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Randomized controlled trial of geriatric screening and surveillance in general practice

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Abstract

A randomized controlled trial of geriatric screening and surveillance was undertaken on a practice population of 295 patients aged 70 years or more over a two-year period. In the screened group (145 patients) many social problems were found and a total of 380 medical conditions were reported during the study period, 144 (38 per cent) of which were previously undetected. Conditions found most frequently involved the circulatory, musculoskeletal and nervous systems; 67 per cent of the conditions found were manageable, half being improved and the remainder resolved completely.The screening programme was found to increase the use of social and health services but it did also decrease the expected duration of stay in hospital.Independent assessment of patients in the study and control groups at the end of the two-year period showed that the screening programme had made no significant impact on the prevalence of socio-economic, functional, and medical disorders affecting health.We formed the firm impression that the study patients were made more comfortable (by control of pain) and less disabled, although there was no unequivocal objective evidence of this. They were, however, kept independent for longer.The findings are discussed and a model of geriatric care is suggested combining conventional management on demand with comprehensive screening to identify the high-risk patients on whom care might need to be focussed.

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... Tulloch and Moore conducted a RCT of geriatric screening and surveillance in general practice. (8) Home visits by nurses were offered to the entire 70 years and over population of a practice in Oxford, UK. Once exclusion criteria were applied (in nursing home, died or moved away and inadvertently still on practice list) 295 patients were included in the study. ...
... The independent evaluation, as part of the study, however showed that the program had "no significant impact on the prevalence of socio-economic, functional and medical disorders affecting health." (8) Vetter et al conducted a RCT of the usefulness of a health visitor finding problems in people aged 70 and over. (9) This was conducted in two practices: one rural (Powys) and one urban (Gwent), both in South Wales. ...
... RCTs have been performed in Great Britain (8,9,11,14,33), but are no longer possible. The obligation on all British GPs to offer annual 'health checks' to all people aged 75+ on their practice lists (15), precludes the establishment of a valid control group. ...
... In the UK the tradition of self assessment lies predominantly in the area of screening, being most notably apparent in the tradition of research enquiry. Examples include the General Health Questionnaire (GHQ) (Goldberg, 1972) which has been used in primary care (whilst waiting for the GP) and the various screening tools in primary care which were originally used for case-finding (Tulloch and Moore, 1979;Bowns et al., 1991). The use of such screening tools, however, still requires further interpretation and action, which are often linked to a subsequent secondstage assessment usually from a person with a professional qualification. ...
... Much of the literature on self assessment in the UK has focused on the use of casefinding in general practice and has been undertaken in a research enquiry tradition. Interest in this area grew out of early seminal work that found a high prevalence of previously asymptomatic and/or unreported remediable health problems in community-dwelling elderly people (Williamson et al., 1964;Thomas, 1968;Tulloch and Moore, 1979). Given the potential expense of mounting a comprehensive case finding and surveillance programme, most studies utilized a two stage strategy whereby a self-completed screening questionnaire identified those at highest risk, who then received a more comprehensive professional assessment (Bowns et al., 1991;Fletcher, 1998;Griffiths et al., 2005). ...
... Most studies of CGA have examined inpatient hospital care; few have been conducted in ambulatory care settings. 18,19 To the authors' knowledge, no study of CGA has included the outcome measures of quality of life, sense of security, or total cost of social and health care. The aim of this study was thus to compare costs and effects between participants with access to CGA at an ambulatory geriatric unit and a control group receiving usual care only. ...
... We have found only a few studies of the effects and outcomes of team-based care in an ambulatory setting as in ours. An early report by Tulloch and Moore 19 showed that more health and social services were provided to the intervention group due to the identification of medical or social conditions that would otherwise remain untreated, as in our study. Similarly, Weinberger et al 42 determined that active follow-up after hospitalization increased rather than decreased the rate of rehospitalization, due to the identification of previously undetected health problems in an older population with heart failure. ...
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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 At baseline there were no differences in baseline characteristics. 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). There was a tendency to lower mortality in the IG than in the CG (hazard ratio=1.51; 95% confidence interval, 0.988-2.310; P=0.057. 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 Although the AGU intervention did not reduce the number of hospitalizations, it significantly reduced the number of inpatient days. This might indicate that a systematic assessment and personalized multidisciplinary care is promising to improve outcomes without significantly affecting costs or quality of life negatively. These finding give new insights on the effectiveness of AGU and can help to plan future interventions for older people. The study is registered in Clinical Trials nr NCT01446757
... Most studies of CGA have examined inpatient hospital care; few have been conducted in ambulatory care settings. 18,19 To the authors' knowledge, no study of CGA has included the outcome measures of quality of life, sense of security, or total cost of social and health care. The aim of this study was thus to compare costs and effects between participants with access to CGA at an ambulatory geriatric unit and a control group receiving usual care only. ...
... We have found only a few studies of the effects and outcomes of team-based care in an ambulatory setting as in ours. An early report by Tulloch and Moore 19 showed that more health and social services were provided to the intervention group due to the identification of medical or social conditions that would otherwise remain untreated, as in our study. Similarly, Weinberger et al 42 determined that active follow-up after hospitalization increased rather than decreased the rate of rehospitalization, due to the identification of previously undetected health problems in an older population with heart failure. ...
... Most studies of CGA have examined inpatient hospital care; few have been conducted in ambulatory care settings. 18,19 To the authors' knowledge, no study of CGA has included the outcome measures of quality of life, sense of security, or total cost of social and health care. The aim of this study was thus to compare costs and effects between participants with access to CGA at an ambulatory geriatric unit and a control group receiving usual care only. ...
... We have found only a few studies of the effects and outcomes of team-based care in an ambulatory setting as in ours. An early report by Tulloch and Moore 19 showed that more health and social services were provided to the intervention group due to the identification of medical or social conditions that would otherwise remain untreated, as in our study. Similarly, Weinberger et al 42 determined that active follow-up after hospitalization increased rather than decreased the rate of rehospitalization, due to the identification of previously undetected health problems in an older population with heart failure. ...
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To examine costs and effects of care based on comprehensive geriatric assessment (CGA) provided by an ambulatory geriatric care unit (AGU) in addition to usual care. Assessor-blinded, single-center randomized controlled trial. AGU in an acute hospital in southeastern Sweden. Community-dwelling individuals aged 75 years or older 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 and randomized to the intervention group (IG; n = 208) or control group (CG; n = 174). Mean age (SD) was 82.5 (4.9) years. Participants in the IG received CGA-based care at the AGU in addition to usual care. The primary outcome was number of hospitalizations. Secondary outcomes were days in hospital and nursing home, mortality, cost of public health and social care, participant' sense of security in care, and health-related quality of life (HRQoL). Baseline characteristics did not differ between groups. The number of hospitalizations did not differ between the IG (2.1) and CG (2.4), but the number of inpatient days was lower in the IG (11.1 vs 15.2; P = .035). The IG showed trends of reduced mortality (hazard ratio 1.51; 95% confidence interval [CI] 0.988-2.310; P = .057) and an increased sense of security in care interaction. No difference in HRQoL was observed. Costs for the IG and CG were 33,371£ (39,947£) and 30,490£ (31,568£; P = .432). This study of CGA-based care was performed in an ambulatory care setting, in contrast to the greater part of studies of the effects of CGA, which have been conducted in hospital settings. This study confirms the superiority of this type of care to elderly people in terms of days in hospital and sense of security in care interaction and that a shift to more accessible care for older people with multimorbidity is possible without increasing costs. This study can aid the planning of future interventions for older people. clinicaltrials.gov identifier: NCT01446757. Copyright © 2015 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.
... [11,12] Another randomised study [13] suggested that health checks at 3-month interval resulted in reductions in mortality rate and duration of hospital stay. A study [14] also showed an apparent reduction in mortality and few studies [15,16] have shown improvements in morale. ...
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Background: The present study was undertaken to screen the employees of a tertiary care hospital aged ≥40 years to know their health status and to diagnose their new health problems. Methods: This cross-sectional, descriptive study was conducted with 487 employees of our hospital aged ≥40 years from November 2019 to February 2020. Study procedures included haemogram, fasting plasma glucose, fasting lipid profile, thyroid profile, renal function test, electrocardiogram (ECG) and abdominal ultrasound for both the genders. For female employees, additionally, mammograms and pap smears were performed. Results: A total of 487 hospital employees were studied. 43.5% were overweight and 17.0% were obese. Of these, 2.8% had abnormal ECG findings. A total of 131 (26.9%) new medical problems were detected. Among these, anaemia (8.0%), hypertriglyceridaemia (5.1%), hypothyroidism (4.5%), hypertension (4.1%) and diabetes mellitus (2.7%) constituted the major diseases. Conclusions: This study has proved that the general health check-ups are important to diagnose minor to major health problems at early stages and to treat them properly to cure the problem or to prolong the advancement of the disease.
... Most of this work lies in the area of screening. Examples include the GHQ (Goldberg, 1972) which was used originally in primary care (while waiting for the general practitioner) and the various screening tools in primary care which were for case finding (Tulloch and Moore, 1979;Bowns et al., 1991). Critics of selfassessment are concerned that it will lead to under-reporting of need (Williamson, 1981;Ford and Taylor, 1983). ...
... As pessoas idosas, ao contrário do que habitualmente se pensa, tendem a ocultar queixas importantes: muitas vezes associam essas queixas ao próprio envelhecimento ou têm alterações cognitivas ou depressivas que comprometem a consciência ou a verbalização das mesmas. 18,24 Por outro lado, os médicos, às vezes, também interpretam algumas destas queixas como parte do processo de envelhecimento, desvalorizando ou adiando a sua resolução. 18 Por isso, Freer defende que os cuidados preventivos a prestar a esta população devem ter em consideração as necessidades não reportadas. ...
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Aging of the population has implications for society in general and health systems in particular. The enhancement of function and autonomy in old age should guide the provision of health care to this group. Concealment of complaints, which may lead the doctor to miss important health problems, is one of the problems of clinical evaluation in older patients. A structured assessment of health needs may contribute to a better identification of problems linked to functional deterioration. Studies conducted in many countries have identified five key areas for assessment of the needs of the elderly in primary care: vision and hearing, mobility and falls, incontinence, memory, and emotional distress. A systematic evaluation of these areas may contribute to the early detection of risk factors that lead to functional decline, affecting the quality of life of these patients. Feasibility studies of routine needs assessment of the elderly in general practice are warranted.
... As noted elsewhere, this is at variance with approaches in health settings, which in the UK, for example, have traditionally related to the area of screening for further enquiry. Examples include the General Health Questionnaire (GHQ) (Goldberg, 1972) which was used in primary care (whilst waiting for the GP) and the various screening tools in primary care which were originally used for case-finding (Tulloch and Moore, 1979;Bowns et al., 1991). In this study the opportunity for using self-assessment as a means of checking pre-client status has therefore not been demonstrated. ...
... In Bicester, trained volunteers visited the over 75s at home to give health education and to brief them about benefits and entitlements, as well as helping them to complete the health and social questionnaire. 7 In Cirencester trained volunteers were introduced after the community health visitor and nurse had assessed the patient as disabled and vulnerable. 8 They follow-up these patients with a 3-monthly assessment using the Winchester Questionnaire, which stratified disability into low, medium, and high. ...
Article
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In the December issue Iliffe1 assured us that our article ‘anticipatory care of older patients represented the triumph of hope over experience’.2 We find this a bewildering claim in view of the extensive research evidence to the contrary. No less than six controlled trials between 1979 and 1993 showed that a programme of care, tailored to the special needs of those in advanced old age, reduced the time spent in institutional care (hospitals and nursing homes). They …
... In Bicester, trained volunteers visited the over 75s at home to give health education and to brief them about benefits and entitlements, as well as helping them to complete the health and social questionnaire. 7 In Cirencester trained volunteers were introduced after the community health visitor and nurse had assessed the patient as disabled and vulnerable. 8 They follow-up these patients with a 3-monthly assessment using the Winchester Questionnaire, which stratified disability into low, medium, and high. ...
Article
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The projected doubling of the >75-year-old population in the next 20 years presents a major challenge.1 While standards of care in general practice have risen steadily over the past 30 years, for vulnerable older people the picture is different. The term ‘vulnerable’ covers multimorbidity, functional incapacity, and socioeconomic and psychological problems severe enough to put the patients at significantly increased risk of hospital and institutional admission. Routine GP surgery sessions alone are inadequate to assess complex comorbidity, polypharmacy, and adherence, in addition to reviewing disabilities and carer pressure. At the age of 75 years, patients will have, on average, three medical disorders. At least one-quarter will have a significant level of functional disability, rising exponentially with increasing age, and they will often have socioeconomic and psychological problems which loom larger in advanced old age. It is vital that all these problems are addressed if the patient’s needs are to be adequately met. We challenge primary care to develop cost-effective ways to integrate population scanning of the older population, most logically for those over the age of 75 years, leading to risk stratification and a coordinated primary care and community response. Community programmes, working with primary care, are also needed to reduce behavioural risks such as smoking cessation as well as encourage exercise and give dietary advice. In our own practices we valued cooperative work with trained volunteers.2 De Maeseneer, argued that ‘practices integrate individual and population-based care, blending the clinical skills of practitioners with epidemiology, preventive medicine and health promotion’.3 The first requirement may be to change the mindset, from student level into practice, of some GPs in their management of vulnerable older people; recognising that they require a different programme of care geared to …
... In Bicester, trained volunteers visited the over 75s at home to give health education and to brief them about benefits and entitlements, as well as helping them to complete the health and social questionnaire. 7 In Cirencester trained volunteers were introduced after the community health visitor and nurse had assessed the patient as disabled and vulnerable. 8 They follow-up these patients with a 3-monthly assessment using the Winchester Questionnaire, which stratified disability into low, medium, and high. ...
Article
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We contest D’Souza and Guptha’s claim that “no convincing evidence exists that increases in the provision of community services reduce the length of stay for frail older people.”1 There are two commonly used markers of the effectiveness of such programmes in older patients—the number of institutional referrals and time spent in institutional care. The ultimate objective of care in this field is to keep these vulnerable old people active and independent for as long as possible. Thus, the effectiveness of these measures is best reflected by reductions in the number of bed days of institutional care rather than the number of institutional referrals. The authors …
... Hanger & Sainsbury (1990) in a study population of204 aged 65 and over from a city suburb in New Zealand, demonstrated that 99% of the study 52 53 population had a concern or risk, of which 66% were unrecognized. Over a period of two years, Tulloch & Moore (1979) in a practice population of295 patients aged 70 years and over, found many social problems and a total of380 medical conditions, of which 144 (38%) were undetected. Many of these concerns have the potential to increase health care expenditures if left undetected and, therefore, untreated. ...
Article
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Objectives. (1) Develop, implement and evaluate a new model for delivering services to frail seniors, focussing on health promotion and preventive care provided by a Registered Nurse within the context of home care services. (2) Provide information on the health outcomes and costs associated with existing policies regarding the provision of preventive home care services for frail seniors living at home. (3) Provide scientific support for the role of a Registered Nurse in health promotion and preventive care within the context of home care services. ^ Intervention. Proactive health promotion and preventive care provided by a Registered Nurse for frail elderly home care clients eligible for personal support services. The intervention consisted of a minimum of one contact (primarily home visits) per month by an RN over a 6-month period. ^ Research design. Randomized controlled trial with baseline (pre-randomization) and 6 month follow-up and outcome assessment. ^ Sample and setting. 94 individuals (44 experimental, 50 controls) 75 years and older newly referred to and eligible for personal support services through a home care programme in Southern Ontario, Canada. ^ Results. Clinically and statistically significant improvements in physical and mental health functioning and increased level of perceived social support for clients was associated with the study intervention at no additional expense from a societal perspective. There was an economically important difference in the use of acute hospitalization in the intervention group compared to usual care which translates into an annual cost saving of $200,879 within 1 year for every 100 elderly home care clients. ^ Implications. Under the current home care delivery system, this study demonstrates that it is more effective and no more expensive to provide proactive RN health promotion to a general population of frail seniors than to provide professional services on a reactive and piecemeal basis. ^
... This view leads naturally from the psychological to the social component of psychosocial epidemiology. Here the emphasis is on what, over and above the formal increase in failing faculties, has been called ' the real pathology of old age... pain, disablement, frustration, boredom, lack of purpose, and loss of identity and self-respect, all of which lead to dissatisfaction with the quality of life' (Tulloch & Moore, 1979). Most of these features have been confirmed by recent surveys of old people, and many of the problems are summarized in the so-called 'environmental docility' hypothesis, according to which: 'As the competence of the individual decreases, the proportion of behaviour attributable to environmental as compared with personal characteristics increases' (Amann, 1982). ...
... hospitalization and nursing home placement (Kennie, 1986;Roos & Shapiro, 1981;Somers, 1984). As a result, several studies of screening and case finding among elderly persons have been conducted in an attempt to proactively identify and address problems to reduce the use of costly resources later (Brown, Boot, Groom, & Williams, 1997;Caulfield et al., 1986;Hanger & Sainsbury, 1990;Hay, Browne, Roberts, & Jamieson,1995;Ramsdell, Swart, Jackson, & Renvall, 1989;Stuck, Mayer-Oakes, & Rubenstein, 1993a;Tulloch & Moore, 1979). ...
... La valoración geriátrica global identifica y cuantifica los problemas de los ancianos para posteriormente ofrecerles tratamiento e implementar acciones de prevención [11][12][13] . La evaluación global se ha estudiado en ensayos clínicos, con resultados heterogéneos, y todavía existe incertidumbre sobre cuál es el método óptimo para realizar un cribado inicial [14][15][16] . Smeeth et al 17 , en un reciente ensayo clínico realizado en Inglaterra, compararon diversos métodos de administración de un cuestionario de evaluación en ancianos. ...
Article
Objective To assess the response rate to a multidimensional, self administered questionnaire in patients ≥75 years old attending a primary health care center and to establish the prevalences of problems in the following dimensions: socioeconomical, cognitive, morbidity, polypharmacy, physical activity, falls, and activities of the daily living. Design Cross-sectional descriptive study based on a self-administered questionnaire posted by mail. Setting A primary health care center in Barcelona. Spain. Participants A total of 1299 patients ≥75 years old. Main measurements Social surroundings, activities of the daily living, sensorial problems, morbidity, physical symptoms including sphincter's incontinence, cognitive status, and medication use. Results The response rate was 68% (95% CI, 0.65-0.70). The average age of the women who participated was significantly greater than the one of the men (82.5±5.3 vs 81.6±5.0, respectively). A significantly greater proportion of women than of men lived single (38.2 vs 10.9%); they had difficulties to maintain its house cosy (15.6 vs 8.8%) and they had difficulties to make ends meet (18.0 vs 13.6%). Globally, there were a greater proportion of women than of men whom they had: medical problems, cognitive problems, depression, and difficulties to carry out activities of the daily living. Overall, subjects that have had difficulties to make ends meet had greater prevalences of problems in all the dimensions of this evaluation. On the other hand, subjects that lived single had lower prevalences of problems in all the dimensions except they had a greater prevalence of depression. Conclusion The multidimensional evaluation in elderly patients by the postal method is an efficient procedure that allows identifying many socioeconomic and health problems. In addition, it is feasible to identify to most fragile subjects and latter on to carry out preventive and curative interventions on them as well as to make their follow up.
... In Bicester, trained volunteers visited the over 75s at home to give health education and to brief them about benefits and entitlements, as well as helping them to complete the health and social questionnaire. 7 In Cirencester trained volunteers were introduced after the community health visitor and nurse had assessed the patient as disabled and vulnerable. 8 They follow-up these patients with a 3-monthly assessment using the Winchester Questionnaire, which stratified disability into low, medium, and high. ...
... Pero tal vez sean las diferencias sanitarias en los diferentes países lo que desempeñe un papel más relevante al comparar resultados y efectividad de las intervenciones. En general, los resultados parecen demostrar un aumento de la supervivencia 18,25,28,29 , disminución de las admisiones y estancia media hospitalarias y en sus urgencias 14,20,21,[24][25][26]28,30 , de la institucionalización definitiva 22,[25][26] , mejor funcionalidad y retraso de la incapacidad 5,8,10,[13][14][16][17]22 , satisfacción con la intervención 12,18-,19,21 , disminución de los costes económicos globales o beneficio coste-efectividad 5,11,18,19,21,24,28 . Algunos estudios refieren resultados más específicos, según su contenido, como son aumento en la cobertura de inmunizaciones 6,7,23 y disminución en el consumo de medicamentos 14,23 , de caídas 26 o en la percepción de sobrecarga por parte de los cuidadores 4 . ...
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Background: Visual problems in older people are common and frequently under-reported. The effects of poor vision in older people are wide reaching and include falls, confusion and reduced quality of life. Much of the visual impairment in older ages can be treated (e.g. cataract surgery, correction of refractive error). Vision screening may therefore reduce the number of older people living with sight loss. Objectives: The objective of this review was to assess the effects on vision of community vision screening of older people for visual impairment. Search methods: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Trials Register) (2017, Issue 10); Ovid MEDLINE; Ovid Embase; the ISRCTN registry; ClinicalTrials.gov and the ICTRP. The date of the search was 23 November 2017. Selection criteria: We included randomised controlled trials (RCTs) that compared vision screening alone or as part of a multi-component screening package as compared to no vision screening or standard care, on the vision of people aged 65 years or over in a community setting. We included trials that used self-reported visual problems or visual acuity testing as the screening tool. Data collection and analysis: We used standard methods expected by Cochrane. We graded the certainty of the evidence using GRADE. Main results: Visual outcome data were available for 10,608 people in 10 trials. Four trials took place in the UK, two in Australia, two in the United States and two in the Netherlands. Length of follow-up ranged from one to five years. Three of these studies were cluster-randomised trials whereby general practitioners or family physicians were randomly allocated to undertake vision screening or no vision screening. All studies were funded by government agencies. Overall we judged the studies to be at low risk of bias and only downgraded the certainty of the evidence (GRADE) for imprecision.Seven trials compared vision screening as part of a multi-component screening versus no screening. Six of these studies used self-reported vision as both screening tool and outcome measure, but did not directly measure vision. One study used a combination of self-reported vision and visual acuity measurement: participants reporting vision problems at screening were treated by the attending doctor, referred to an eye care specialist or given information about resources that were available to assist with poor vision. There was a similar risk of "not seeing well" at follow-up in people screened compared with people not screened in meta-analysis of six studies (risk ratio (RR) 1.05, 95% confidence interval (CI) 0.97 to 1.14, 4522 participants high-certainty evidence). One trial reported "improvement in vision" and this occurred slightly less frequently in the screened group (RR 0.85, 95% CI 0.52 to 1.40, 230 participants, moderate-certainty evidence).Two trials compared vision screening (visual acuity testing) alone with no vision screening. In one study, distance visual acuity was similar in the two groups at follow-up (mean difference (MD) 0.02 logMAR, 95% CI -0.02 to 0.05, 532 participants, high-certainty evidence). There was also little difference in near acuity (MD 0.02 logMAR, 95% CI -0.03 to 0.07, 532 participants, high-certainty evidence). There was no evidence of any important difference in quality of life (MD -0.06 National Eye Institute 25-item visual function questionnaire (VFQ-25) score adjusted for baseline VFQ-25 score, 95% CI -2.3 to 1.1, 532 participants, high-certainty evidence). The other study could not be included in the data analysis as the number of participants in each of the arms at follow-up could not be determined. However the authors stated that there was no significant difference in mean visual acuity in participants who had visual acuity assessed at baseline (39 letters) as compared to those who did not have their visual acuity assessed (35 letters, P = 0.25, 121 participants).One trial compared a detailed health assessment including measurement of visual acuity (intervention) with a brief health assessment including one question about vision (standard care). People given the detailed health assessment had a similar risk of visual impairment (visual acuity worse than 6/18 in either eye) at follow-up compared with people given the brief assessment (RR 1.07, 95% CI 0.84 to 1.36, 1807 participants, moderate-certainty evidence). The mean composite score of the VFQ-25 was 86.0 in the group that underwent visual acuity screening compared with 85.6 in the standard care group, a difference of 0.40 (95% CI -1.70 to 2.50, 1807 participants, high-certainty evidence). Authors' conclusions: The evidence from RCTs undertaken to date does not support vision screening for older people living independently in a community setting, whether in isolation or as part of a multi-component screening package. This is true for screening programmes involving questions about visual problems, or direct measurements of visual acuity.The most likely reason for this negative review is that the populations within the trials often did not take up the offered intervention as a result of the vision screening and large proportions of those who did not have vision screening appeared to seek their own intervention. Also, trials that use questions about vision have a lower sensitivity and specificity than formal visual acuity testing. Given the importance of visual impairment among older people, further research into strategies to improve vision of older people is needed. The effectiveness of an optimised primary care-based screening intervention that overcomes possible factors contributing to the observed lack of benefit in trials to date warrants assessment; trials should consider including more dependent participants, rather than those living independently in the community.
Article
Ein höheres Lebensalter geht meist mit Multimorbidität aufgrund chronischer Erkrankungen einher. Intermittierend kommen akute Erkrankungen und oft auch Exazerbationen bestehender chronischer Leiden hinzu. Physische und psychische degenerative Erkrankungen bestehen dabei häufig parallel. Heilung im klassischen Sinne kann meist nicht das diagnostische und therapeutische Ziel sein, sodass eine Priorisierung im Sinne der Patientenorientierung wichtig ist. Dies betrifft auch die Multimedikation, die die Multimorbidität meist begleitet. Das therapeutische Handeln und die angestrebten Endpunkte sind anders, da oft nicht das Überleben, sondern der Erhalt der Funktionalität und damit der Selbstständigkeit das Primat darstellt. Rehabilitative Ansätze sind deshalb überall dort angezeigt, wo betagte und hochbetagte Menschen betreut werden. Bei all dem spielt auch eine Rolle, dass betagte oder hochbetagte Menschen wie auch ihre (pflegenden) Angehörigen meist andere Zeit- und Zielgrößen haben.
Chapter
Our concepts of the place of the elderly in the health care system tend to be very much influenced by the arrangements which prevail in our own particular countries. These differences owe less to rational planning than to our respective social, political and economic histories and to the varying degree to which the whims and power of the medical profession have been harnessed to the real needs of the population they should be serving. Provision for the elderly has also further varied according to the way the responsibility has been shared between health, social services and private care. The experience which unites most of us has been the inadequate and delayed priority afforded to the elderly in the face of the eminently foreseeable demographic changes.
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The review allows the following conclusions: 1. Some form of geriatric assessment appear beneficial for older cancer patients; this assessment may allow to estimate life-expectancy and tolerance of treatment, to reveal reversible conditions that may influence the treatment, and to provide a common language to classify older individuals in clinical practice and clinical trials. The geriatric assessment is also the background of any decision analysis related to the study and the management of older patients, capable to accommodate new insights in the biology of cancer and aging and to address problems related to the management of specific diseases. 2. Some age related changes may affect the pharmacology of antineoplastic agents in the majority of older individuals and justify some general guidelines for the administration of chemotherapy that include: Adjustment of the doses of the first chemotherapy to the glomerular filtration rate in individuals aged 65 and older. If no toxicity is observed, the following doses should be increased to prevent under-treatment Prophylactic use of filgrastim or pegfilgrastim in patients aged 65 and older receiving chemotherapy of moderate dose intensity, comparable to CHOP Maintenance of the hemoglobin of patients receiving chemotherapy at 12 gm/dl or higher Aggressive management of mucositis with timely fluid resuscitation Prevention of mucositis by substituting capecitabine for intravenous fluorinated pyrimidine Specific guidelines for the management of individual diseases may be necessary as illustrated. The geriatric assessment may provide the framework of reference to estimate benefits and risks.
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The general approach to prevention in elderly patients differs from that for younger patients. In the elderly, most of the preventive activites performed by family physicians are tertiary. Prevention and cure of disease often overlap. The major health problem in elderly patients is the development of progressive incapacity. The evaluation of risk factors for this condition is the principal purpose of the periodic health examination of these patients. This article summarizes the principal recommendations for the periodic health examination of the elderly and discusses barriers to their implementation.
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In zahlreichen deskriptiven Untersuchungen wurde über eine verbesserte Diagnostik und Therapie mit Steigerung der körperlichen und geistigen Leistungsfähigkeit bei alten, gebrechlichen Personen berichtet [6,9,23,24,27,30,40]. Erst in den letzten Jahren jedoch wurden auch randomisierte Studien zur Effektivität des geriatrischen Assessments durchgeführt.
Chapter
Die Vielschichtigkeit der Erkrankungen und die daraus resultierenden Probleme machen eine Diagnostik, Beurteilung und Behandlung im interdisziplinären Team erforderlich. Die Zusammensetzung der Arbeitsgruppe hängt von den strukturellen Bedingungen, der Auswahl der Patienten und den Behandlungszielen ab. Typischer-weise besteht das Kernteam aus einem Arzt, Krankenpfleger und Sozialarbeiter [21]. Es wird je nach Anforderung ergänzt durch Krankengymnasten, Ergotherapeuten, Logopäden, Psychologen, Seelsorger, Ernährungsberater.
Chapter
Previous chapters in this section have described the views of the individual professional groups that make up the multidisciplinary team.
Chapter
Diagnostisch sind bei älteren und sehr alten Menschen einige Charakteristika zu berücksichtigen. Nicht selten besteht eine erstaunliche Gelassenheit bis Indolenz von Patienten, gelegentlich auch deren familiären Umfelds, was gesundheitliche Veränderungen anbelangt. Der „Gesundheitsoptimismus“ alt gewordener Menschen korrespondierte in zahlreichen Untersuchungen mit positiver Selbsteinschätzung des Gesundheitszustands. Im Extremfall erreicht diese „Zufriedenheit“ das Ausmaß ausgeprägter Selbstvernachlässigung. Als Diogenes-Syndrom mit der Folge katastrophaler Verwahrlosung wurde dies 1975 erstmals als geriatrische Entität beschrieben [3]. Positive Selbsteinschätzung kann dazu verleiten, wichtige Befunde zu übersehen. Dieses Risiko nimmt bei Multimorbidität, dem Vorliegen mehrerer Erkrankungen zu [27] und steigt deshalb auch mit höherem Lebensalter [20]. Aufgrund der Chronizität vieler Erkrankungen werden Exazerbationen selbstverständlich erwartet, neu hinzukommende Störungen und Symptome jedoch gerade bei lang bekannten Patienten schwieriger erkannt oder verpasst.
Chapter
Ein 72jähriger litt zu gleicher Zeit an folgenden Affektionen: Hypertonie, Herzfehler (Kardiosklerose) mit tachykardem Vorhofflimmern und kardiovaskulärer Dekompensation, Angina pectoris, infektiöse Bronchitis, chronische Zystitis bei Prostatahypertrophie II. Grades, mäßiger Diabetes mellitus mit Pruritis, Morbus Parkinson mit Neigung zu seelischen Depressionen und Schlaflosigkeit. Diese Leiden können nicht gleichzeitig mit etwa 10 Medikamenten pro Tag behandelt werden. Die das gesamte Krankheitsbild beherrschende Herzinsuffizienz besserte sich in wenigen Tagen nach oralen Gaben von Digitoxin, wobei auch die Schlaflosigkeit zurückging (1. Medikament). Von einer intensiven diuretischen Therapie, z. B. mit Furosemidpräparaten, haben wir wegen der Gefahr der Überlaufblase bei fortgeschrittener Prostatahypertrophie Abstand genommen. Die diätetisch nicht ganz einstellbare Zuckerkrankheit sprach auf kleine Dosen von Glibenclamid unter Beachtung des Hyperglykämien gut an (2. Medikament). Die gleichzeitig bestehende chronische Zystitis haben wir — entsprechend dem bakteriologischen Harnbefund — mit langfristigen Gaben eines Sulfonamidpräparats (Trimethoprim+Sulfamethoxazol) beherrscht (3. Medikament). Die Zystitistherapie mit Gentamycin ist wegen der Gefahr der Hörschädigung bei meist bestehender Altersschwerhörigkeit kontraindiziert. Da das Hautjucken, das sich auf die eingeleitete Diabetesbehandlung hin nur wenig besserte, wandten wir mit gewissem Erfolg antipruriginöse Salben (4. Medikament) an. Auf eine orale Behandlung mit Kortisonpräparaten sollte man in Anbetracht der damit verbundenen Osteoporosegefährdung bei Betagten verzichten: auch vermieden wir, den gleichzeitig bestehenden Morbus Parkinson mit den üblichen anticholinergischen Pharmaka wegen der Gefahr der Blasenatonie bei fortgeschrittener Prostatahypertrophie anzugehen. Erst Wochen später konnte die Parkinsonsymptomatik mit kleinen Dosen Bromocriptin (5. Medikament) beherrscht werden (Franke 1984).
Chapter
Eine 75jährige Frau ist Scit 3 Jahrzehnten wegen einer Querschnittslähmung an den Rollstuhl gefesselt. Obwohl sie mit viel Energie gegen diese Behinderung ankämpft, ist sie bei vielen Verrichtungen auf ihre Tochter angewiesen, z. B. beim Baden, beim Haarewaschen oder bei der Fußpflege. Da sie durch das Beklopfen der Blase selbständig eine regelmäßige Miktion erreichen kann, ist sie kontinent. Sie braucht jedoch wegen ihrer eingeschränkten Beweglichkeit beim Säubern auf der Toilette Hilfe. In ihrer Wohnung sind die Türen verbreitert und Rampen eingebaut, so daß sie hier voll mobil ist. In der Küche sind die Arbeitsflächen auf die Höhe einer Rollstuhlfahrerin eingerichtet, so daß sie sich trotz einer zusätzlich schlechten Sehfähigkeit ein Essen warm machen und das Geschirr spülen kann.
Chapter
Full-text available
Comprehensive geriatric assessment is a multidimensional, often interdisciplinary diagnostic process designed to define an elderly individual’s medical, psychosocial, and functional capabilities and problems to arrive at an overall plan for therapy and long-term follow-up. While comprehensive clinical assessment methodologies have benefited nonelderly groups of patients as well, multidimensional assessment has asssumed a key role in geriatric care because the delicate complexity of the typical frail elderly patient demands multidimensional diagnosis to attain both a reasonable understanding of the patient’s problems and a prudent plan of treatment.
Chapter
This chapter provides background information on geriatric assessment for hospitalists through a framework for geriatric assessment. It presents a brief review of evidence regarding comprehensive geriatric assessment (CGA). The chapter also provides specific recommendations for applying geriatric assessment in daily practice in hospital medical services. The routine application of geriatric assessment among high‐risk older patients to identify hidden morbidities can substantially improve care and care coordination among older adults. Based on the results of the Hospitalized Elder Life Program (HELP) trials and the success of Acute Care for Elders (ACE) units, the Society of Hospital Medicine , the American Geriatrics Society, and the British Geriatrics Society recommend routine assessment of high‐risk older patients' cognitive and functional status at hospital admission, periodically during the hospital stay, and at discharge.
Article
Objective: to examine the relationship between incontinence and mortality in elderly people living at home. Design: of the randomly selected people aged 65 years and older living in Settsu city, Osaka in October 1992, 1405 were contacted and constituted the study cohort. Follow-up for 42 months was completed for 1318 (93.8%; 1129 alive, 189 dead). Measures: data on general health status, history of health management, psychosocial conditions and urinary and faecal incontinence were collected by interview during home visits at the time of enrolment. Results: from the Kaplan‐Meier analysis, the estimated survival rates decreased with a decline in continence in both the 65‐74 and 75 years and older age groups. From the Cox proportional hazards model, unadjusted hazard ratios of minor, moderate and severe incontinence for mortality, compared with continence, were 2.27, 2.96 and 5.94, respectively. Multivariate analysis yielded adjusted hazard ratios of minor, moderate and severe incontinence of 0.99, 1.17 and 1.91, respectively, leaving severe incontinence as the significant factor, when other indicators are controlled. Conclusions: incontinence is related to mortality and severe incontinence represents an increased risk factor for mortality in elderly people living at home.
Article
Objective: To assess the effects of preventive home visits to elderly people living in the community. Design: Systematic review. Setting: 15 trials retrieved from Medline, Embase, and the Cochrane controlled trial register. Main outcome measures: Physical function, psychosocial function, falls, admissions to institutions, and mortality. Results: Considerable differences in the methodological quality of the 15 trials were found, but in general the quality was considered adequate. Favourable effects of the home visits were observed in 5 out of 12 trials measuring physical functioning, 1 out of 8 measuring psychosocial function, 2 out of 6 measuring falls, 2 out of 7 measuring admissions to institutions, and 3 of 13 measuring mortality. None of the trials reported negative effects. Conclusions: No clear evidence was found in favour of the effectiveness of preventive home visits to elderly people living in the community. It seems essential that the effectiveness of such visits is improved, but if this cannot be achieved consideration should be given to discontinuing these visits.
Article
OBJECTIVE: To describe the development and operation of a practical model of outpatient geriatric evaluation and management (GEM) for high-risk, community-dwelling older adults.PARTICIPANTS: Community-dwelling Medicare beneficiaries age 70 years and older who were medically stable but had a high probability of repeated admission to hospitals (Pra > .40) in the future (n = 248).INTERVENTION: Outpatient GEM.MEASUREMENTS: Demographic, clinical, and use-of-hospital characteristics of patients; nature and quantity of GEM services; satisfaction of patients and their established primary physicians.RESULTS: At enrollment, the average patient was 78.7 years old, took 5.0 long-term prescription medications and was unable to perform 0.5 (of six) activities of daily living (ADL) and 1.4 (of seven) instrumental ADL. Many patients (71.3%) reported hospital days during the previous year. Each of three interdisciplinary teams (geriatrician, gerontological nurse practitioner, nurse and social worker) performed comprehensive assessments and then provided primary care and case management to a case load of 45 to 52 patients. On average, GEM required 6 months, during which patients visited the GEM clinic 7.4 times, had 10.4 active problems addressed, spoke to GEM staff members weekly by telephone, and were referred to two other providers. Most patients (94.4%) completed the GEM program; 66.7% completed advance directives. Satisfaction with GEM was high among the patients and their established primary physicians. The cost of the GEM personnel averaged about $1540 per patient treated.
Article
The Australian Capital Territory (ACT) community health service successfully introduced a single point of entry and single assessment process for its community health services at the same time as the ACT government moved to outcomes-based funding. This article discusses an attempt to measure the outcomes of the single assessment process, which was part of a larger study to explore the practicalities of routine outcomes measurement in clinical practice. The aim was to investigate whether it is possible to introduce routine outcome measures for an assessment and complex intervention. A quasi-experimental design was developed, which involved the 3-month follow-up of all patients who underwent an assessment during a single month. Outcome measures included the Dartmouth Primary Care Cooperative Information Project (COOP) charts and achievement of patient goals. While the quantifiable outcomes improved slightly across some domains, one third of the participants developed new needs over the 3-month follow-up period. While the Dartmouth COOP charts were easy to use in this setting, rates of adherence to the tool were low, and the tool provided less valuable information than simply asking the clients whether they had achieved their goals. As a result of the project, the service introduced routine 3-month telephone follow-up to ascertain changes in health-care needs and the achievement of client goals. This study highlights the dynamic nature of older people’s needs and the need for ongoing monitoring and care, rather than a snap-shot assessment of outcomes, and makes recommendations for services attempting to introduce a comprehensive assessment process.
Article
Full-text available
BACKGROUND Home visits by health and social care professionals aim to prevent cognitive and functional impairment, thus reducing institutionalisation and prolonging life. Visitors may provide health information, investigate untreated or sub-optimally treated problems, encourage compliance with medical care, and provide referrals to services. Previous reviews have reached varying conclusions about their effectiveness. This review sought to assess the effectiveness of preventive home visits for older adults (65+ years) and to identify factors that may moderate effects. OBJECTIVES To systematically review evidence on the effectiveness of preventive home visits for older adults, and to identify factors that may moderate effects. SEARCH STRATEGY We searched the following electronic databases through December 2012 without language restrictions: British Nursing Index and Archive, C2-SPECTR, CINAHL, CENTRAL, EMBASE, IBSS, Medline, Nursing Full Text Plus, PsycINFO, and Sociological Abstracts. Reference lists from previous reviews and from included studies were also examined. SELECTION CRITERIA We included randomised controlled trials enrolling persons without dementia aged over 65 years and living at home. Interventions included visits at home by a health or social care professional that were not directly related to recent hospital discharge. Interventions were compared to usual care, wait-list, or attention controls. DATA COLLECTION AND ANALYSIS Two authors independently extracted data from included studies in pre-specified domains, assessed risk of bias using the Cochrane Risk of Bias tool, and rated the quality of evidence using GRADE criteria. Outcomes were pooled using random effects models. We analyzed effects on mortality, institutionalization, hospitalization, falls, injuries, physical functioning, cognitive functioning, quality of life, and psychiatric illness. RESULTS Sixty-four studies with 28642 participants were included. There was high quality evidence that home visits did not reduce absolute mortality at longest follow-up (Risk ratio=0.93 [0.87 to 0.99]; Risk difference=0.00 [-0.01 to 0.00]). There was moderate quality evidence of no clinically or statistically significant overall effect on the number of people who were institutionalised (Risk ratio=1.02 [0.88, 1.18]) or hospitalised (Risk ratio=0.96 [0.91, 1.01]) during the studies. There was high quality evidence of no statistically significant effect on the number of people who fell (Odds ratio=0.86 [0.73, 1.01]). There was low quality evidence of statistically significant effects for quality of life (Standardised mean difference=-0.06 [-0.11, -0.01]) and very low quality evidence of statistically significant effects for functioning (SMD=-0.10 [-0.17, -0.03]), but these overall effects may not be clinically significant. However, there was heterogeneity in settings, types of visitor, focus of visits, and control groups. We cannot exclude the possibility that some programmes were associated with meaningful benefits. AUTHORS’ CONCLUSIONS We were unable to identify reliable effects of home visits overall or in any subset of the studies in this review. It is possible that some home visiting programmes have beneficial effects for community-dwelling older adults, but poor reporting of how interventions and comparisons were implemented prevents more robust conclusions. While it is difficult to draw firm conclusions given these limitations, estimates of treatment effects are statistically precise, and further small studies of multi-component interventions compared with usual care would be unlikely to change the conclusions of this review. If researchers continue to evaluate these types of interventions, they should begin with a clear theory of change, clearly describe the programme theory of change and implementation, and report all outcomes measured.
Article
Full-text available
Home visits for older adults aim to prevent cognitive and functional impairment, thus reducing institutionalization and mortality. Visitors may provide information, investigate untreated problems, encourage medication compliance, and provide referrals to services. Data Sources: Ten databases including CENTRAL and Medline searched through December 2012. Study Selection: Randomized controlled trials enrolling community-dwelling persons without dementia aged over 65 years. Interventions included visits at home by a health or social care professional that were not related to hospital discharge. Data Extraction and Synthesis: Two authors independently extracted data. Outcomes were pooled using random effects. Main Outcomes and Measures: Mortality, institutionalization, hospitalization, falls, injuries, physical functioning, cognitive functioning, quality of life, and psychiatric illness. Sixty-four studies with 28642 participants were included. Home visits were not associated with absolute reductions in mortality at longest follow-up, but some programs may have small relative effects (relative risk = 0.93 [0.87 to 0.99]; absolute risk = 0.00 [-0.01 to 0.00]). There was moderate quality evidence of no overall effect on the number of people institutionalized (RR = 1.02 [0.88 to 1.18]) or hospitalized (RR = 0.96 [0.91 to 1.01]). There was high quality evidence for number of people who fell, which is consistent with no effect or a small effect (odds ratio = 0.86 [0.73 to 1.01]), but there was no evidence that these interventions increased independent living. There was low and very low quality evidence of effects for quality of life (standardised mean difference = -0.06 [-0.11 to -0.01]) and physical functioning (SMD = -0.10 [-0.17 to -0.03]) respectively, but these may not be clinically important. Home visiting is not consistently associated with differences in mortality or independent living, and investigations of heterogeneity did not identify any programs that are associated with consistent benefits. Due to poor reporting of intervention components and delivery, we cannot exclude the possibility that some programs may be effective.
Article
Purpose: The long-term effectiveness and efficiency of an outpatient geriatric evaluation and management (GEM) program was compared to usual primary care (UPC). Design and Method: A randomized controlled group design was used. Health care utilization, cost of care, and survival were assessed during a 48-month period among a sample of 160 male veterans age 55 and over who were above-average users of outpatient services. Results: The results indicate that GEM patients incurred significantly lower overall health care costs than UPC patients by 24 months and that cost savings plateaued during the 24- to 48-month period. Cost savings were due primarily to fewer hospital days of care. No significant differences were found in survival. Implications: Results of this follow-up study suggest that outpatient GEMoffers a specialized health delivery option for frail older persons that may reduce costs over the long term without having a negative impact on survival rates.
Article
Objective Self-assessment has been advocated in community care but little is known of its cost effectiveness in practice. We evaluated cost effectiveness of pilot self-assessment approaches. Methods Data were collected from 13 pilot projects in England, selected by central government, between October 2006 and November 2007. These were located within preventative services for people with low-level needs, occupational therapy, or assessment and care management. Cost effectiveness, over usual care, was assessed by incremental cost-effectiveness ratios (ICERs), in British pounds per unit gain in assessment satisfaction. A public-sector perspective was adopted; the provider costs of the agencies taking part. Results At 2006–07 prices, including start-up and on-going costs, only three pilots demonstrated cost effectiveness. Two pilots in assessment and care management had ICERs of £3810 and £755 per satisfaction gained, well below a benchmark from a trial of usual assessment of £18296 per satisfaction gained. When extrapolating uptake to numbers accessing assessments over 1 year, one occupational therapy pilot, of £123/satisfaction gained, also fell below this benchmark in sensitivity analysis. There was less evidence for preventative services. Conclusions and implications Most pilot projects were not cost effective. However, self assessment is potentially cost effective in assessment and care management and occupational therapy services. Better quality cost data from pilot sites would have permitted more detailed analysis. Measuring downstream effects in terms of users’ well being from receipt of self-assessment would also be beneficial.
Article
The rationale for geriatric assessment programs includes a reduction in nursing home admissions, improved health outcomes and improved physical function. However the evidence for these benefits may not be directly transferable to all models of geriatric assessment programs. This study is a review of published studies of most relevance to aged care assessment teams with regard to one important outcome, nursing home admission. However the conclusions are limited in that no studies are directly comparable to the situation in which aged care assessment teams function. In addition, traditional outcome measures may not be appropriate in considering the effectiveness of similar models of geriatric assessment.
Article
The emphasis in this article is on the effects of Ageism, Complacency and Prejudice on the delivery of effective health care to the elderly disabled population. It does not set out to support or deny the efficacy of the more traditional modalities used in Preventative care among the elderly. Rather it suggests that the adverse effects of Ageism, Complacency and Prejudice are very evident in our society and that they are clearly preventable.
Article
We describe a comprehensive screening project in a general practice in which patients over the age of 65 were assessed both socially and medically. We conclude from our results that there was little treatable but previously undiagnosed illness within the community studied.
Article
All the 855 patients over the age of 65 in one general practice were reviewed. Those under care were excluded (316-37 per cent), and the rest were offered a screening examination in the practice. In all, 335 were examined and several had been previously screened. The yield of conditions found is reported and the advantage of the work in general practice discussed.
Article
In an urban practice of about 5300 units, 540 patients, aged over 65, replied to a questionary on social and welfare facilities in 1968. The results were compared with those of a survey in the practice in 1960-61. The proportion living alone increased from 15% to 22%. Hospital admissions were unchanged at 29%. 88% were using solid fuel in 1961 and 62% in 1968; 26% were unable to heat their bedrooms, and 29% were using oil-stoves, in the later survey. Not much was achieved in educating the practice in knowledge of available services in the period between the surveys. The proportion of patients who claimed to be able to " leave the house with help " rose from 6% to 11%, and that of those completely confined to the house was halved.
Article
A medico-social survey of 259 elderly patients aged 70-72 was carried out by three doctors, a health visitor and a nurse in an urban general practice. Seven hundred and ninety diseases or disabilities were identified-an average of 3.2 per patient-of which 20.5% were unknown to the doctors. Using a simple check list for symptom inquiry, the health visitor or nurse missed very little of the physical or psychological disease. In some respects their symptom inquiry was more revealing than that of the doctors but they had difficulty in eliciting evidence of malnutrition, masked depression, and incipient dementia. Initial health screening of the elderly for unreported disease in general practice can easily be done by a health visitor with training in geriatric problems and the recognition of psychiatric illness.Initial health screening can also be done by a nurse with community-nursing experience but she will require additional training in the techniques of social assessment. The doctor must examine those patients found to be suffering from alerting symptoms. A general practice of three or four doctors requires one health visitor for routine work and one additional health visitor or nurse for screening of the elderly. Unreported disease in the elderly indicates failure to make contact and failure to ask the right questions. Unknown disease may be due to inadequate records.
Article
This paper reviews the relevant literature concerning the care of the elderly outside of hospitals since the inception of the National Health Service in 1948 and offers some suggestions regarding the organisation of geriatric care with a short commentary on implications for the future.
Article
In a survey of people of 75 years and over in a general practice situated in the north-west of England a total of 297 patients was examined. Among the many previously unreported medical conditions and social needs were seven unknown malignant conditions, 28 patients with heart failure, five with diabetes, and one with myxoedema. A high incidence of nutritional anaemia was also found. It is concluded that such a survey can detect much hidden illness and disability and that general practice is the right setting for it.
Article
A study of the reasons for admission of 280 patients from their own homes to a geriatric unit in the East End of Glasgow showed that in two-thirds of cases patients were admitted primarily because they failed to receive adequate basic care at home (usually because of lack of relatives) or because their relatives suffered undue strain in caring for them. Neglect by relatives played a negligible part in the need for admission.
Article
Medical examination was offered to a group of "high risk" old people who were not necessarily patients or known to their family doctors, but with the agreement of these family doctors. Two clinics set up for this purpose have been running for several years, and the results of examination and follow-up of 300 consecutive patients are reported.Major conditions were found in two-thirds of patients producing functional impairment in most of these.Recommendations as to therapy and management were carried out in 161 of 194 patients but not in the remainder.Clear evidence of improvement was found in half of the patients who carried out recommendations, and this improvement was attributable to earlier diagnosis than would have been achieved without these clinics in 42% of cases.Including all patients examined, the proportion helped by early diagnosis at 18 to 30 months' follow-up was 23%.It is concluded that the offer of a routine examination to high risk groups is of benefit to old people and a form of medical practice which should be widely adopted.
Article
Most of the elderly, over 70, were receiving regular medical attention. A number of people were not in regular contact with their doctors and had symptoms which might indicate treatable illness. A high proportion of people, 19%, were getting out of the house less than once a week. These were mostly women, and it was not always accounted for by physical symptoms. More than half the people interviewed had had an eye test within 2 years. Almost all the blind were receiving regular attention but a larger group of partially sighted might benefit from registration and help with welfare. Almost a third of the people seen had not seen a dentist for 10 years or more. Decayed teeth and defective dentures were common. Most of the people who were seriously deaf used, or had attempted to use, a hearing aid. A number of people with moderate deafness would probably benefit from hearing aids. A quarter of the elderly people seen lived alone. 11% were both living alone and without regular daily contacts. 5.8% of people were living alone and without a telephone that they could use nearby. A third of the people had not been away on holiday for 3 years or more. About one-fifth were in favour of a day centre for the elderly. The proportion of the elderly in council houses is rather low relative to the rest of the town. A high proportion of owner-occupied and private-tenanted houses were lacking basic facilities. Considering the personal services, there appears to be an unmet demand which is considerable for meals-on-wheels and chiropody; less so for home helps and wheelchairs; and little if any for nursing and related services, on the criteria currently used.
Article
A twelve-month survey was made in general practice in an English town, to determine the incidence of incapacitating diseases in patients over 65 years old. Among the 885 patients in this age group, there were three times as many women as men, and 56 of the group (6.3 per cent) had diseases which rendered them totally incapacitated. They were cared for in their homes by interested relatives, friends or landladies. Cerebral arteriosclerosis, ischaemic heart disease and rheumatic diseases were the three leading crippling diseases. The diseases, and the care of elderly patients in their home are discussed. Old patients are treated best in their homes. They know the familiar corners of their rooms, furniture, views from the windows, and their neighbours. It is important that they have willing relatives or friends to look after them. A family doctor can give them adequate medical care provided he has the full co-operation of ancillary services.
Article
Two groups of old-age pensioners in St. Paul's Cray were screened for physical illness, social and family connexions, and personal activities. The first group comprised 100 people (10% random sample of a suburban practice of 12,000 patients), and the second group comprised the total population of a sheltered area (85 people).The findings showed that geographical separation of relatives was a significant factor in the isolation of old people. Lack of exercise and obesity seriously increased the risk of urinary infection; malnutrition and nutritional anaemia were found to be other potentially important problems in the elderly. In 13% of the elderly population three out of five seriously adverse factors (over 80, isolation, housebound, living alone, serious chronic Illness) were found to be present.It is imperative that the group of high-risk elderly should receive the services they need; it is suggested that a policy of an adequate sheltered area supported by a geriatric service should be an extension of group medical practice.
Survey of geriatric services
  • J T Leeming
  • A I Ross
Leeming, J. T. & Ross, A. I. (1967). Survey of geriatric services. Bolton County Borough 1964. Medical Officer, 118, 93-99, 103-108.
Prevention rather than cure Experiences of two preventive clinics for the elderly
  • W Mckendrick
  • F P Peach
McKendrick, W. & Peach, F. P. (1968). Prevention rather than cure. Medical Officer, 120, 247-250. 9. Thomas, P. (1968). Experiences of two preventive clinics for the elderly. British Medical Journal, 2, 357-360.
The Redbridge scheme for routine medical examination of elderly people
  • T B Dunn
Dunn, T. B. (1971). The Redbridge scheme for routine medical examination of elderly people. Modern Geriatrics, 1, 261-263.
The content of practice: the elderly
  • M K Thompson
Thompson, M. K. (1977). The content of practice: the elderly. In Trends in General Practice. London: British Medical Journal.
Health and Personal Social Services Statistics for England 1973 London: HMSO. 36 Screening in Medical Care. A Collection of Essays
  • Department
  • Health
  • Social
  • Security
Department of Health & Social Security (1973). Health and Personal Social Services Statistics for England 1973. London: HMSO. 36. Nuffield Provisional Hospitals Trust (1968). Screening in Medical Care. A Collection of Essays. London: Oxford University Press.
Effectiveness and Efficiency
  • A L Cochrane
Cochrane, A. L. (1972). Effectiveness and Efficiency. Random Reflections on Health Services. Rock Carling Fellowship 1971. Nuffield Provisional Hospitals Trust
Registrar General's Quarterly Returns of Births, Deaths and Marriages. England and Wales. Appendix D39
Office of Population Censuses & Surveys (1972). Registrar General's Quarterly Returns of Births, Deaths and Marriages. England and Wales. Appendix D39. London: HMSO.
Survey of geriatric services. Bolton County Borough 1964
  • J T Leeming
  • A I Ross
Leeming, J. T. & Ross, A. I. (1967). Survey of geriatric services. Bolton County Borough 1964. Medical Officer, 118, 93-99, 103-108.
Report of symposium held at Belfast City Hospital, October. Northern Ireland Council for Post- Graduate Medical Education
  • W G Irwin
Irwin, W. G. (1970). Report of symposium held at Belfast City Hospital, October. Northern Ireland Council for Post- Graduate Medical Education.
Integrated patient care. Upjohn Fellowship Report
  • A J Tulloch
Tulloch, A. J. (1976). Integrated patient care. Upjohn Fellowship Report. In press.
Screening in Medical Care. A Collection of Essays
Nuffield Provisional Hospitals Trust (1968). Screening in Medical Care. A Collection of Essays. London: Oxford University Press.
Health and Personal Social Services Statistics for England
Department of Health & Social Security (1973). Health and Personal Social Services Statistics for England 1973. London: HMSO.