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Admission to Department of General Internal Medicine

or Department of Geriatrics

St. Olavs HospitalUniversity Hospital of Trondheim

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 NorwayElderly 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?

12

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

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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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Ref: Rubenstein & al N Engl J Med, 1984

1984

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No. at riskGEMU 112 107 102 92MW 93 90 85 84

MW

Months

0 3 6 9 120.0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1.0

Medical Wards (MW)Geriatric Unit (GEMU)

(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

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

• Prolonged bedrest

• Depression

• Confusion

• Mild / moderate dementia

• Urinary incontinence

• Polypharmacy

• Vision or hearing impairment

• Social / family problems

Ref : Winograd & al J Am Ger Soc 1991

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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

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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)

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Time to discharge

Time from inclusion (days)

Percen

tage o

f p

ati

en

ts d

isch

arged

0

20

40

60

80

100

GEMU MW

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No. at riskGEMU 112 107 102 92MW 93 90 85 84

MW

Months

0 3 6 9 120.0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1.0

Medical Wards (MW)Geriatric Unit (GEMU)

Cumulative survival

(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 12 months

GEMU MW GEMU MW

Heart disease – no (%)

Infectious disease* – no (%)

Cerebrovascular disease – no (%)

Cancer – no (%)

Other – no (%)

6

5

0

1

3

(40.0)

(33.3)

(0)

(6.7)

(20.0)

18

4

4

5

3

(52.9)

(11.8)

(11.8)

(14.7)

(8.8)

14

12

1

3

5

(40.0)

(34.2)

(2.9)

(8.6)

(14.3)

23

6

5

6

3

(53.5)

(13.9)

(11.6)

(13.9)

(7.0)

Total 15 (100) 34 (100) 35 (100) 43 (100)

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Table 4: Number of readmissions to hospital

GEMU MW

N % N %

0-3 months 1 20 (17.4) 22 (21.8)

2 ormore 10 (8.7) 8 (7.9)

0-6 months 1 19 (17.0) 26 (26.3)

2 ormore 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

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.

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Hospital

Home

0

25

50

75

100

GEMU

Per

cent

age

1 2 3 4 5 6

Hospital

Home

0

25

50

75

100

MW

Per

cent

age

1 2 3 4 5 6

Time (months)

Partitioned survival curves

Nursing home

Nursing home

30

12

2620 16

24 27 28

4538

2733 34

2935

45

34

45 44

0

20

40

60

80

100GEMUMW

%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).

Poor outcomes

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88

38 35

21

84

43

31

22

72

3428

21

73

3127

12

71

34

25

12

66

31

2114

0

20

40

60

80

100GEMU MW

3 months 6 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.

%

Positive outcomes

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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 ina 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?

No. at riskGEMU 112 107 102 92MW 93 90 85 84

MW

Months

0 3 6 9 120.0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1.0

Medical Wards (MW)Geriatric Unit (GEMU)

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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 reviewsComprehensive 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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