of devices is available to support activities of daily living, mobility, home management, and safety. The use of personal computers is significantly expanding the possibility of independent living through support systems, monitoring systems, and information resources.

Guidelines Abstracted from the Department of Veterans Affairs/Department of Defense Clinical practice guideline for the management of stroke rehabilitation.

OBJECTIVES: To assist facilities in identifying those evidence‐based processes of poststroke care that enhance measurable patient outcomes. The guideline(s) should be used by facilities (hospitals, subacute‐care units and providers of long‐term care) to implement a structured approach to improve rehabilitative practices and by clinicians to determine best interventions to achieve improved patient outcomes.