Results of the largest study to date to identify the best ways to assess and treat elderly patients is published in this week's issue of THE LANCET. No single approach in terms of assessment (universal or targeted assessment to those with the greatest health-care needs) nor the location of treatment (primary care or hospital geriatric department) was found to offer substantial advantages in terms of reduced mortality or quality of life.
A 1990 UK health policy required all general practitioners to offer an annual multidimensional assessment to patients aged 75 years and older. Although the contract specified the broad areas for assessment, it gave little guidance on the method, level, and nature of assessment. Astrid Fletcher (London School of Hygiene and Tropical Medicine, UK) and colleagues did a trial in the setting of general practice in the UK to measure the effects of different approaches to the assessment and management of elderly people.
The study included over 43,000 patients aged 75 years or older from 106 UK general practices and compared (1) universal versus targeted assessment and (2) subsequent management by hospital outpatient geriatric team versus the primary-care team. All participants received a brief assessment followed by a nurse-led in-depth assessment in the universal group, whereas in the targeted group the in-depth assessment was offered only to those with problems established at the brief assessment. The primary outcome measures of the study were death, admissions to hospital and institution, and quality of life.
After 3 years of follow-up, there were no improvements in survival or reductions in admissions to hospital, nursing or residential homes with in-depth assessment or outpatient geriatric management. There was a small benefit in social functioning from hospital- based outpatient geriatric management.
Professor Fletcher comments: "It is disappointing that our trial, which is by far the largest ever conducted does not provide support for the policy of comprehensive in-depth assessment of older people in general practice. We need to find effective strategies to improve the health and well-being of older people but it is essential that these are rigorously evaluated before their introduction as policy"
In an accompanying commentary (p 1641), Andreas Stuck (University of Berne, Switzerland) and colleagues conclude: "Clearly, the trial's findings should inform the implementation of the UK National Service Framework Programme, which calls for health promotion in older people and a uniform geriatric assessment process. The number of disabled older people is expected to increase worldwide over the next decades. Programmes that reduce or delay the onset of disability in older people should therefore receive high policy priority."
Contact: Professor Astrid Fletcher, Dept of Epidemiology & Population Health, London School of Hygiene & Tropical Medicine, Keppel St, London WC1E 7HT, UK; T)44-207-927-2253/8110; astrid.fletcher@LSHTM.AC.UK
Professor Andreas E Stuck, Department of Geriatrics, University of Berne, Spital Bern-Ziegler, CH-3001 Bern, Switzerland; T) 41-31-971-7767; andreas.stuck@spitalbern.ch
Journal
The Lancet