Identifying vulnerable older adults with cancer: integrating geriatric assessment into oncology practice. Controlled trial of a geriatric case-finding and liaison service in an emergency department. The feasibility of inpatient geriatric assessment for older adults receiving induction chemotherapy for acute myelogenous leukemia. End points and trial design in geriatric oncology research: a joint European organisation for research and treatment of cancer--Alliance for Clinical Trials in Oncology--International Society Of Geriatric Oncology position article. Assessing Care of Vulnerable Elders: ACOVE Project Overview A comprehensive geriatric intervention detects multiple problems in older breast cancer patients. Effectiveness of a Geriatric Care Model for frail older adults in primary care: Results from a stepped wedge cluster randomized trial. Prediction of falls in older adults with cancer: a preliminary study A randomized controlled trial of the Geriatric Depression Scale in an inpatient ward for older adults Impact of continued geriatric outpatient management on health outcomes of older veterans. A randomized trial of early psychiatric intervention in residential care: impact on health outcomes. Drugs prescribed for patients hospitalized in a geriatric oncology unit: Potentially inappropriate medications and impact of a clinical pharmacist. Geriatric Assessment Improves Prediction of Surgical Outcomes in Older Adults Undergoing Pancreaticoduodenectomy: A Prospective Cohort Study Geriatric assessment is associated with completion of chemotherapy, toxicity, and survival in older adults with cancer. Evaluation of geriatric assessment in patients with chronic lymphocytic leukemia: Results of the CLL9 trial of the German CLL study group Comprehensive geriatric assessment and comorbidities predict survival in geriatric oncology Development and delivery of patient treatment in the Trondheim Hip Fracture Trial. A new geriatric in-hospital pathway for elderly patients with hip fracture The Quality of Pharmacologic Care for Vulnerable Older Patients Geriatric Resources for Assessment and Care of Elders (GRACE): a new model of primary care for low-income seniors. Systematic reviews in public health: old chestnuts and new challenges. Multidimensional geriatric assessment in treatment decision in elderly cancer patients: 6-year experience in an outpatient geriatric oncology service. Geriatric home assessment after hospital discharge. The Quality of Medical Care Provided to Vulnerable Community-Dwelling Older Patients
OBJECTIVES To integrate the principles of geriatric assessment into the care of older patients with cancer in order to identify vulnerable older adults and develop interventions to optimize cancer treatment . DESIGN A brief , comprehensive , self-administered question naire and intervention algorithm were developed consisting of measures of  geriatric assessment  that are brief , reliable , vali date d , and predictive of mortality and morbidity in older patients . SETTING Academic tertiary care cancer center and community-based satellite practice . PARTICIPANTS Patients aged 65 and older with cancer . MEASUREMENTS The question naire solicits information about the patient 's functional status , comorbidity , psychological status , nutritional status , and social support . A scoring algorithm for referral to a multidisciplinary team was developed . RESULTS Two hundred forty-five of 250 patients completed the question naire ( mean age 76 , range 65 - 95 ) . The majority of patients were women ( 71 % ) , white ( 95 % ) , married ( 52 % ) , and retired ( 90 % ) , with a variety of tumor types and stages . Most patients ( 78 % ) completed the question naire on their own and reported acceptance of question naire length ( 91 % ) , no difficult questions ( 94 % ) , no up setting questions ( 96 % ) , and no missing questions ( 89 % ) . The mean time to completion was 15 minutes , with a median of 12.5 ( st and ard deviation 10 , range 2 - 60 ) . Information from this question naire helped identify physical and psychological impairments , poor nutrition , lack of social support , and untreated comorbidities . Appropriate referrals to a multidisciplinary team were made . CONCLUSION This brief , comprehensive , self-administered question naire is feasible for use in the outpatient oncology setting and helped identify the needs of geriatric oncology patients . Prospect i ve trials are needed to determine the effectiveness of the interventions offered OBJECTIVE To evaluate the effects of a program of case-finding and liaison service for older patients visiting the emergency department . DESIGN Nonr and omized controlled trial with systematic ally assembled intervention cohort and matched control group . SETTING An urban teaching hospital . PARTICIPANTS There were 385 intervention subjects aged 65 years and older and 385 control subjects matched by day of visit , gender , and age within 5 years . INTERVENTIONS Geriatric medical , dental and social problems were identified in intervention subjects by a geriatric nurse clinician using well vali date d assessment instruments during a 30-minute evaluation . Recommendations were made to the patient , family , and attending emergency department physician , and attempts were made to arrange appropriate follow-up services . MEASUREMENTS Frequency with which geriatric problems were identified in intervention subjects ; physician , patient , and family compliance with recommendations ; and mortality , institutionalization , health status , use of medical and social services , presence of an advanced directive , and quality of life at 3-month follow-up . RESULTS Sixty-seven percent of patients were dependent in at least one activity of daily living , 82 % had at least one geriatric problem identified , and 77 % reported at least one unmet dental or social support need . The cost of identifying geriatric and dental/social issues was $ 5 and $ 1 , respectively , for each problem . Physicians compiled with 61.6 % of suggestions , and patients and families complied with 36.6 % of recommendations . Mortality and nursing home residence proportions at 3 months were not significantly different ( 9.3 % vs 9.7 % and 5.0 % vs 2.5 % in intervention and control groups , respectively ) . Intervention subjects reported more difficulty communicating ( 21 % fair or poor ability vs 13 % , P = 0.2 ) than did control subjects . There were strong trends for fewer subsequent visits to emergency departments ( 0.26 intervention vs 0.39 control , P = .06 ) and more advance directives in the intervention group ( 6.7 % intervention vs 2.9 % control , P = .07 ) . There was no statistically or clinical ly significant difference in any other health outcome . The number of new dental or social services initiated per patient over the 3-month follow-up was nearly identical ( 1.7 in the intervention group vs 1.5 in the control ) . Results in subjects aged 75 years and older and those discharged home from the emergency department were essentially identical to those in the main group . CONCLUSIONS Numerous previously unrecognized geriatric medical and social problems can be detected in older persons visiting the emergency department . Despite this , an emergency department-based geriatric assessment and management program failed to produce improved outcomes . This suggests that either disease acuity is an overwhelming factor in subsequent outcome or , alternatively , more control over medical and social service delivery during and after the emergency department visit than was demonstrated in this program will be required before successful outcomes can be assured OBJECTIVES To test the feasibility and utility of a bedside geriatric assessment ( GA ) to detect impairment in multiple geriatric domains in older adults initiating chemotherapy for acute myelogenous leukemia ( AML ) . DESIGN Prospect i ve observational cohort study . SETTING Single academic institution . PARTICIPANTS Individuals aged 60 and older with newly diagnosed AML and planned chemotherapy . MEASUREMENTS Bedside GA was performed during inpatient exmination for AML . GA measures included the modified Mini-Mental State Examination ; Center for Epidemiologic Studies Depression Scale ; Distress Thermometer , Pepper Assessment Tool for Disability ( includes self- reported activities of daily living ( ADLs ) , instrumental ADLs , and mobility questions ) ; Short Physical Performance Battery ( includes timed 4-m walk , chair st and s , st and ing balance ) ; grip strength , and Hematopoietic Cell Transplantation Comorbidity Index . RESULTS Of 54 participants ( mean age 70.8 ± 6.4 ) eligible for this analysis , 92.6 % completed the entire GA battery ( mean time 44.0 ± 14 minutes ) . The following impairments were detected : cognitive impairment , 31.5 % ; depression , 38.9 % ; distress , 53.7 % ; impairment in ADLs , 48.2 % ; impaired physical performance , 53.7 % ; and comorbidity , 46.3 % . Most were impaired in one ( 92.6 % ) or more ( 63 % ) functional domains . For the 38 participants rated as having good performance status according to st and ard oncologic assessment ( Eastern Cooperative Oncology Performance Scale score ≤1 ) , impairments in individual GA measures ranged from 23.7 % to 50 % . Significant variability in cognitive , emotional , and physical status was detected even after stratification according to tumor biology ( cytogenetic risk group classification ) . CONCLUSION Inpatient GA was feasible and added new information to st and ard oncology assessment , which may be important for stratifying therapeutic risk in older adults with AML Selecting the most appropriate end points for clinical trials is important to assess the value of new treatment strategies . Well-established end points for clinical research exist in oncology but may not be as relevant to the older cancer population because of competing risks of death and potentially increased impact of therapy on global functioning and quality of life . This article discusses specific clinical end points and their advantages and disadvantages for older individuals . R and omized or single-arm phase II trials can provide insight into the range of efficacy and toxicity in older population s but ideally need to be confirmed in phase III trials , which are unfortunately often hindered by the severe heterogeneity of the older cancer population , difficulties with selection bias depending on inclusion criteria , physician perception , and barriers in willingness to participate . All clinical trials in oncology should be without an upper age limit to allow entry of eligible older adults . In setting s where so-called st and ard therapy is not feasible , specific trials for older patients with cancer might be required , integrating meaningful measures of outcome . Not all questions can be answered in r and omized clinical trials , and large observational cohort studies or registries within the community setting should be established ( preferably in parallel to r and omized trials ) so that treatment patterns across different setting s can be compared with impact on outcome . Obligatory integration of a comparable form of geriatric assessment is recommended in future studies , and regulatory organizations such as the European Medicines Agency and US Food and Drug Administration should require adequate collection of data on efficacy and toxicity of new drugs in fit and frail elderly sub population Civilization and modern medicine now allow an unprecedented number of people to survive to old age . Not only has the definition of old evolved , but the aims of medical care for the elderly have progressed far beyond survival to maximizing functional and cognitive status , improving quality of life , and preserving productivity . Although many health problems in older age can be prevented or postponed by medical interventions , the quality of medical care for older persons remains largely unexamined . Previous work on quality -of-care measurement has focused on specific diseases or aspects of care , and in some cases targeted only a slice of the older population ( 16 ) . Such targeted approaches may not present a fair picture of overall quality and may lead to unintended incentives ( gaming the system ) ( 7 ) . Although broad systems of quality -of-care evaluation are less susceptible to gaming , they seldom include quality indicators focused on aspects of care important to older sick persons ( 8 , 9 ) . Substantial variation in preferences may make quality of care for older adults particularly difficult to measure . For example , older adults do not consistently prefer care that prolongs life , particularly if this care occurs at the expense of comfort . Furthermore , many ill , older adults can not advocate for themselves and may have no family members or friends to do so on their behalf . Thus , objective measures of the care they receive are particularly important . The Assessing Care of Vulnerable Elders ( ACOVE ) project endeavored to develop a comprehensive set of  quality - assessment tools for ill older persons . Because ill older persons constitute a heterogeneous cohort that is not easily delineated , we created a system to identify high-risk , community-dwelling individuals and targeted the most important clinical conditions affecting them . Specifically , our goals for this project were the following : 1 . Develop a definition of vulnerable elders that delineates a group of community-living persons 65 years of age and older who are at high risk for death or functional decline , and develop a system to identify them . 2 . Identify important medical conditions that affect vulnerable elders and for which effective methods of prevention or management exist . 3 . Develop a set of evidence -based , quality -of-care indicators that are relevant to vulnerable elders using systematic literature review s , expert opinion , and the guidance of expert groups and stakeholders . 4 . Design a chart abstract ion tool , interview instrument , and administrative data analytic methods to implement the quality -of-care indicator system . Project Structure : Advisory Boards To make the ACOVE tools as clinical ly useful as possible and to enhance their value to those who may use them , two advisory committees oversaw the project . The Clinical Committee directed the definition of the target population and identified the target conditions . It also review ed the full set of quality indicators assembled by the expert panels ( see the Methods paper ) . The Policy Advisory Committee directed the structure of the quality indicator system and the measurement approach . This committee review ed the sampling system , considered the value of a community surveybased sample versus a sample drawn from administrative data , advised the project on methods of data collection , and advocated the use of process measures rather than outcomes .Project Overview The Appendix lists the members and institutional affiliations of the Clinical Committee and the Policy Advisory Committee and ACOVE investigators and staff . Definition and Selection of the Patient Sample We termed our target sample vulnerable elders . With the assistance of the Clinical Committee , we defined vulnerable elders as persons 65 years of age and older who are at increased risk for death or functional decline . We considered several methods of identifying a community-based sample for measurement , including use of administrative data and survey sampling . The Policy Advisory Committee advised against using a sampling method based solely on administrative data because , by definition , using utilization data to define health status and disease burden disproportionately sample s persons with higher utilization of health services and may not identify persons who are undertreated or underdiagnosed . We selected a survey method that would identify vulnerable elders regardless of the amount of health care they used and that would be versatile for use across venues and health insurance systems . Using the Medicare Current Beneficiary Survey , we determined that functional status is a more important predictor of death and functional decline than are specific clinical conditions . A parsimonious set of factors that could be asked about in a brief interview , including age , self-rated health , and functional disabilities and limitations , predicted functional decline and death . Using these factors , we developed a scoring system that identified 32 % of a nationally representative sample as vulnerable : This group had more than four times the risk for death or functional decline over a 2-year period compared to the lower-scoring majority of the sample ( 10 ) . When we applied this definition to a r and om sample of persons 65 years of age and older enrolled in managed care plans , 21 % of elders were classified as vulnerable . Target Conditions for Assessing Quality of Care We selected the target conditions for quality -of-care assessment using literature review s and a formal group-judgment process . Target conditions were conceptualized as prevalent , important to health status and quality of life , having outcomes affected by medical care , feasible to measure , and geriatric . The Clinical Committee used these criteria to select 21 diseases , geriatric syndromes , physiologic impairments , and clinical situations ( see the Methods article for a list of these 21 conditions ) . The Policy Advisory Committee added a 22nd condition , continuity and coordination of care . According to national survey estimates , the prevalence of the selected conditions ranged from 10 % to 50 % among community-dwelling elders . These conditions accounted for at least 43 % of acute hospital admissions and 33 % of office visits for persons 65 years of age and older . The process of selecting the conditions is discussed in detail elsewhere ( 11 ) . Developing  Quality -of-Care Indicators  for Vulnerable Elders Clinical experts developed potential quality indicators for each target condition using existing guidelines and clinical opinion . Indicators covered the domains of prevention , diagnosis , treatment , and follow-up . Structured literature review s were then performed to assess the evidence supporting a link between the proposed processes of care and improved outcomes in older adults . We subsequently presented the proposed quality indicators and the literature syntheses to panels of experts in geriatric care and medical specialists . These expert panels considered the indicators ' validity and feasibility . On the basis of the panels ' ratings and a comprehensive review of the set by the Clinical Committee , we developed a set of 236  quality indicators  covering the 22 conditions . The Methods article describes this process in detail . This set of indicators was review ed and modified by the American College of PhysiciansAmerican Society of Internal Medicine ( ACPASIM ) Task Force on Aging . The full set of quality indicators with the literature substantiation for 11 of the conditions constitute the remainder of this supplement . A review of the accepted quality indicators reveals their decidedly geriatric nature . Many of them focus on the transfer of information between the health care provider and the patient or patient 's proxy . In addition to disease management , the indicators pay attention to detecting classically underidentified conditions , such as depression , dementia , and functional impairment . Consideration of proportionate care , informed consent , and end-of-life issues permeates the set . Implementing the Quality Indicators We developed instruments to implement the quality indicators using information collected from three sources : the medical record , a patient ( or , if necessary , proxy ) interview , and administrative data . Medical records include all inpatient and outpatient care over a 1-year period . The interview is design ed to be conducted by telephone with the patient to identify aspects of care that are not well captured in the medical record . The  quality indicators  presented here are currently undergoing feasibility testing in two managed care plans . Scoring the quality indicators accounts for clinical circumstances , patient preferences , and patient prognosis . The scoring of each quality indicator accounts for these factors at the following five levels : 1 . Any chart documentation indicating that a care process does not apply to the patient excludes application of this indicator to the patient . 2 . Any care process that is contraindicated because of comorbidity , allergy , or intolerance ( such as contraindications to medication ) excludes application of the indicator to the patient . 3 . If an indicator states that a care process should be offered to a patient , this indicator is satisfied if the care process occurs , if the medical record ( or patient interview ) indicates that the patient rejected the care process , or if the medical record ( or patient interview ) documents that the care process was offered to the patient . 4 . If the medical record contains documentation or if during an interview a patient states that he or she would not want , under any circumstances , to be hospitalized , then the 11 indicators that would require hospitalization do not apply . Similarly , a preference not to accept surgery would exclude from application to that patient the 9 indicators that prescribe surgery or procedures that would lead to surgery . 5 . If a patient has advanced dementia or a chart-documented poor prognosis ( expected survival < 6 months ) , then UNLABELLED Studies of comprehensive geriatric assessment ( CGA ) have shown the importance of follow-up for effectiveness , but this has not been tested in an oncology clinic . In this pilot study , we enrolled 15 early breast cancer patients , aged 70 and older . They received a multidisciplinary CGA every 3 months and structured follow-up from the SAOP nurse practitioner , dietitian , social worker , and pharmacist according to risk . Total follow-up was 6 months . Median age of evaluable patients was 79 years ( range 72 - 87 ) .  Median number of comorbidities by Cumulative Index Rating Scale-Geriatric ( CIRS-G ) was 5 ( 3 - 9 ) at baseline . Ten patients were at pharmacological risk , five at psychosocial risk , and eight at nutritional risk . Patients presented on average six problems initially , and three new problems during follow-up . The intervention directly influenced oncological treatment in four cases . It ensured continuity/coordination of care in seven cases . Success rate in addressing problems was 87 % . Mean Functional Assessment of Cancer Treatment-Breast ( FACT-B ) scores improved from 110.5 ( S.D. 16.7 ) to 116.3 ( S.D. 16.5 ) ( t=0.025 ) . Function and independence were maintained . CONCLUSIONS Older patients with early breast cancer have a high prevalence of comorbidity . A CGA with follow-up has potential for improving the treatment and prognosis of these patients and is feasible in an academic oncology setting BACKGROUND Primary care-based comprehensive care programs have the potential to improve outcomes in frail older adults . We evaluated the impact of the Geriatric Care Model ( GCM ) on the quality of life of community-dwelling frail older adults . METHODS A 24-month stepped wedge cluster r and omized controlled trial was conducted between May 2010 and March 2013 in 35 primary care practice s in the Netherl and s , and included 1147 frail older adults . The intervention consisted of a geriatric in-home assessment by a practice nurse , followed by a tailored care plan . Re assessment occurred every six months . Nurses worked together with primary care physicians and were supervised and trained by geriatric expert teams . Complex patients were review ed in multidisciplinary consultations . The primary outcome was quality of life ( SF-12 ) . Secondary outcomes were health-related quality of life , functional limitations , self-rated health , psychological wellbeing , social functioning and hospitalizations . RESULTS Intention-to-treat analyses based on multilevel modeling showed no significant differences between the intervention group and usual care regarding SF-12 and most secondary outcomes . Only for IADL limitations we found a small intervention effect in patients who received the intervention for 18months ( B=-0.25 , 95%CI=-0.43 to -0.06 , p=0.007 ) , but this effect was not statistically significant after correction for multiple comparisons . CONCLUSION The GCM did not show beneficial effects on quality of life in frail older adults in primary care , compared to usual care . This study strengthens the idea that comprehensive care programs add very little to usual primary care for this population . TRIAL REGISTRATION The Netherl and s National Trial Register NTR2160 PURPOSE / OBJECTIVES To determine the extent to which falls occur in older adult patients with cancer ; to identify how falls relate to depression , age , functional status , and cognition ; and to develop a model for predicting falls . DESIGN Descriptive , prospect i ve , quantitative . SETTING Patients in the Senior Adult Oncology Program at the H. Lee Moffitt Cancer Center and Research Institute . SAMPLE 165 patients aged 70 years or older with any diagnosis of cancer , treatment type , and stage . METHODS Data were collected during a one-time interview using a comprehensive geriatric assessment consisting of the Instrumental Activities of Daily Living ( IADL ) Scale , Activities of Daily Living ( ADL ) Scale , Geriatric Depression Scale , Mini-Mental State Examination , and a fall assessment .  MAIN RESEARCH VARIABLES Falls , functional status , depression , cognition , age , and gender . FINDINGS IADL scores were found to be a predictor of falls while controlling for age and ADL status . An IADL score of 22 predicts a 21 % risk of a fall . Fall risk increases to 81 % at an IADL score of 9 . CONCLUSIONS IADL score is a predictor of falls in this older adult population with cancer . ADL scores are not a predictor of falls when IADL is included in the model . IMPLICATION S FOR NURSING Nurses must play a vital role in conducting fall screening and risk assessment s for older adults with cancer Objectives : To measure the prevalence of high scores on the Geriatric Depression Scale in an inpatient unit for older people and assess whether administration of this instrument increased the use of antidepressant medication . Design : R and omized controlled trial . Setting : Inpatient unit for assessment , treatment and rehabilitation of older adults in a district hospital . Subjects : Consecutive admissions to the inpatient unit were approached . Of 198 people , 100 gave consent and were r and omized to receive the intervention . Interventions : The  Geriatric Depression Scale and the Folstein Mini-mental State Examination were administered to the intervention group . The Nottingham Instrumental Activities of Daily Living question naire and the Folstein Mini-mental State Examination were administered to the placebo group . The scores of these instruments and a copy of the completed instrument were placed in the subject 's case notes . For those subjects r and omized to receive the Geriatric Depression Scale an interpretation of the score was written in the case notes . Main outcome measures : The primary outcome measure was whether antidepressant medication was listed on the discharge summary for the admission . Other outcome measures were death , readmission and use of antidepressant medication three months after administration of the instruments . Results : There was a prevalence of Geriatric Depression Scale scores greater than 10 of 52 % in the 50 people administered this instrument . Six out of 46 people administered the Geriatric Depression Scale  , who were discharged in the study period , were on antidepressant medication at discharge . Three out of 47 people administered the placebo instrument were on antidepressant medication at discharge . The absolute difference in proportions was 6.7 % , 95 % confidence interval 19 to – 5.3 % . Conclusions : A high proportion of patients admitted to an inpatient unit for assessment , treatment and rehabilitation scored in the depressed range on the Geriatric Depression Scale ; however , use of the Geriatric Depression Scale in this clinical setting did not increase the use of antidepressant medication . This may be because the instrument is too nonspecific BACKGROUND Although previous trials have proved inpatient-based geriatric assessment to be beneficial , to our knowledge , the effectiveness of outpatient geriatric assessment has not been established . We examined the effectiveness of an outpatient geriatric evaluation and management ( GEM ) clinic . METHODS Hospitalized veterans aged 65 years or older with impairment of activities of daily living , chronic disease , polypharmacy , or two or more hospitalizations in the previous year were r and omized to an outpatient GEM team clinic ( n = 60 ) or usual care ( n = 68 ) . After an initial comprehensive assessment , they received long-term management in the geriatric clinic . Principal outcomes included health status ( mortality , hospitalizations , health perception , and medications ) , function ( activities of daily living , instrumental ADL , and social activity ) , affect ( Center for Epidemiologic Studies -Depression test score and life satisfaction ) , and cognition ( Mini-Mental State examination score ) . RESULTS At r and omization , no significant differences were noted between the groups . The average age of the patients was 71 years ( range , 65 to 93 years ) . At 1 year following r and omization , GEM clinic patients compared with subjects receiving usual care had significantly improved health perception , took fewer medications despite increased number of diagnoses , reported greater social activity , had improved Center for Epidemiologic Studies -Depression scale scores , and had higher life satisfaction scores . There was a trend toward improved performance of activities of daily living for GEM clinic patients . The GEM clinic patients had a 54 % lower mortality ( 6.8 % vs 14.9 % ) . Overall , no differences were observed in the total number of hospitalizations between the groups . CONCLUSIONS The combination of long-term management following comprehensive outpatient assessment significantly improved aspects of health status ( including health perception and medications ) , function ( including social activity ) , and affect ( including depression and life satisfaction ) for older veterans and may influence mortality and function BACKGROUND The prevalence of psychological and behavioral disturbances among older adults living in residential care facilities is high , and it has been shown previously that people with such symptoms have poorer health outcomes . This study was design ed to assess the efficacy of an early psychiatric intervention on the 12-month health outcomes of older adults admitted to residential care facilities in Perth , Western Australia . We hypothesized that subjects in the intervention group would have better mental and physical health outcomes than controls . METHODS The study was design ed as a r and omized , single-blinded , controlled trial . All subjects aged 65 years or over admitted to one of the 22/26 participating residential care facilities of the Inner City area of Perth were approached to join the study and were allocated r and omly to the intervention or usual care group . Demographic and clinical information ( including medications and use of physical restraint ) was gathered systematic ally from all participants at baseline , and at 6 and 12 months . At each assessment , the Geriatric Depression Scale ( GDS ) , the Health of the Nation Outcome Scales for older adults ( HoNOS 65 + ) , the Mini-mental State Examination ( MMSE ) and the Neuropsychiatric Inventory ( NPI ) were administered . Subjects in the intervention group who screened positive at the baseline assessment for psychiatric morbidity were review ed within a 2-week period by the Inner City Mental Health Service of Older Adults ( ICMHSOA ) . If clinical ly appropriate , mental health services were introduced without the involvement of the research team . RESULTS One hundred and six subjects and their next of kin consented to participate in the study ( 53 in each group ) . Mental health screening and early referral to a psychogeriatric service did not significantly change the average number of medical contacts , self-rated health , use of psychotropic or PRN medication , use of physical restraint , 12-month mortality , or mental health outcomes , as measured by the GDS-15 , HoNOS 65 + and NPI ( p > 0.05 for all relevant outcomes ) . CONCLUSION Systematic mental health screening of older adults admitted to residential care facilities and early clinical intervention does not change 12-month health outcomes . More effective interventions to improve the health outcomes of older adults with psychological and behavioral disturbances admitted to residential care facilities are needed OBJECTIVES The aim of this study was to assess the prevalence of potentially inappropriate medication ( PIM ) use upon admission and at discharge in a geriatric oncology unit after involving a clinical pharmacist . Although the few studies conducted in geriatric oncology units used the 2003 Beers criteria , this study used START and STOPP criteria , a more appropriate tool for European formularies . MATERIAL S AND METHODS Prospect i ve study in older ( ≥70years ) patients consecutively admitted to a geriatric oncology unit in a cancer center from July 2011 to April 2012 .  Clinical pharmacist conducted a complete comprehensive medication review including non-prescription and complementary ( herbals ) medications . This information coupled with the patient 's medical history allows identifying PIMs using the STOPP and START criteria . The number of PIMs at admission and at discharge from the hospital was compared after clinical pharmacist intervention . RESULTS Ninety-one older patients with cancer ( mean age±SD=79±6years ) were included in the study . START criteria identified 41 PIMs for 31 persons ( 34 % ) at admission compared to 7 PIMs for 6 persons ( 7 % ) at discharge . STOPP criteria identified 50 PIMs at admission for 29 persons ( 32 % ) compared to 16 PIMs at discharge for 14 persons ( 16 % ) . Results showed significantly lower START scores at discharge than at admission ( p<0.001 ) ; similarly , STOPP criteria demonstrated fewer PIMs at discharge than at admission ( p<0.001 ) . CONCLUSION The use of START and STOPP criteria by a clinical pharmacist allows identifying PIMs and changing prescriptions for older patients with cancer in agreement with the oncologist and geriatrician of the team Objective : To prospect ively evaluate the additional value of geriatric assessment ( GA ) for predicting surgical outcomes in a cohort of older patients undergoing a pancreaticoduodenectomy ( PD ) for pancreatic tumors . Background : Older patients are less often referred for possible PD . St and ard preoperative assessment s may underestimate the likelihood of significant adverse outcomes . The prospect i ve utility of vali date d GA has not been studied in this group . Methods : PD-eligible patients were enrolled in a prospect i ve outcome study . St and ard preoperative assessment s were recorded . Elements of vali date d GA were also measured , including components of Fried 's model of frailty , the Vulnerable Elders Survey ( VES-13 ) , and the Short Physical Performance Battery ( SPPB ) . All postoperative adverse events were recorded , systematic ally review ed , and grade d using the Clavien-Dindo system by a surgeon blinded to the GA results . Multivariate regression analyses were conducted . Results : Seventy-six older patients underwent a PD . Significant unrecognized vulnerability was identified at the baseline : Fried 's “ exhaustion ” ( 37.3 % ) , SPPB < 10 ( 28.5 % ) , and VES-13 > 3 ( 15.4 % ) . Within 30 days of PD , 46 % experienced a severe complication ( Clavien-Dindo grade ≥III ) . In regression analyses controlling for age , the body mass index , the American Society of Anesthesiologists score , and comorbidity burden , Fried 's “ exhaustion ” predicted major complications [ odds ratio ( OR ) = 4.06 ; P = 0.01 ] , longer hospital stays ( & bgr ; = 0.27 ; P = 0.02 ) , and surgical intensive care unit admissions ( OR = 4.30 ; P = 0.01 ) . Both SPPB ( OR = 0.61 ; P = 0.04 ) and older age predicted discharge to a rehabilitation facility ( OR = 1.1 ; P < 0.05 ) and age correlated with a lower likelihood of hospital readmission ( OR = 0.94 ; P = 0.02 ) . Conclusions : Controlling for st and ard preoperative assessment s , worse scores on GA prospect ively and independently predicted important adverse outcomes  . Geriatric assessment may help identify older patients at high risk for complications from PD OBJECTIVES Our purpose was to determine whether geriatric assessment s are associated with completion of a chemotherapy course , grade III/IV toxicity or survival in older adults with cancer . MATERIAL S AND METHODS In this prospect i ve cohort study , patients aged 65 years and older with colorectal , lung , or breast cancer or lymphoma completed a  brief geriatric assessment prior to chemotherapy . Endpoints included completion of the planned number of chemotherapy cycles , grade III/IV toxicity and survival . Multivariate logistic regression determined which factors were independently associated with completion of therapy , grade III/IV toxicity or death . RESULTS Sixty-five patients were enrolled in the study . The median age was 73 years ( range 65–89 ) .  Geriatric syndromes were common , including depression ( 21.5 % ) , dependence on others to carry out instrumental activities of daily living ( 38.5 % ) and activities of daily living ( 10.8 % ) , and comorbidities ( mild 47.7 % , moderate 20 % , severe 15.4 % ) . Of the 65 participants , 67.6%completed the planned number of chemotherapy cycles . Curative intent therapy [ OR 4.97 ( 95 % CI 1.21–18.81 ) ] , Eastern Cooperative Oncology Group ( ECOG ) performance status 2–3 [ OR 0.089 ( 0.015–0.53 ) ] and renal function [ OR 1.03 ( 1.00–1.06 ) per ml/min ] were significantly associated with therapy completion . Furthermore , 31.1 % experienced grade III/IV nonhematologic toxicity . Moderate to severe comorbidities significantly increased the risk of grade III/IV non-hematologic toxicity [ OR 6.13 ( 1.65–22.74 ) ] . Patients who received chemotherapy with curative intent had lower mortality [ HR 0.15 ( 0.06–0.42 ) ] , while patients who reported a fall in themonth prior to chemotherapy had an increased risk of death [ HR 3.20 ( 1.13–9.11 ) ] . CONCLUSIONS Geriatric assessment is associatedwith completion of a planned number of cycles of chemotherapy , grade III/IV non-hematologic toxicity , and mortality Abstract Multidimensional geriatric assessment ( GA ) has been demonstrated to predict outcomes in older patients with cancer . This study evaluated GA in a cohort of older patients with chronic lymphocytic leukemia ( CLL ) . Seventy-five of 97 subjects with CLL who were enrolled in a clinical trial of the German CLL Study Group underwent GA prior to the start of study treatment ( low-dose chemotherapy with fludarabine ) . GA included  cumulative illness rating scale ( CIRS ) , timed-up- and -go ( TUG ) test , dementia detection ( DEMTECT ) test and instrumental activities of daily living ( IADL ) index . There was little correlation between CIRS , TUG , DEMTECT or IADL results and treatment toxicity , feasibility or efficacy in this study . CIRS and IADL had no statistically significant impact on overall prognosis . However , under-performance in TUG or DEMTECT test was strongly associated with poor survival . The latter findings provide a rationale to further investigate geriatric  assessment in CLL and in the context with other CLL treatments Objectives : The comprehensive geriatric assessment ( CGA ) can detect geriatric problems and potentially improve survival , physical , and cognitive state of patients , as well as increase an older person ’s chances of staying at home longer . In older people , the number and severity of comorbidity increase with age and are an important determinant of survival . The aim of the study was to assess to which extent CGA and comorbidities could be seen as determinants of survival . Material s and methods : This study analyzed data from two hospitals that included geriatric assessment s of patients aged 70 years and more with cancer linked to mortality .  Logistic regression was used to model survival predictors . Results : Two hundred and five various cancer patients ( 47 % females ) with a median age of 79 were included . They presented with a lot of undiagnosed geriatric problems . Screening scales ( G8 , SEGA ) , cognitive , and psychological disorders , and low albumin levels appeared to be independent survival factors . A frailty profile classification was associated with higher mortality . The average comorbidity was grade d 2 according to the Charlson scale . By the geriatric cumulative illness rating scale ( CIRS-G ) , the arithmetic average number of affected organ systems was 5 ( range 0–10 ) in all patients . Cardiovascular disorders were the most common comorbidity . Renal insufficiency and anaemia were negatively associated with survival . Conclusion : Old cancer patients present a lot of comorbidities and newly diagnosed geriatric problems . Several tools provide determinants of survival in old cancer patients . Prospect i ve trials evaluating the utility of a CGA to guide interventions to improve quality of cancer care in older adults are justified Background Hip fractures are common among frail elderly persons and often have serious consequences on function , mobility and mortality . Traditional treatment of these patients is performed in orthopedic departments without additional geriatric assessment . However , studies have shown that interdisciplinary geriatric treatment may be beneficial compared to traditional treatment . The aim of the present study is to investigate whether treatment of these patients in a Department of Geriatrics ( DG ) during the entire hospital stay gives additional benefits as compared to conventional treatment in a Department of Orthopaedic Surgery ( DOS ) . Findings A new clinical pathway for in-hospital treatment of hip fracture patients was developed . In this pathway patients were treated pre- and postoperatively in DG .  Comprehensive geriatric assessment  was performed as an interdisciplinary , multidimensional , systematic assessment of all patients focusing on each patient ’s capabilities and limitations as recommended in guidelines and systematic review s. Identification and treatment of co-morbidities , pain relief , hydration , oxygenation , nutrition , elimination , prevention and management of delirium , assessment of falls and osteoporosis were emphasized .  Discharge planning  started as early as possible . Initiation of rehabilitation with focus on early mobilisation and development of individual plans was initiated in hospital and continued after discharge from hospital . Fracture specific treatment was based upon st and ard treatment for the hospital , expert opinions and a review of the literature . Conclusion A new treatment program for old hip fracture patients was developed , introduced and run in the DG , the potential benefits of which being compared with traditional care of hip fracture patients in the DOS in a r and omised clinical trial Context Prescription and management of medications are important issues for older adults . Contribution Among elders enrolled in two managed care organizations , most quality problems were related to failure to prescribe indicated medications ; failure to monitor medications ; and failure to provide medication along with proper documentation and education in concert with other physicians . Implication s Prescribing inappropriate medications for older adults is less of an issue than other aspects of drug therapy . Quality improvement efforts should focus on avoiding errors of omission in prescribing indicated medications , monitoring , patient education , and follow-up . The Editors Pharmacotherapy is an essential component of medical treatment for older patients , but medications are also responsible for many adverse events in this group . Ninety percent of people 65 years of age or older take at least one medication ( 1 ) . This age group , which represents only 13 % of the population , accounts for one third of all prescription drug expenditures in the United States ( 2 ) . Many older persons take multiple drugs for the treatment of several conditions , which increases the chance of adverse drug reactions , drugdrug interactions , and drugdisease interactions . The frequency of adverse drug events in elderly out patients ranges from 10 % to 35 % , depending on the setting ( 3 - 5 ) . Recognizing the magnitude of medication-related issues , panels of geriatric experts rate medication problems among the most important quality -of-care problems for older patients ( 6 - 8 ) . Reflecting the severity and frequency of adverse drug events in older patients , many investigations have focused on the appropriateness of medication prescribing to elderly persons . Implicit review mechanisms include the Medication Appropriateness Index , which consists of 10 medication characteristics ( including indication , effectiveness , and dosage ) that a trained pharmacist review er can judge as appropriate , marginally appropriate , or inappropriate . An application of the Medication Appropriateness Index to elderly veterans taking 5 or more prescription medications found that 74 % had at least 1 inappropriate aspect to their prescriptions ( 9 , 10 ) . Review s using explicit criteria usually focus on medications that should be avoided in the care of older patients . The list of medications to avoid , which was developed by Beers and colleagues on the basis of a formal consensus of geriatric experts ( 11 - 13 ) , has been applied to various groups of patients , revealing a high prevalence of inappropriate drug use ( 14 - 20 ) . In addition , explicit criteria about drugdrug interactions , treatment duration , and drug contraindications were created by Tamblyn and colleagues and applied to medications prescribed to older patients in Canada ( 21 ) . They found that more than half of older patients took at least one high-risk medication . Health policy efforts , on the other h and , have focused predominantly on finding ways to pay for the medication needed by older patients . Proposals aim to improve access to pharmacologic care but do not strive to develop mechanisms to evaluate or improve the quality of medication management for older patients . Improvement in access to medications without quality assurance may result in a mere increase in care without change in outcomes . To provide a more comprehensive evaluation of the quality of pharmacologic care for older patients , we systematic ally evaluated medication management for a sample of older patients by taking advantage of a set of explicit process of care quality indicators developed and implemented in the Assessing Care of Vulnerable Elders ( ACOVE ) project ( 22 ) . Whereas the earlier ACOVE analysis described overall quality of care and compared care quality for geriatric and medical conditions , this study focuses on pharmacologic care and identifies improvement needs in medication management . Our quality evaluation covered the continuum of pharmacologic care , from recognizing the indications for medications to choosing medication , prescribing appropriately , educating and documenting , and monitoring after prescribing . Methods The ACOVE project developed a set of explicit quality indicators  to evaluate the care provided to vulnerable older persons ( 22 - 24 ) . The system focuses on processes of care within the domains of prevention , diagnosis , treatment , and follow-up and covers the spectrum of care contained in 22 conditions that are important in the care of older patients ( 7 ) . The methods for selecting conditions and developing the quality indicators are described in detail elsewhere ( 7 , 23 ) . Methods included systematic literature review s and multiple layers of expert judgment ( 23 ) . The literature review result ed in proposal of c and i date quality indicators , which were review ed by an expert panel that rated each of the proposed quality indicators for validity and feasibility . This set was modified and approved by a clinical committee of national geriatric experts and by the American College of Physicians Task Force on Aging ( 24 ) . From the final ACOVE set of quality indicators , 43 quality indicators ( Table 1 and Appendix Table ) that pertained to pharmacologic care and had more than 5 eligible patients are included in this analysis . Table 1 .  Medication Quality Indicators , Number of Eligible Patients , and Pass Rates Patients and Data Collection We assessed care provided to older persons who were enrolled in 2 managed care organizations . Each managed care organization , one in the U.S. Northeast and the other in the Southwest , had more than 20 000 senior enrollees and contracted with a network of providers to deliver care . A r and om sample of community-dwelling persons 65 years of age or older was drawn from enrollees in each managed care organization . Eligibility criteria included continuous enrollment in the managed care organization for at least 13 months , no out-of-plan care , and no active treatment for malignant conditions ( excluding nonmelanoma skin cancer ) during the period . In addition , persons who did not speak English were excluded because our interview instruments were not available in other language s. Among the enrollees , we targeted vulnerable elders , defined as persons 65 years of age and older who are at increased risk for death or functional decline . Vulnerable elders were identified on the basis of self-report ( or proxy report ) by using a brief screening survey ( the Vulnerable Elders-13 [ VE-13 ] Survey [ 25 ] ) administered by telephone . The R AND Institutional Review Board approved the study protocol . Data were derived mainly from abstract ing medical records . For participating patients , we identified all inpatient and outpatient medical records during the 13-month period of 1 July 1998 to 31 July 1999 . These medical records were abstract ed by trained nurses with experience in quality assessment . The abstract or considered all of a patient 's medical records when assessing whether a patient was eligible for and received the indicated care processes . Information on eligibility for a quality indicator could be derived from one medical record ( such as a primary care physician starting an appropriate antidepressant ) and the care process delivered and documented from records in another setting ( such as a psychiatric consultant escalating the antidepressant dosage in response to lack of improvement ) . A senior nurse- review er assessed each completed medical record abstract , and physician overreaders review ed quality indicators that required a clinical assessment , such as whether there was follow-up to newly started long-term therapy with a medication or whether newly started therapy with a highly anticholinergic drug had acceptable alternatives . We evaluated inter-rater reliability by re- abstract ing a r and om sample of 10 % of the medical records . These records contained 698 quality indicators ; 97 % had identical eligibility and 95 % demonstrated identical eligibility and score . Details of study enrollment and data collection can be found elsewhere ( 22 ) . Because some aspects of care might not be adequately captured in the medical record ( for example , patient education about medications ) , these data were supplemented by a quality -of-care interview with study participants ( or , if necessary , their proxies ) . During the interview , patients were asked to list all of their medications . On the basis of conditions and medications reported during the interview , patients were asked about specific processes of care they had received . The interview was conducted by telephone  between August and October 2000 . To minimize recall bias , we asked about most recent care when implementing quality indicators that may include multiple events ( for example , education about newly started therapy with a medication ) . Information was obtained from medical records for 37 quality indicators and from the patient interview for 6 quality indicators .  For 4 quality indicators reported previously by using medical record data ( 22 ) , we used interview data in this analysis because subsequent evaluation revealed that interview data on information transfer quality indicators yielded higher pass rates that were aligned with a priori hypotheses and provided more conservative estimates of quality of care . Statistical Analysis A  quality indicator  was scored for a patient if he or she met the eligibility criteria to receive the specified care process . The quality indicator was passed if the care process was implemented for the patient . If the medical record indicated that the patient declined the care process , the quality indicator was considered to be passed . On the other h and , if the patient had a prespecified contraindication to the care process ( such as a patient with asthma who otherwise was eligible to receive a -blocker after a myocardial infa rct ion ) , the patient was considered ineligible for the quality indicator . Quality scores were calculated as the proportion of eligible patients who received indicated care . The majority of older adults receive health care in primary care setting s , yet many fail to receive the recommended st and ard of care for preventive services , chronic disease management , and geriatric syndromes . The Geriatric Re sources for Assessment and Care of Elders ( GRACE ) model of primary care for low-income seniors and their primary care physicians ( PCPs ) was developed to improve the quality of geriatric care so as to optimize health and functional status , decrease excess healthcare use , and prevent long-term nursing home placement . The catalyst for the GRACE intervention is the GRACE support team , consisting of a nurse practitioner and a social worker . Upon enrollment , the  GRACE  support team meets with the patient in the home to conduct an initial comprehensive geriatric assessment . The support team then meets with the larger GRACE interdisciplinary team ( including a geriatrician , pharmacist , physical therapist , mental health social worker , and community-based services liaison ) to develop an individualized care plan including activation of GRACE protocol s for evaluating and managing common geriatric conditions . The GRACE support team then meets with the patient 's PCP to discuss and modify the plan . Collaborating with the PCP , and consistent with the patient 's goals , the support team then implements the plan . With the support of an electronic medical record and longitudinal tracking system , the GRACE support team provides ongoing care management and coordination of care across multiple geriatric syndromes , providers , and sites of care . The effectiveness of the GRACE intervention is being evaluated in a r and omized , controlled trial The Bulletin ’s editorial team has decided to encourage systematic review s. This is an important decision and is to be welcomed . However it is possible that it will not be received positively by all . Some may feel that systematic review s are not suitable for answering wider public health questions , and that the new section will simply result in the publication of systematic review s addressing narrowly focused , clinical questions with a focus on r and omized controlled trials alone.1 There is no reason why this should be so , and there are far too many examples of systematic review s of non- clinical interventions ( including government policies ) , which include non-r and omized studies , to list.2 Systematic review s of qualitative research are also becoming more common.3 Nonetheless misconceptions about the scope and flexibility of systematic review s still surface occasionally and it never fails to surprise me when I stumble across one of these hoary old chestnuts . If it really were true that systematic review s were only for simple , individual-level interventions , systematic review ers working in public health would be very concerned . After all , public health problems require us to draw on complex sets of qualitative as well as quantitative evidence ; and some policy interventions have never been subjected to r and omized controlled trials ( RCTs ) but have been evaluated using other approaches ; everything from controlled and uncontrolled before- and -after studies , to time series analyses , to qualitative methods . In such cases , systematic review s that focused on RCTs alone would have little to say and we would end up producing many “ empty review s ” , which contain no studies at all . These would be undoubtedly quicker to do and quicker to read than the typical systematic review , but would be of limited use for making policy . However this is not the case . In public health we already have a wealth of review s that prioritize RCTs where they are available , but which draw upon a range of other evidence where they are appropriate to answering the review question .2 Take , as an example , transport policies , an important social determinant of health.4 Public health decision-makers have been interested in the effects on health of building new roads for decades , but there has never been a r and omized controlled trial , for obvious reasons . Yet it would make no sense to cl aim that there is no evidence to be review ed ; rather , there have been many controlled and uncontrolled studies that have examined the effects of new roads on respiratory symptoms , injuries , community severance , disturbance and a variety of other outcomes of public health importance . These studies have in fact been systematic ally review ed.5 Many other examples of review s of complex interventions that impact on public health could be given , which appear on the Cochrane Data base and elsewhere,6,7 and such review s are the main focus of the recently-established Cochrane Public Health Review Group . It is also worth noting that both the Cochrane and Campbell Collaboration include increasing numbers of review s that are relevant to low- and middle- income countries,8 though there is a particular need for more systematic review s that consider the effects on equity of the interventions that they include.9 Currently systematic review s have a “ utilitarian bias ” – they tend to be concerned more with the effects on population s and average effects than with distributional effects and impacts in disadvantaged subgroups . It is to be hoped that systematic review s su bmi tted to the Bulletin will routinely consider the effects of interventions on health inequities . The Cochrane Health Equity Field ( http://equity.cochrane.org/en/index.html ) was set up explicitly to further this agenda , to encourage systematic review authors to explicitly assess the effects of interventions not only on the whole population , but on the disadvantaged . So where does this leave non- systematic review s ? Should every review be a systematic review ? This is a difficult question to answer in a short editorial . My own view is that not all review s need to be systematic review s ; there is still a place for review papers that provide a broad overview , and that discuss a range of evidence and make a contribution to wider debates about what might work in particular setting s. However , while such discussion s help place evidence in context and suggest how it may be used , they should not be confused with the evidence -based conclusions of a transparent , scientific review , which systematic ally attempts to find all the relevant evidence , appraises its strengths and limitations in a transparent fashion , and draws that evidence together in such a way that the more robust studies are given greater weight . Finally , the challenges are many . Evidence on interventions to improve public health is in short supply , particularly evidence on social determinants . Systematic review ers therefore face a real challenge in making best use of the sometimes poor , often sparse and usually heterogeneous evidence available to them . It is easy to set narrow inclusion criteria for a review and then sift through the evidence before concluding that there is n’t enough – and what there is , is n’t very good anyway . Such “ evidential nihilism ” is probably not helpful to decision-makers , and public health systematic review ers need to continue to develop new methods and better frameworks within which different types of research evidence can be integrated to inform decision-making . Publishing systematic review s in the Bulletin should give an added impetus to this ongoing work . This prospect i ve cohort study of consecutive elderly cancer patients was undertaken to evaluate the role of the multidimensional geriatric assessment ( MGA ) as an aid in treatment decision-making . A total of 571 cancer patients ( aged > or = 70 ) were enrolled during 6-year ( 1999 - 2005 ) . All underwent MGA as part of the first evaluation . In multivariate analysis , the probability of receiving active , instead of palliative , treatment was negatively associated with increasing age ( odds ratio=0.69 every 5 years , p=0.005 ) , living alone ( OR=0.54 , p=0.031 ) , dependence in activities of daily living ( ADL score > 0 , OR=0.41 , p=0.003 ) and a low body-mass index ( BMI ) ( OR=0.51 , p=0.061 ) ; while a positive association emerged for instrumental activities of daily living ( IADL ) score ( OR=1.12 per point , p=0.019 ) . Our data suggest that MGA , in addition to age , is a useful tool in clinical practice for deciding cancer treatment in elderly patients , with a major independent role played by living alone , ADL , IADL and BMI OBJECTIVES To evaluate the feasibility of an intervention involving post-discharge geriatric home assessment and follow-up and to describe the spectrum of significant clinical problems identified during the home assessment . DESIGN Prospect i ve observational study nested within a r and omized controlled trial . SETTING Inpatient service of a large academic medical center in Southern California . PATIENTS There were 152 adults aged 65 or greater who had one or more specific risk factors for functional decline or increased mortality , who were awaiting discharge from the hospital , and who were assigned to the intervention arm of a r and omized controlled trial of post-discharge comprehensive geriatric home assessment .  MAIN RESULTS During the home assessment , the gerontologic nurse practitioner ( GNP ) identified new or worsening problems in 150 patients ( 99 % ) ; 61 problems ( eg , serum sodium 125 mg/dL ; severe orthostatic hypotension ) were considered by a review ing physician to require urgent medical attention . Older age , non-white race , and new incontinence were associated independently with a greater number of findings ( P < 0.05 ) . Based on the findings , an interdisciplinary team made an average of 3.4 recommendations per patient ; only two of 111 requests for written approval of recommendations were rejected . CONCLUSIONS Post-discharge visitation by a GNP to patients at high risk is capable of detecting a high yield of important and potentially reversible clinical problems . This multidisciplinary approach is acceptable to physicians . Research is needed to identify additional links between short hospital stays , impairment or instability at discharge , and adverse outcomes Context Many Americans 65 years of age and older are at risk for functional decline , yet we know little about the quality of care for geriatric conditions . Contribution This study used a 13-item survey about functional status to evaluate the care of 420 people 65 years of age and older whom the investigators identified as vulnerable to functional decline .  Quality of care was highly variable from condition to condition but was generally better for general medical conditions , such as diabetes , than for geriatric conditions , such as incontinence . Implication s Efforts to improve care for vulnerable elders should focus on the geriatric conditions that profoundly influence functional status . The Editors The quality of care among patients 65 years of age and older has not been extensively investigated , and most existing studies have focused on general adult medical conditions . This is surprising , considering that more than 40 % of all medical expenditures are for persons 65 years of age and older ( 1 ) . The most comprehensive study to date of quality of care among older patients evaluated 24 process indicators among U.S. Medicare beneficiaries in all 50 states between 1997 and 1999 ( 2 ) . Care for acute myocardial infa rct ion , heart failure , stroke , and pneumonia was evaluated by using inpatient medical records . Pneumonia , breast cancer , and diabetes indicators were evaluated by using survey and Medicare cl aims data . The investigators found that the percentage of patients receiving appropriate care varied widely by measure and state . Several other studies of older patients evaluated cardiovascular conditions , diabetes , or aspects of preventive care and medication use ( 3 - 10 ) . No study , however , has assessed the quality of medical care provided for geriatric conditions that profoundly affect the lives of vulnerable older patients . Furthermore , surveys find that older persons often prioritize function and comfort over disease treatment and prolongation of life ( 11 ) . Quality -of-care measurement for older patients that examines only a few conditions and only indicators aim ed at prolonging life yields an incomplete assessment because it ignores other conditions and aspects of care that are of equal or even greater importance to older patients . For this reason , we developed a  quality assessment system  that assesses more conditions . Together , these conditions account for a majority of all of the care older patients receive ( 12 ) and include several geriatric syndromes . We used this quality assessment system to evaluate the care provided to a sample of vulnerable elders at increased risk for death or functional decline . Methods The Assessing Care of Vulnerable Elders ( ACOVE ) project developed and applied a quality assessment system for vulnerable older persons . The assessment system aim ed to develop quality indicators ( QIs ) that cover the spectrum of care for these patients . Indicators were implemented by using medical record abstract ion and patient interview . The ACOVE Quality -of-Care Assessment System The ACOVE investigators developed a system of QIs to cover the most important conditions vulnerable elders encounter in all care venues . This system focused on processes ( care behaviors ) rather than outcomes for 2 reasons . First , although most agree that outcomes should be adjusted for risk when quality is measured , there is little consensus regarding the best severity measurement system ( 13 ) . Second , measurement of processes of care is thought to be a more direct assessment of quality than measurement of outcomes ( 14 ) . The process measures were selected to represent the various domains of care : screening and prevention , diagnosis , treatment , and follow-up . The development of the assessment system was guided by a Policy Advisory Committee , which helped to direct the focus toward practical applications , and by a Clinical Committee , which provided clinical expertise for development and monitored the assembly of the QIs into a comprehensive system ( 15 ) . The methods for selecting conditions and developing the QIs have been described in detail elsewhere ( 12 , 16 ) . In brief , the Clinical Committee used the criteria of prevalence , impact , effectiveness of prevention or treatment , need for quality improvement , feasibility of measurement , and geriatric niche in a formal group rating process to identify 22 target conditions for quality improvement ( 12 ) . For each of the 22 conditions , we developed a set of  evidence -based QIs  for vulnerable elders using a combination of systematic review s and expert judgment ( 16 ) . Of 420 proposed QIs , the 2 expert panels , the Clinical Committee , and the American College of Physicians Task Force on Aging accepted 236 as valid indicators ; these were assembled into the ACOVE QI set ( 17 ) . The 236 QIs covered the domains of care as follows : Sixty-one ( 26 % ) focused on screening and prevention , 50 ( 21 % ) focused on diagnosis , 84 ( 36 % ) focused on treatment , and 41 ( 17 % ) focused on follow-up and continuity of care . Examples of ACOVE QIs for each condition are presented in Table 1 . Table 1 . Examples of Assessing Care of Vulnerable Elders Quality Indicators Patients and Data Collection Using the ACOVE QI set , we assessed care provided to seniors who were enrolled in 2 managed care organizations . These patients were defined as vulnerable on the basis of self-report or proxy report on a brief , 13-item screening survey ( Vulnerable Elders-13 [ VE-13 ] Survey [ 18 ] ) . Vulnerable elders , identified by this function-based survey , are community-dwelling persons 65 years of age and older who have 4 times the risk for functional decline or death over the next 2 years compared with individuals not identified as vulnerable ( 18 ) . Each managed care organization , 1 in the northeastern United States and the other in the southwestern United States , had more than 20 000 elderly enrollees and contracted with a network of providers to deliver care . Eligibility criteria included continuous enrollment in the managed care organization for at least 13 months and no out-of-plan care or active treatment for malignant conditions ( excluding nonmelanoma skin cancer ) during this period . A r and om sample of 3207 community-dwelling elderly adults was drawn from eligible persons in each managed care organization by using a r and om-number generator . Vulnerable elders were identified by using the VE-13 Survey as part of a telephone interview . Patients who did not speak English were not eligible to participate . The R AND Institutional Review Board approved the study protocol . Medical Record Review Using administrative data , we identified all inpatient and outpatient medical care received by study participants during the 13-month period of 1 July 1998 to 31 July 1999 . Medical records were requested from primary care and specialist providers ( including eye care and mental health providers ) , acute care hospitals , skilled-nursing facilities , home health agencies , and facilities providing outpatient services ( for example , physical therapy ) . Identifying information of patients and providers was removed from the medical records . Trained nurses with previous experience in quality assessment performed medical record abstract ion . Abstract ors were provided with written abstract ion guidelines and real-time consultation with a senior nurse review er . The abstract or considered all of a patient 's records when assessing whether he or she was eligible for and received the indicated care processes . In other words , information on eligibility for a QI could have been derived from 1 record ( such as an outpatient note ) while the care process was delivered and documented in another setting ( for example , inpatient medical record ) . If the care process was performed in the defined time interval , care was scored as complying with the QI . The senior nurse review er also assessed each completed medical record abstract ion . Physicians review ed QIs that required a more detailed level of clinical assessment . Examples include whether the elements of a delirium evaluation had been completed or whether an adequate intervention was performed for hyperlipidemia . An ophthalmologist evaluated selected data elements addressing vision care . Ten percent of all records were re abstract ed to evaluate reliability of the abstract ion process . Exact agreement on QI eligibility and score was 95 % . ( For details of abstract or preparation and abstract ion material s , see the Appendix . ) Quality -of-Care Interview A quality -of-care interview was conducted to ask study participants ( or , if participants were incapable of responding , their proxies ) about aspects of their care that might not be captured in the medical record ( for example , physicianpatient counseling ) . On the basis of conditions and medications reported during the interview , patients were asked about specific processes of care they had received . Patients were also asked about care preferences that might affect the applicability of QIs . In addition , the interview included demographic questions and functional status items . The quality -of-care interview was conducted by telephone between August and October 2000 and required , on average , 44 minutes to complete . Statistical Analysis Of the 236 QIs , we were able to evaluate 207 using chart abstract ion ( n = 185 [ 89 % ] ) or interview ( n = 22 [ 11 % ] ) . Interview was used to score  QIs  for data elements that we did not collect from the medical record . A QI was scored for a patient if he or she satisfied the IF statement of the QI and thus was eligible to receive the specified care process ( Table 1 ) . A score of 1 was awarded if the care process was carried out , and a score of 0 was assigned if it was not . For QIs that included several triggering events , a score between 0 and 1 was possible . If the medical record indicated that the patient declined the care process , the QI was considered to be passed ( the care was credited in both the numerator and the denominator of the indicator score ) . On the other h and , if the patient had a
Geriatric assessment  was most often completed to describe a patient 's health and functional status .
Geriatric assessment  in the oncology setting is feasible , and some domains are associated with adverse outcomes .
However , there is limited evidence that geriatric assessment impacted treatment decision making .
BACKGROUND Geriatric assessment is a multidisciplinary diagnostic process that evaluates the older adult 's medical , psychological , social , and functional capacity .
No systematic review of the use of geriatric assessment in oncology has been conducted .
The goals of this systematic review were : 1 ) to provide an overview of all geriatric assessment instruments used in the oncology setting ; 2 ) to examine the feasibility and psychometric properties of those instruments ; and 3 ) to systematic ally evaluate the effectiveness of geriatric assessment in predicting or modifying outcomes ( including the impact on treatment decision making , toxicity of treatment , and mortality ) .