Medical Crises in Older People: cohort study of older people attending acute medical units, developmental work and randomised controlled trial of a specialist geriatric medical intervention for high-risk older people; cohort study of older people with mental health problems admitted to hospital, developmental work and randomised controlled trial of a specialist medical and mental health unit for general hospital patients with delirium and dementia; and cohort study of residents of care homes and interview study of health-care provision to residents of care homes
- PMID: 25973516
- Bookshelf ID: NBK293738
- DOI: 10.3310/pgfar03040
Medical Crises in Older People: cohort study of older people attending acute medical units, developmental work and randomised controlled trial of a specialist geriatric medical intervention for high-risk older people; cohort study of older people with mental health problems admitted to hospital, developmental work and randomised controlled trial of a specialist medical and mental health unit for general hospital patients with delirium and dementia; and cohort study of residents of care homes and interview study of health-care provision to residents of care homes
Excerpt
Background: This programme of research addressed shortcomings in the care of three groups of older patients: patients discharged from acute medical units (AMUs), patients with dementia and delirium admitted to general hospitals, and care home residents.
Methods: In the AMU workstream we undertook literature reviews, performed a cohort study of older people discharged from AMU (Acute Medical Unit Outcome Study; AMOS), developed an intervention (interface geriatricians) and evaluated the intervention in a randomised controlled trial (Acute Medical Unit Comprehensive Geriatric Assessment Intervention Study; AMIGOS). In the second workstream we undertook a cohort study of older people with mental health problems in a general hospital, developed a specialist unit to care for them and tested the unit in a randomised controlled trial (Trial of an Elderly Acute care Medical and mental health unit; TEAM). In the third workstream we undertook a literature review, a cohort study of a representative sample of care home residents and a qualitative study of the delivery of health care to care home residents.
Results: Although 222 of the 433 (51%) patients recruited to the AMIGOS study were vulnerable enough to be readmitted within 3 months, the trial showed no clinical benefit of interface geriatricians over usual care and they were not cost-effective. The TEAM study recruited 600 patients and there were no significant benefits of the specialist unit over usual care in terms of mortality, institutionalisation, mental or functional outcomes, or length of hospital stay, but there were significant benefits in terms of patient experience and carer satisfaction with care. The medical and mental health unit was cost-effective. The care home workstream found that the organisation of health care for residents in the UK was variable, leaving many residents, whose health needs are complex and unpredictable, at risk of poor health care. The variability of health care was explained by the variability in the types and sizes of homes, the training of care home staff, the relationships between care home staff and the primary care doctors and the organisation of care and training among primary care doctors.
Discussion: The interface geriatrician intervention was not sufficient to alter clinical outcomes and this might be because it was not multidisciplinary and well integrated across the secondary care–primary care interface. The development and evaluation of multidisciplinary and better-integrated models of care is justified. The specialist unit improved the quality of experience of patients with delirium and dementia in general hospitals. Despite the need for investment to develop such a unit, the unit was cost-effective. Such units provide a model of care for patients with dementia and delirium in general hospitals that requires replication. The health status of, and delivery of health care to, care home residents is now well understood. Models of care that follow the principles of comprehensive geriatric assessment would seem to be required, but in the UK these must be sufficient to take account of the current provision of primary health care and must recognise the importance of the care home staff in the identification of health-care needs and the delivery of much of that care.
Trial registration: Current Controlled Trials ISRCTN21800480 (AMIGOS); ClinicalTrials.gov NCT01136148 (TEAM).
Funding: This project was funded by the NIHR Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 3, No. 4. See the NIHR Journals Library website for further project information.
Copyright © Queen’s Printer and Controller of HMSO 2015. This work was produced by Gladman et al. under the terms of a commissioning contract issued by the Secretary of State for Health. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK.
Sections
- Plain English summary
- Scientific summary
- Chapter 1. Introduction
- Chapter 2. The acute medical unit workstream
- Chapter 3. The medical and mental health unit workstream
- Chapter 4. The care home workstream
- Chapter 5. Synthesis
- Chapter 6. Concluding observations
- Acknowledgements
- References
- Appendix 1 Grant submission documents
- Appendix 2 The interface between acute hospitals and community care for older people presenting to acute medical units: a mapping review – databases and searches
- Appendix 3 Interface between acute hospitals and community care for older people presenting to acute medical units: a mapping review – data extraction (results) table
- Appendix 4 A systematic review of comprehensive geriatric assessment to improve outcomes for frail older people being rapidly discharged from acute hospital: databases and searches
- Appendix 5 A systematic review of comprehensive geriatric assessment to improve outcomes for frail older people being rapidly discharged from acute hospital: data extraction (results) table
- Appendix 6 Umbrella review of tools to assess the risk of poor outcome in older people attending acute medical units: databases and searches
- Appendix 7 Umbrella review of tools to assess the risk of poor outcome in older people attending acute medical units: data extraction (results) table
- Appendix 8 Identification of Seniors at Risk tool questions (answered yes or no)
- Appendix 9 The Identification of Seniors at Risk score to predict clinical outcomes and health service costs in older people discharged from UK acute medical units: the Acute Medical Unit Outcome Study – baseline patient-identifiable data form
- Appendix 10 The Identification of Seniors at Risk score to predict clinical outcomes and health service costs in older people discharged from UK acute medical units: the Acute Medical Unit Outcome Study – baseline patient interview form
- Appendix 11 The Identification of Seniors at Risk score to predict clinical outcomes and health service costs in older people discharged from UK acute medical units: the Acute Medical Unit Outcome Study – baseline patient data collection form
- Appendix 12 The Identification of Seniors at Risk score to predict clinical outcomes and health service costs in older people discharged from UK acute medical units: the Acute Medical Unit Outcome Study – follow-up patient data collection form
- Appendix 13 Acute Medical Unit Comprehensive Geriatric Assessment Intervention Study: patient screening data form
- Appendix 14 Acute Medical Unit Comprehensive Geriatric Assessment Intervention Study: baseline patient-identifiable data form
- Appendix 15 Acute Medical Unit Comprehensive Geriatric Assessment Intervention Study: patient baseline initial interview form
- Appendix 16 Acute Medical Unit Comprehensive Geriatric Assessment Intervention Study: patient baseline initial data collection form
- Appendix 17 Acute Medical Unit Comprehensive Geriatric Assessment Intervention Study: patient follow-up data collection form
- Appendix 18 Acute Medical Unit Comprehensive Geriatric Assessment Intervention Study: carer baseline data collection form
- Appendix 19 Acute Medical Unit Comprehensive Geriatric Assessment Intervention Study: carer follow-up data collection form
- Appendix 20 The Better Mental Health cohort study: screening form
- Appendix 21 The Better Mental Health cohort study: patient baseline data form
- Appendix 22 The Better Mental Health cohort study: carer baseline form
- Appendix 23 The Better Mental Health cohort study: patient outcome form
- Appendix 24 The Better Mental Health cohort study: carer outcome form
- Appendix 25 Comparison of a specialist Medical and Mental Health Unit with standard care for older people with cognitive impairment admitted to a general hospital: a randomised controlled trial: patient baseline data form
- Appendix 26 Comparison of a specialist medical and mental health unit with standard care for older people with cognitive impairment admitted to a general hospital: a randomised controlled trial – carer baseline data form
- Appendix 27 Comparison of a specialist medical and mental health unit with standard care for older people with cognitive impairment admitted to a general hospital: a randomised controlled trial – patient outcome form
- Appendix 28 Comparison of a specialist medical and mental health unit with standard care for older people with cognitive impairment admitted to a general hospital: a randomised controlled trial – carer outcome form
- Appendix 29 Comparison of a specialist medical and mental health unit with standard care for older people with cognitive impairment admitted to a general hospital: a randomised controlled trial – medical data form
- Appendix 30 Comparison of a specialist medical and mental health unit with standard care for older people with cognitive impairment admitted to a general hospital: a randomised controlled trial – methods for analysis of the staffing interviews
- Appendix 31 Literature review of care home randomised controlled trials: databases and searches
- Appendix 32 Literature review of care home randomised controlled trials: data extraction (results) tables (selected)
- Appendix 33 A cohort study of the health status and outcomes of care home residents: baseline data collection form
- Appendix 34 A cohort study of the health status and outcomes of care home residents: baseline interview form
- Appendix 35 A cohort study of the health status and outcomes of care home residents: follow-up data collection form
- Appendix 36 A cohort study of the health status and outcomes of care home residents: follow-up interview form
- Appendix 37 An interview study of the actors involved in the health care of care home residents: methods
- Appendix 38 NHS Outcomes Framework 2012–13
- Glossary
- List of abbreviations
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