Authors: T. Pepersack
Categories: Article, Geriatric assessment, hospitalization, aged, quality, elderly, frailty, education
Source: The Journal of Nutrition, Health & Aging
Doi: 10.1007/BF02982666
Authors: T. Pepersack
Background: Health services for the elderly are becoming increasingly important in industrialized nations, and comprehensive geriatric assessment (CGA) is one of the procedures designed to improve the health of this sector of the population. In 2003 a survey among Belgian geriatricians showed that despite the interest of the geriatric teams for comprehensive geriatric assessment, it was not used enough. Considering these results, as a first step, screening tools were proposed for the main geriatric domains (Minimum Geriatric Screening Tools, MGST).Objectives: To assess the feasibility of a MGST within the teams of geriatric units and to evaluate the efficacy of a MGST on the detection rate of the geriatric problems of admitted subjects.Design: Prospective observational survey.Methods: The teams were first asked to encode active geriatric problems suspected according to their conventional assessment. Then, in a second phase, a complete MGST was completed by the same team within the first week after admission.Results: Three hundred and twenty six registrations from 33 centres were available. Mean (±SD) number of screened geriatric problems was 1.5±1.2 without MGST and 4.7±1.7 (p< 0.0001) using the MGST. Except for the assessment for the risk of falls, the MGST leads to a better screening for the seven other main geriatric domains (functional, continence, cognition, depression, nutrition, pain, social).Conclusions: An improvement associated with the use of simple minimal geriatric tools to screen geriatric problems was evident. This approach has additional value for education and quality assurance.
Health services for the elderly are becoming increasingly important in industrialized nations, and comprehensive geriatric assessment (CGA) is one of the procedures designed to improve the health of this sector of the population (1). Geriatric assessment determines an elderly person’s medical, psychosocial, functional, environmental resources and problems and produces an overall plan for treatment and follow-up ( 1., 2., 3.).
In general, quality of care can be measured using implicit criteria (i.e., the measurement effort defines no explicit standards, and healthcare professionals use their own individual judgments to determine the quality) or explicit criteria (i.e., criteria for what should be done are established, and then the care received is compared with these standards) (4).
A study has suggested that older patients are receiving improved care for common diseases affecting this age group (e. g., acute myocardial infarction, diabetes mellitus, pneumonia), although geriatric syndromes (e.g., dementia, urinary incontinence, falls) were not assessed (5). Despite this improvement, the current quality of care rendered to older persons is less than optimal, and there is substantial room for continued improvement. For example, in Belgium, only 50% of elderly hospitalized geriatric patients present adequate immunization against tetanus (6).
In 2003, a survey from a quality program on behalf of the
Belgian College for Geriatrics showed that despite the interest of geriatric teams for comprehensive geriatric assessment, the procedure to detect common geriatric problems was underused (systematic tools to detect the “geriatric problems” such as the risk of fall, malnutrition, pain, etc. were used by less than 60% of the teams) (7).
Considering these results, the Belgian College for Geriatrics reviewed the literature in order to propose instruments which could be accepted by the teams. The criteria proposed to accept these instruments screening tools, feasibility, sensitivity, specificity, validity, allowing to be followed by interventional algorithms.
The result of this work was discussed at the Consensus Conference of May 7th, 2004 with the collaboration of the Belgian Society of Gerontology and Geriatrics (8).
The tools proposed are the basis of a “Minimum Geriatric Screening Tools” (MGST).
The aims of this project 1) to assess the feasibility of a MGST within the teams of Belgian geriatric units; 2) to assess the efficacy of a MGST on the detection rate of the geriatric problems; and 3) to analyze quality variables within the data collected.
Prospective observational survey followed by bench marking (feed back).
Each Belgian acute geriatric unit was asked to use the MGST for 10 consecutive admissions between March to June 2005.
Initially, within the 48h after admission and without any MGST procedure, the teams were asked to encode the active geriatric problems suspected for which a geriatric intervention should be programmed. Then, on a second occasion, and within the week, a complete MGST was performed by the same team.
For each patient, the age, the length of stay was noted.
1.The assessment of the activities of daily living used the Belgian scale adapted from the Katz’s scale (9). This included the following bathing, dressing, transfer, toilet, continence, and eating. Each task is graded in a 4-level scale (1 to 4 for Katz’s scale), where lower levels represent the absence of dependence, and upper level the maximal dependence for the task.2.Instrumental Activities of daily living assessment used the Lawton scale (10).3.The risk of fall was assessed with the ‘stratify’ score (11).4.Cognition problem was screened using the “Clock Drawing Test” (12, 13).5.Depression was screened with a short form of the Geriatric Depression Scale (14) for communicative subjects and with the Cornell Scale for Depression (CSDD) for demented patients (15).6.The presence of social complexity was screened with the “Socios” scale (16).7.Malnutrition was screened using the 3 first questions of the Malnutrition Universal Screening Tool (MUST) (17).8.The presence of pain was screened either asking the patient for the presence of pain or other complaints synonymous with pain (Burning, Discomfort, Aching, Soreness, Heaviness, Tightness), or using a vertical presentation like the pain thermometer (18, 19). For non communicative elderly or the elderly with moderate to severe dementia, a check list of non verbal pain indicators was done (20).9.The “Identification of Seniors At Risk” (ISAR) assessed the frailty (risk of functional decline and adverse outcomes) (11).
The number of different drugs at admission was collected.
Used a comorbidity index adapted from Greenfield et al. 21 at the end of the hospitalization.
Results from groups of patients are presented as means±SD. Non-paired Student t test was used to compare means of the parameters. Z-score with Yates correction was used to assess the differences between proportions of conditions.
Three hundred and twenty six registrations from 33 centres were available. Mean (SD) age of the patients was 83,3 (6,8) yr (median: 83,3 yr; range 64 -102yrs); mean length of stay was 18,5 (15,8) days (median 16 d, 1 -102 days).
Residences of the admitted patients 68% private, 24% nursing home, 5% other wards of the hospital, and 3% others. Comorbidity and severity of the medical conditions of the patients are illustrated in Figure 1.Figure 1aGlobal comorbidity and severity of the medical conditions of the patients. Bars represent the proportions of patients presenting with uncontrolled condition. GI= gastro-intestinal pathology; Muscles= musculo-skeletal pathologyFigure 1bUncontrolled severity of the medical conditions of the patients are illustrated in Bars represent the proportion of patients presenting with uncontrolled condition. GI= gastro-intestinal pathology; Muscles= musculo-skeletal pathology
A mean (±SD) of 6.6 (3.4) different drugs at admission per patient was observed (median: 6; 0-21).
Ninety percent of the patients presented a ISAR score ≥2; 82% a score ≥3. A score ≥2 is associated with a risk of unfavourable outcome or functional decline increased by 2; a score ≥3 the risk is increased by 3.
Functional characteristics the patients are presented in Figure 2a. Bars represent the proportions (%) of patients presenting with no-, -intermediate, or -total dependence in their activities of daily living. For example in this figure we observe 60% of the patients screened for partial of complete urinary incontinence (without the systematic use of this Katz scale, urinary incontinence was declared as a geriatric problems in only 4% of the case (Table 1). Figure 2b shows dependence for instrumental activities for daily living.Figure 2aFunctional characteristics the patients. Bars represent the proportions (%) of patients presenting with no, -partial, or - complete dependence for their basic activities of daily livingTable 1Added-value of Minimum Geriatric Screening Tools: proportion of screened risks for geriatric problems before or after Minimum Geriatric Screening Tools (expressed as percentage and -/+95% confidence limits for means)Geriatric problemsBefore MGSTAfter MGSTGainpADL-IADL26%(21-31)89%(86-93)63%(59-69)<0.0001Incontinence4%(3-9)60%(55-65)56%(48-59)<0.0001Falls35%(30-40)46%(41-52)11%(7-26)0.1497Cognition34%(29-39)68%(67-77)34%(27-48)<0.0001Depression13%(9-17)49%(43-54)46%(33-43)<0.0001Social7%(5-11)45%(44-55)38%(35-50)<0.0001Nutritional17%(13-21)65%(60-71)48%(45-57)<0.0001Pain8%(5-11)43%(38-49)35%(32-42)<0.0001Total of suspected problems / patient (mean±SD)1.5±1.24.7±1.73.2±1.8<0.0001Figure 2bDependence for instrumental activities for daily living from lowest (0) to highest dependence (4)
Falls or risk for falls was mentioned for 35% of the admissions whereas using STRATIFY, 46% of the admitted patients were screened as patients at risk for falls (Table 1).
Cognition disorders were mentioned for 34% of patients at admission whereas using CDT, 68% of the admitted patients were screened as patients at risk for cognitive problems.
Depression was mentioned for 3% of the admissions whereas using GDS or Cornell scale, 49% of the admitted patients were screened as patients at risk for depression.
Using the SOCIOS scale, 45% of the patients presented a risk of social complexity whereas only 7% of the patients were declared presenting this problem at admission (Table 1).
According to the MUST score, patients are categorized as presenting respectively high, medium, or low risk for malnutrition (58%; 7%; 35%) whereas this problem was mentioned only for 17% of the patients at admission.
Only 7% of the admitted patients were declared to present a pain problems, the systematic ask for pain or use of a non verbal scale for indicators of pain, 43% of the patients were screened for pain problems.
Mean (±SD) number of screened geriatric problems was 1.5±1.2 without GMST and 4.7±1.7 (p<0.0001) using the MGST (Table 1).
The number of geriatric problems screened with MGST was significantly correlated to the length of stay (R=0.22, p<0.05) and the ISAR score(R=0.35, p<0.0001), but not with age.
Except for the risk of falls, all the other geriatric problems were significantly better screened using MGST (p<0.0001).
“Added-value” of the Minimum Geriatric Screening Tools (MGST) is variable according the centres). This graph with the results of the 8 domains investigated in the MGST were sent to all participants anonymously (except for their known) data in order to offer them the opportunity to compare their results.
Thirty three centres among 104 Belgian geriatric units participated in this National program (32%). There was no obligation to participate. Participating centres received a small fee only. In general, dissemination of interventions to improve quality of care for older persons can be aimed at individual providers, medical groups, or health plans. For practitioners in small or moderate-size groups, the infrastructure and impetus to support systematic practice changes designed to improve quality of care does not exist. Even within large groups, particularly in healthcare markets dominated by fee for service, there has been little incentive to initiate quality-improvement programs. In contrast to health plans, medical groups have not been evaluated on quality, although this is likely to begin.
The tools of the MGST were proposed by working groups of the College for Geriatrics according to the following validity, sensitivity, specificity, and feasibility. These tools were only considered as screening tools. MGST is not really a comprehensive geriatric assessment but a first step to identify geriatric problems at admission. Further algorithms are needed once the risk for a geriatric condition is established (for example, risk of falls for a hospitalized patient?). These algorithms will be established according to the literature review and disseminated in a future program of the College.
Three hundred twenty six patients were enrolled. Their characteristics fulfilled those of vulnerable geriatric patients since they presented with high comorbidity, polypharmacy, and functional, social, cognitive problems. Eighty percent of them were considered as frail according to the cut-off 3 on the ISAR score. The high level of dependence is a common observation within hospitalized geriatric patients in Belgium (22).
As with many other “geriatric” problems, urinary incontinence is often not mentioned (only 4% of patients without using MGST). Using the Katz scale it appeared that 60% of the patients presented urinary incontinence. In 2003, a quality program of the College for geriatrics sensitized the team to urinary incontinence (unpublished data). In this registration of 834 hospitalized patients, 45% of them presented urinary 75% of chronic incontinence and 25% of transient incontinence. Unfortunately, in this 2005 program, without MGST, urinary incontinence remains a “forgotten problem”.
Without using STRATIFY, the risk for falls was already established for 35% of the admissions, the systematic use of S TRATIFY does not lead to a significant increase of recognition of the risk (45%). The natural high incidence of falls as a cause of admission (27%) could explain this observation.
Cognition problems were recognized without the use of the clock drawing test for 34% of the admission. Using the clock drawing test and its simplistic interpretation (correct vs incorrect), 68% of the patients were classified as presenting a risk of cognitive disorders. This incidence is probably overestimated. Nevertheless, according to the comorbidity scale used in this program, the three conditions commonly associated with cognitive disorders in geriatric wards e.g. dementia, delirium and depression were quite well dementia 44%, delirium 17%, and depression 35% of the cases.
Once again depression also remains a forgotten problem (only 3% of patients considered at risk at admission) whereas using GDS half of the patients were considered at risk. Depression is common among hospitalised geriatric patients. However, the diagnosis of depression is often not recognised for several reasons. The severity of the medical problems could lead the geriatrician to under-estimate the affective disorders of the geriatric patients. Depression is consistently reported to be more prevalent in physically ill elderly subjects than in their healthy counterparts. This may be particularly true for some subgroups of the elderly. Beeckman et al. (23) found that the association between poor physical health and depression was much stronger for the old-old (age>75) and for men than for the young-old (55-64) and women. They also noted that more subjective measures of physical health (pain and self rating of health) appeared to have a much stronger relation with depression than relatively objective measures (number of chronic diseases, degree of functional limitation). In the community dwelling elderly Kennedy et al. (24) indicated that 30% of elderly subjects with four or more medical conditions were depressed compared to only 5% of those without medical illnesses. Similarly, Evans (25) and Katona (26) observed that the prevalence of depression in elderly primary care attenders with poor physical health was double that in the physically healthy. Studies in hospitalised subjects show conflicting The prevalence of depression in physically ill inpatients has been reported as being between 11% and 59%, depending on the instrument used, sex, age and type of ward ( 26., 27., 28.).
Using the SOCIOS instrument, forty percent of patients were considered at risk for social complexity (versus only 7% without this screening). The early recognition of social complexity is a important part of comprehensive geriatric assessment and leads to a reduction in the length of stay and the risk of re-hospitalization (2).
Using a systematic screening of malnutrition, 65% of the patients presented a risk. We have already observed this high incidence in a previous study of the College for Geriatrics recently published (29).
Finally, pain was also demonstrated to be under-detected: (only 8% detected without a systematic screening versus 43% of the patients at risk). Chronic pain was observed among 25 to 50% of autonomous subjects of >70 years old (30, 31). For nursing home residents, this prevalence can reach 45-80 % (32, 33).
Our study has some limitations that deserve comment. This short-time survey was the first attempt for the teams to list “a priori” geriatric problems for a limited number of successive patients; this situation was probably not associated with a “training effect”. On the other hand, the sensitivity of the screening tools is high and allows a good detection of well known problems but is not always suitable for intervention or for potential improvement. Moreover the delay before and after the use of the MGST may be associated with the occurrence of new geriatric problems; this situation might “overestimated” the added value of the MGST.
The risk of underestimation could also be for example, for initial diagnosis there was a time window of two days, however, for a geriatric assessment diagnosis, there was a time window of seven days. For some problems, the length of observation may be important, for example, in the detection of urinary incontinence.
The possibility of over-diagnosis may also have been present. Did 49% of patients have depression? The use of too sensitive instruments could identify risks rather than problems. Nevertheless, at the end of hospitalization the prevalence of depression assessed by the comorbidity index remained high.
The main causes usually seen for admission are of great importance for the choice of the tools. The MGST was proposed a priori for all patients admitted in Belgian acute geriatric units independently of the main causes of admission.
Finally, the time necessary for the minimum geriatric data set assessment was not calculated and this study was not designed to assess the effect of MGST on the outcomes of the patients.
The quality of care of older persons remains far from optimal, particularly for conditions that exemplify the clinical discipline of geriatrics 34-36. Quality improvement efforts for older persons will likely remain piecemeal, largely confined to managed care and research settings. At the dawn of the third millennium, the distance to the goal line of uniformly high quality of care for older persons remains many yards away.