Transcript Ingen lysbildetittel

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St. Olavs Hospital
University Hospital of Trondheim
Admission to
Department of General Internal Medicine
or Department of Geriatrics
Does it matter?
Olav Sletvold
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Reasons for asking………
• Demographics and epidemiological trends
– Greying of nations
– Geriatric giants incidence/prevalence-incidence
• Concern about future organisation
– Health care models
• Hospitals/primary sector
– Specialties
• ”Obsolete” traditions
• Ongoing discussions
– Journals/associations/health authorities
• Scientific evidence
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Demographics of Norway
Elderly persons > 67 years
Ref: Statistics Norway 2008, http://www.ssb.no/folkfram/
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Reasons for asking………
• Demographical and epidemiological trends
– Greying of nations
– Geriatric giants incidence/prevalence-incidence
• Concern about future organisation
– Health care models
• Hospitals/primary sector
– Specialties
• ”Obsolete” traditions
• Ongoing discussions
– Journals/associations/health authorities
• Scientific evidence
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”The Malta Definition”
EUGMS
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“The Malta Definition” of Geriatric Medicine
•
Geriatric Medicine is a specialty of medicine concerned with physical, mental,
functional and social conditions occurring in the acute care, chronic disease,
rehabilitation, prevention, social and end of life situations in older patients.
•
This group of patients are considered to have a high degree of frailty and active
multiple pathology, requiring a holistic approach. Diseases may present
differently in old age, are often very difficult to diagnose, the response to
treatment is often delayed and there is frequently a need for social support.
•
Geriatric Medicine therefore exceeds organ orientated medicine offering
additional therapy in a multidisciplinary team setting, the main aim of which is to
optimise the functional status of the older person and improve the quality of life
and autonomy.
•
Geriatric Medicine is not specifically age defined but will deal with the typical
morbidity found in older patients. Most patients will be over 65 years of age but
the problems best dealt with by the speciality of Geriatric Medicine become
much more common in the 80+ age group.
•
It is recognised that for historic and structural reasons the organisation of
geriatric medicine may vary between European Member Countries.
Ref: Minutes GMS UEMS-meeting Malta, accepted 03/5/08
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Comprehensive geriatric assessment
(CGA)
• Key components of geriatric medicine
– Co-ordinated multidisciplinary assessment
– Identification of medical, functional, social and psychological
problems
– The formation of a plan of care including appropriate rehabilitation
– The ability to directly implement treatment recommodations made
by the multidisciplinary team
– Long term follow-up
Ref:
Ellis G, Whitehead M, Robinson D, O’Neill D, Langhorne P. Comprehensive geriatric
assessment for older adults admitted to hospital: a systematic review (prototcol) (2006). The
Cochrane Library 2008, Issue 3
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Categorisation of CGA programmes
• GEMU
– Hospital geriatric evaluation and management unit, a designated inpatient
unit for CGA and rehab
• IGCS
– Inpatient geriatrics consultation service, non-designated units where CGA is
provided to hospital patients on a consultative basis
• HAS
– Home assessment service, in-home CGA for community dwelling persons
• HHAS
– Hospital home assessment service, in-home assessment for recently
discharged patients
• OAS
– Outpatient assessment service, CGA in outpatient settings
Ref:
Stuck AE, Siu AL, Wieland, GD, Adams J, Rubenstein LZ.
Comprehensive geriatric assessment: a metaanalysis of controlled trials.
Lancet, 1993,342:1032-1036
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Structure of specialities
• Internal Medicine
– Independent main specialty
(most countries)
• Including subspecialties of
– Geriatrics
– Cardiology
– Hematology
– Pulmology
– Nephrology
– Endocrinoloy
– Gastroenterology
– Infectious diseases
– General Internal
Medicine (i.e.
Denmark)
• Geriatrics
– Independent main specialty
(many countries) (UK, Sweden)
– Independent subspeciality of
• Internal Medicine (Norway)
– Variants
• Independent
specialty/subspecialty (Finland)
• Diploma/certification (USA)
– No specialty
• Portugal
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Admission to Department of
General Internal Medicine or
Department of Geriatrics
Does it really
matter?
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Selected references
Geriatrics vs. internal medicine
•
Rubenstein LZ, Josephson KR, Wieland GD, English PA, Sayre JA, Kane RL. Effectiveness of a
geriatric evaluation unit. A randomized clinical study. N Engl J Med, 1984, 311: 1664-1670
•
Harris RD, Hevnscke PJ, Popplewell PY, Radford AJ, Bond MJ, Turnbull RJ, Hobbin ER,
Chalmers JP, Tonkin A, Stewart AM. A randomised study of outcomes in a defined group of
acutely ill elderly patients managed in a geriatric assessment unit or a general medical unit. Aus
NZ J Med, 1991, 21:230-234.
•
Counsell SR, Holder CM, Liebenauer LL, Palmer RM Fortinsky RH, Kresevic DM , Quinn LM,
Allen KR, Covinsky KE, Landefeld CS. Effect of a multicomponent intervention on functional
outcomesand process of care in hospitalized older patients: a randomized controlled trial of
Acute Care for Elders (ACE) in a community hospital. J Am Ger Soc 2000, 48:1572-1581
•
Asplund K, Gustafson Y, Jacobsson C, Bucht G, Wahlin, A, Peterson J, Blom JO, Ängquist KA.
Geriatric-based versus general wards for older acute medical patients:a randomized comparison
of outcomes and use of resources. J Am Ger Soc 2000, 48:1381-1388.
•
I Saltvedt, ES Opdahl Moe, P Fayers, S Kaasa, O Sletvold. Reduced mortality in treating
acutely sick, frail elderly patients in a geriatric and evaluation and management unit. J Am Ger
Soc 2002, 50: 792-798
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Trials not considered
• RCTs on
– CGA in combined units
• Casemix of both medical and surgical patients
– Discharge-planning teams
– Extended care services
• Hospital-based
– Outpatient clinics
– Home-based services
• Non-RCTs
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1984
Ref: Rubenstein & al N Engl J Med, 1984
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2002
MW
1.0
0.9
0.8
0.7
0.6
Medical Wards (MW)
Geriatric Unit (GEMU)
0.5
0.4
0.3
0.2
0.1
Months
0.0
0
No. at risk
GEMU
MW
3
6
9
12
112
93
107
90
102
85
92
84
(p= 0.004 at 3 months, p=0.02 at 6 months, and p=0.06 after 12 months)
Ref: I Saltvedt & al J Am Ger Soc 2002
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Rubenstein & al N Engl J Med, 1984
• Geriatric Unit (15 beds) of the Sepulveda VA Medical
Center
• Intermediate care (non-acute) area of the hospital
• Inclusion criteria
– All persons admitted to acute-care services of a VA medical center still
in hospital after one week
– Patients 65 + years with continued medical, functional or psychological
problems preventing discharge home
• Exclusion criteria
– Patients with severe dementia, terminal illness, other severe conditions
resistant to treatment, inevitably nursing home placement.
– Those well enough to return home without further support services
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Rubenstein & al N Engl J Med, 1984
• Intervention group
– After randomisation patients were admitted to the
Geriatric unit intervention usually within 48 hours
– Geriatric work-up
– Interdisciplinary team
• Control group
– Usual hospital acute care services
• Age >70 years (79 vs 77 years)
• Male-VA (95 vs 96 %)
• LOS (55 vs 44 days)
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Findings in favour of GU
• At one year
– Lower mortality (23.8 vs 48.3%)
– Fewer had initially been discharged to a nursing
home (12.7 vs 30.0%)
– Patients were less likely having spent time in a
nursing home (26.9 vs 46.7)
– They more likely had improvement of functional
status
– Lower direct costs
Ref: Rubenstein & al N Engl J Med, 1984
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Ref: Rubenstein N Engl J Med, 1984
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Saltvedt & al J Am Ger Soc 2002
• Section of Geriatrics (9 beds), Department of Internal
Medicine, St. Olav University Hospital of Trondheim
• Acute hospital
• Inclusion criteria
– Age > 75 years
– Admitted as an emergency to the Department of Internal Medicine
– Having at least one of Winograd’s targeting criteria
• Exclusion criteria
– Living in nursing home, previously independent and expected to be so
without geriatric intervention, cancer with metastasis,
or other disorder with short living expectation,
advanced dementia, need for specific treatment
in another ward
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Targeting criteria
• Acute impairment of
single ADL
• Imbalance, dizziness
• Impaired mobility
• Chronic disability
• Weight loss,
malnutrition
• Falls during the last 3
months
• Depression
• Confusion
• Mild / moderate
dementia
• Urinary incontinence
• Polypharmacy
• Vision or hearing
impairment
• Social / family
problems
• Prolonged bedrest
Ref : Winograd & al J Am Ger Soc 1991
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Baseline characteristics
GEMU
MW
(n=127)
(n=127)
Age - mean SD
82  5
82  5
Female - no (%)
81 (64)
84 (66)
Widowed/living alone - no(%)
Living location
Private home - no(%)
Sheltered housing - no(%)
Days in hospital before inclusion
- median (iqr*)
No. of targeting criteria
- median (iqr*)
93 (73)
85 (67)
115 (91)
12 (9)
110 (87)
17 (13)
2 (1;5)
3 (1;6)
4 (3;5)
4 (3;5)
*iqr= interquartile range
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Saltvedt & al J Am Ger Soc 2002
• Intervention group
– After randomisation patients were transferred to
the Geriatric unit the same day
– Geriatric work-up
– Interdisciplinary team
• Control group
– Usual acute hospital care services
• LOS (19 vs 13 days)(median)
Time from inclusion (days)
0
-10
91
-90
-80
-70
-60
-50
-40
-30
-20
-15
60
81
71
61
51
41
31
21
16
11
0
6-1
3-5
0-2
Percentage of patients discharged
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Time to discharge
100
80
GEMU
MW
40
20
0
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Cumulative survival
MW
1.0
0.9
0.8
0.7
0.6
Medical Wards (MW)
Geriatric Unit (GEMU)
0.5
0.4
0.3
0.2
0.1
Months
0.0
0
No. at risk
GEMU
MW
3
6
9
12
112
93
107
90
102
85
92
84
(p= 0.004 at 3 months, p=0.02 at 6 months, and p=0.06 after 12 months)
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Table 4. Causes of death 3 and 12 months after inclusion.
3 months
GEMU
12 months
MW
GEMU
MW
Heart disease – no (%)
6
(40.0)
18
(52.9)
14
(40.0)
23
(53.5)
Infectious disease* – no (%)
5
(33.3)
4
(11.8)
12
(34.2)
6
(13.9)
Cerebrovascular disease – no (%)
0
(0)
4
(11.8)
1
(2.9)
5
(11.6)
Cancer – no (%)
1
(6.7)
5
(14.7)
3
(8.6)
6
(13.9)
Other – no (%)
3
(20.0)
3
(8.8)
5
(14.3)
3
(7.0)
15
(100)
34
(100)
43
(100)
Total
35 (100)
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Table 4: Number of readmissions to hospital
0-3 months
0-6 months
GEMU
MW
N
%
N
%
1
20
(17.4)
22
(21.8)
2 or
more
10
(8.7)
8
(7.9)
1
19
(17.0)
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(26.3)
2 or
more
25
(22.3)
15
(15.2)
None of the differences were statistically significant (Mann Whitney U Test)
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Number of patients living at home
GEMU (n=127)
MW (n=127)
3 months
6 months
101 (80%)
80 (64%)
92 (73%)
76 (61%)
HR : 2.1 (1.3; 3.4) after 3 months.
HR : 1.7 (1.1; 2.6) after 6 months.
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Partitioned survival curves
Percentage
100
75
Home
50
25
0
Nursing home
Hospital
GEMU
1
2
3
4
5
6
Percentage
100
75
50
Home
25
0
Hospital
1
MW
Nursing home
2
3
4
5
6
Time (months)
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Poor outcomes
100
GEMU
MW
80
60
3 months
6 months
12 months
%
40
45
20
27 26
12
34
33
20
29
45 45
35
24
28
27
34
38
44
16
ea
d/
D
l
D ow ead
ea
Ba
d/
lo rth
w
e
M l
M
SE
D
ea
d/
lo Dea
w
D
ea
Ba d
d/
lo rth
w
e
M l
M
SE
D
D
ea
d/
D
l
D ow ead
ea
Ba
d/
lo rth
w
e
M l
M
SE
0
Figure 2a. Proportion of the total number of patients in the GEMU and
MW group who experienced a poor outcome (dead , dead or Barthel
Index scores below 12, and dead or MMSE scores below 20).
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Positive outcomes
100
80
GEMU
88
84
3 months
73
60
40
%
12 months
72
66
43
38
31
20
6 months
71
MW
35
34 31
27
34 31
25 22
21
12
28
21 21
14
12
M e
M
SE
Ba
rt
he
l
IA
D
L
liv
A
M e
M
SE
Ba
rt
he
l
IA
D
L
liv
A
A
liv
M e
M
SE
Ba
rt
he
l
IA
D
L
0
Figure 2b. Proportion of the total number of all patients recruited to the Geriatric Evaluation and
Management Unit (GEMU) (n=127) and general medical wards (MW) (n=127) who experienced a
positive outcome defined as surviving, having normal scores for Mini Mental Status Examination
(MMSE), Barthel Index or Instrumental Activities of Daily Living (IADL). Differences in survival
were statistically significant at 3 (p= 0.004) and 6 months (p=0.02). None of the other differences
were statistically significant.
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Drug use in favour of GEMU
More often discontinued
– Anticholinergic drugs
– CV-drugs
• Digitoxin
– Psychotrope dugs
• Neuroleptics
• More drugs started (trend):
– Antidepressants
– Estriol
• Reduction of patients on potential drug-drug interactions
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Conclusion
Treatment of acutely sick frail elderly patients in
a geriatric evaluation and management unit
(GEMU) gave
• considerable reduction of mortality
• increased the patients’ chances of being able
to live in their own homes
Ref: I Saltvedt & al J Am Ger Soc 2002
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Does it matter?
MW
1.0
0.9
0.8
0.7
0.6
Medical Wards (MW)
Geriatric Unit (GEMU)
0.5
0.4
0.3
0.2
0.1
Months
0.0
0
No. at risk
GEMU
MW
3
6
9
12
112
93
107
90
102
85
92
84
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36
Comprehensive geriatric assessment
(CGA)
• Key components of geriatric medicine (CGA)
– Co-ordinated multidisciplinary assessment
– Identification of medical, functional, social and psychological
problems
– The formation of a plan of care including appropriate rehabilitation
– The ability to directly implement treatment recommodations made
by the multidisciplinary team
– Long term follow up
• Additional premises (?) for improved prognosis
– Targeting (age & frailty)
– Clinical skills and dedication
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From GEMU to acute geriatric care
St. Olav University Hospital 2010
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Why?
• Asplund K, Gustafson Y, Jacobsson C, Bucht G, Wahlin, A,
Peterson J, Blom JO, Ängquist KA. Geriatric-based versus
general wards for older acute medical patients:a randomized
comparison of outcomes and use of resources. J Am Ger Soc
2000, 48:1381-1388.
• Baztan JJ & al. Effecticeness of acute geriatric units on
functional decline, living at home, and case fatality among older
patients admitted to hospital for acute medical disorders:
Metaanalysis. BMJ 2009;338:b50 doi:101136/bmj.b50
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Elderly patients referred to
St. Olav University Hospital
• At admittance in Emergency Department
– Initial assessment
• Physician on call
• ECG, urin analysis, blood testing, preliminary X-ray
– Triage
• Evaluating patients according to geriatric giants
•
At admittance in Geriatric Ward (80-90% from ED)
– Initial evaluation and management
• Acute assessment and care by nurse and physician (geriatrician)
– Check lists
– Establish links with PHCS
• Preliminary assessments by other team members
• Informal consultations
– MD vs RN vs OT vs PT vs XX
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Geriatrics at St. Olav University Hospital
• Day 1-2
– More extensive geriatric assessment, and management
• Pre-ward round
• Evaluation by team members
– Follow-up of check-lists
– Treatment guidelines
• Ward round
• Informal consultations
• Formal meeting (2 PM, 5-15 min)
– All team members report their results from their own preliminary
evaluation
– Agree on work-up and management (aims, care plan, discharge
prerequisits, estimated LOS)
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Geriatrics at St. Olav University Hospital
• Day 2-3-x
– Continuous evaluation and management
• Daily routines
– Pre-ward round
– Ward round
– Follow-up of check-lists
– Treatment according to guidelines
• Informal consultations
• Formal meetings
– Evaluation of work-up and management (aims, discharge planning,
estimated LOS)
– Networking with primary care professionels
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Nurse
• General condition and needs
– Patient & caregivers
• Situation at home
– Contact with the PHCS
• Report on functional limitations, resources i.a.
– Structured observations
• BP, BMI, Barthel ADL-index i.a.
• Checklists
– Case history/observations/evaluations/planning of nursing
care/discharge/reporting
• Care plan
– Follow-up
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Physiotherapist
• PT work-up
– Evaluation of
• Falls, balance problems, immobility, physical activity limitations
–
–
–
–
–
Mobility aids
Compression stockings
Hip protectors
Exercise classes
Potential for rehab
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Consequences of CGA
• Additional interventions
– Internal referrals
• More-targeted interventions
– Development of individual care plans
– Early start of discharge planning
– Timely rehabilitation
• Post discharge follow-up
– Outpatient geriatric clinic
• Work-up on cognitive decline etc
– (Interdisciplinary home intervention team)
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Meta-analyses and reviews
Comprehensive Geriatric Assessment
•
•
•
•
•
Stuck AE & al, Comprehensive geriatric assessment: a metaanalysis
of controlled trials. Lancet, 1993, 342:1032-1036.
Day & Rasmussen What is the evidence for the effectiveness of
specialist geriatric services in acute, post-acute and sub-acute
settings? New Zealand Health Technology Assessment Report
2004;7(3).
http://nzhta.chmeds.ac.nz/publications/geriatric_services.pdf.
Baztan JJ & al. Effecticeness of acute geriatric units on functional
decline, living at home, and case fatality among older patients admitted
to hospital for acute medical disorders: Metaanalysis. BMJ
2009;338:b50 doi:101136/bmj.b50
Van Craen K & al. The effectiveness of inpatient geriatric evaluation
and management units: A systematic review and metaanalysis. J Am
Ger Soc 2010, 58,1:88-92
Bachmann S & al. Inpatient rehabilitation designed for geriatric
patients: Systematic review and meta-analysis of randomised
controlled trials. BMJ 2010; 340:c1718 doi: 10.1136/bmj.c1718
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Challenges
• S Shepperd & al. Can We Systematically Review
Studies That Evaluate Complex Interventions? PLoS
Medicine, August 2009, Vol 6, Issue 8,
doi:10.1371/journal.pmed.1000086.t001
• Van Ness & al. Gerontologic Biostatistics: The
Statistical Challenges of Clinical Research with Older
Study Participants. JAGS 2010 Jul;58(7):1386-92.
Epub 2010 Jun 1.
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Evaluating and reviewing CGA
• Intervention content
– Describe the content (the active ingredients)
– Describe any intervention received by the control group, including the
content of ”usual care”
– Describe how the interventions were delivered (and any differences in
delivery across included trials”
– (Describe the contextual similarities and differences between the trials)
• Intervention fidelity
– Include details describing whether the interventions (included in a review)
do what is intended or if they deviated from the intended shape or form
during the course of the implementation
– Include an assessment of whether an intervention failed because it was
poorly implemented or it was not effective
• Intervention sustainability
– Include details on the sustainability of interventions ocver time
S Shepperd & al. Can We Systematically Review Studies That
Evaluate Complex Interventions? PLoS Medicine, August 2009,
Vol 6, Issue 8, doi:10.1371/journal.pmed.1000086.t001
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Evaluating and reviewing CGA ctd.
• Roll out/Scaling up of the intervention
– Report data on accessability, risk of AE, cost-effectiveness, or
budget impact of interventions
– Address the following questions regarding the applicability of the
evidence to individual patients:
• Have biological results (age, co-morbidities) that might modify the
treatment respons been excluded?
• Can consumers comply with the treatment requirements?
• Can health care providers comply with the treatment requirements
• Are the likely benefits worth the potential risks and cost?
S Shepperd & al. Can We Systematically Review Studies
That Evaluate Complex Interventions? PLoS Medicine,
August 2009, Vol 6, Issue 8,
doi:10.1371/journal.pmed.1000086.t001
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Evaluating and reviewing CGA ctd.
• Address the following questions regarding the
applicability of the evidence in other health care
systems
– Are there important differences or similarities in the structural
elements of health systems or of health services between where
the research was done and where it will be applied?
– Are there important differences in the on-the ground realities and
constraints (governance, financial, delivery arrangements)?
– Are there likely to be important differences in the baseline
conditions between where the research was done and other
settings?
– Are there important differences in perspectives and influences of
health system stakeholders between where the research was done
and where it could be applied that might mean an intervention will
not be accepted or taken up in the same way?
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Geriatric research-Statistical
challenges
• Multicomponent interventions
– Clinical trial design
• Multiple outcomes
– Multiple testing procedures
• State transitions
– Longitudinal transitions models
• Floor and ceiling effects
– Item respons
– Theory methods and regression models
• Missing data
• Qualitative and quantitative data
– Mixed methods
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How is real life?
• J Latour & al. Short term geriatric assessment units:
30 years later. BMC Geriatrics 2010, 10:40
http:www.biomedcentral.com/1471-2318/10/41
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