Geriatric Interventions: The Evidence Base for Comprehensive Health Care Services for Older People

Article excerpt

Abstract

Specialist geriatric services apply a comprehensive, multidisciplinary evaluation and management approach to the multidimensional and usually interrelated medical, functional and psychosocial problems faced by at-risk frail elderly people. This paper examines currently available data on geriatric interventions and finds ample evidence supporting both the efficacy and the cost-effectiveness of these specialist interventions when utilised in appropriately targeted patients. It is proposed that substantial investment in these programs is required to meet the future demands of Australia's ageing population.

Aust Health Rev 2005: 29(2): 151-155

FRAIL ELDERLY PATIENTS frequently pose complex and interrelated medical, functional and psychosocial challenges. To address the need for comprehensive holistic management approaches to these multidimensional problems, specialist geriatric medical units were established in Australian hospitals during the 1960s. The scope of these specialist services was expanded in the 1980s following the introduction of multidisciplinary Geriatric Domiciliary Care/Aged Care Assessment Teams, with specialised medical, nursing, physiotherapy, occupational therapy and social work inputs. Staff providing these inputs continue to form the nucleus of modern acute hospital, rehabilitation and outpatient health care services for older people and represent the technology of geriatric medicine today.

Programs instituted by Australian health service providers for older people are modeled on the principles of Comprehensive Geriatric Assessment (CGA) and Geriatric Evaluation and Management (GEM). CGA is a technique that aims to uncover the multidimensional problems of at-risk frail elderly people, with the purpose of planning and/or implementing coordinated medical, psychosocial and rehabilitative care tailored to the patients specific needs.1"3 The term GEM is appropriate when CGA is coupled with some therapy.2,4 GEM models have been implemented and their effectiveness evaluated in both inpatient and outpatient settings.

Evaluation of the evidence for geriatric interventions is challenging for a variety of reasons. Firstly older patients are often excluded from intervention studies, with results frequently extrapolated from data in younger subjects.5 Outcome measures for therapeutic interventions in younger cohorts (eg, cure rates, survival) are not always the most appropriate markers of treatment success in frail elderly patients. Furthermore, even studies comparing the effectiveness of specialist geriatric services with "usual medical care" occasionally apply only agerelated admission criteria, thereby inappropriately recruiting elderly patients with single diagnoses but no other features suggesting the need for specialist geriatric intervention.6 This literature review discusses the effectiveness of geriatric interventions based on currently available data, mainly focusing on data from randomised controlled trials comparing GEM related interventions with usual medical care in elderly patients presenting with multidimensional problems. The main outcome measures reported are those particularly relevant to geriatric populations, including functional status, quality of life and avoidance or delay of nursing home admission.

Inpatient GEM interventions

Rubenstein and colleagues undertook a comparison of inpatient GEM interventions with usual medical care in an acute hospital setting in 1984.7 In this 1-year follow up study, frail elderly patients undergoing GEM-model inpatient care demonstrated significantly greater improvements in functional status (48% more GEM patients with improvements on the Personal Self Maintenance Scale), fewer initial discharges to nursing homes (58% fewer), less time spent in nursing homes and acute care hospitals (mean 42% and 25% less, respectively), as well as fewer acute care hospital readmissions (30% less).7 The GEM intervention was also associated with improved morale, much lower mortality (51 % lower) and lower direct costs for institutional care (19% lower). …