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Admission to Department of General Internal Medicine or Department of Geriatrics

St. Olavs Hospital University Hospital of Trondheim. Admission to Department of General Internal Medicine or Department of Geriatrics. Does it matter?. Olav Sletvold. Reasons for asking………. Demographics and epidemiological trends Greying of nations

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Admission to Department of General Internal Medicine or Department of Geriatrics

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  1. St. Olavs Hospital University Hospital of Trondheim Admission to Department of General Internal Medicine or Department of Geriatrics Does it matter? Olav Sletvold

  2. 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

  3. Demographics of NorwayElderly persons > 67 years Ref: Statistics Norway 2008, http://www.ssb.no/folkfram/

  4. 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

  5. ”The Malta Definition” EUGMS

  6. “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 offrailty 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

  7. 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

  8. 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

  9. 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 Structure of specialities

  10. Admission toDepartment of General Internal Medicine or Department of Geriatrics Does it really matter?

  11. Selected referencesGeriatrics 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

  12. 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

  13. 1984 Ref: Rubenstein & al N Engl J Med, 1984

  14. 2002 (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

  15. 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

  16. 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)

  17. 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

  18. Ref: Rubenstein N Engl J Med, 1984

  19. 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

  20. Acute impairment of single ADL Imbalance, dizziness Impaired mobility Chronic disability Weight loss, malnutrition Falls during the last 3 months Prolonged bedrest Depression Confusion Mild / moderate dementia Urinary incontinence Polypharmacy Vision or hearing impairment Social / family problems Targeting criteria Ref : Winograd & al J Am Ger Soc 1991

  21. Baseline characteristics Age - mean SD Female - no (%) 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*) GEMU (n=127) 82  5 81 (64) 93 (73) 115 (91) 12 (9) 2 (1;5) 4 (3;5) MW (n=127) 82  5 84 (66) 85 (67) 110 (87) 17 (13) 3 (1;6) 4 (3;5) *iqr= interquartile range

  22. 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)

  23. Time to discharge

  24. Cumulative survival (p= 0.004 at 3 months, p=0.02 at 6 months, and p=0.06 after 12 months)

  25. Number of patients living at home 3 months 6 months GEMU (n=127) 101 (80%) 92 (73%) MW (n=127) 80 (64%) 76 (61%) HR : 2.1 (1.3; 3.4) after 3 months. HR : 1.7 (1.1; 2.6) after 6 months.

  26. Partitioned survival curves Nursinghome Nursinghome Time (months)

  27. Poor outcomes 3 months 6 months 12 months % 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).

  28. Positive outcomes 6 months 3 months 12 months % 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.

  29. 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

  30. 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

  31. Does it matter?

  32. 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

  33. From GEMU to acute geriatric care St. Olav University Hospital 2010

  34. 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

  35. 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

  36. 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)

  37. 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

  38. 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

  39. Physiotherapist • PT work-up • Evaluation of • Falls, balance problems, immobility, physical activity limitations • Mobility aids • Compression stockings • Hip protectors • Exercise classes • Potential for rehab

  40. 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)

  41. Meta-analyses and reviewsComprehensive Geriatric Assessment • StuckAE & 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

  42. Takk for meg

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