Syllabi - Geriatric Medicine - Therapy Scenario (Alternative Scenario)
Read the article and decide:You are responsible for a geriatric assessment program in your region that involves having people ≥ 75 years of age who live at home, seen by a multidisciplinary geriatric team. You are asked by a relative to see an 80 year old woman who lives by herself in the community and who has refused (on several occasions) to visit her GP. She has some difficulty with ambulating since she had a stroke 5 years previously. Her family is concerned because she has noted a decrease in visual acuity and hearing and they have noticed that her memory has declined. When you visit her, you find she is a very pleasant, independent woman who wants to know why you are there and how you can help her. You explain that you want to assess her physical and functional status and social situation because your aim is to help people maintain their independence in the community. She says "Prove it to me".
You formulate the question, "In an elderly patient who lives at home, does a comprehensive geriatric assessment decrease the risk of nursing home admission and improve functional status?" Fortunately, you have brought your notebook computer with you which has the latest version of Best Evidence on it. You search Best Evidence using the term "geriatric assessment" and find an abstract and commentary on an article by Stuck et al which looks promising. NEJM 1995;333:1184-9 You tell the patient that you will obtain this article from your office and will return to her with the evidence.
- Is the evidence from this randomised trial valid?
- If valid, is this evidence important?
- If valid and important, can you apply this evidence in caring for your patient?
Completed Therapy Worksheet for Evidence-Based Geriatric Medicine
Citation
Stuck AE, Aronow HU, Steiner A et al. A trial of annual in-home comprehensive geriatric assessments for elderly people living in the community. NEJM 1995;333:1184-9Are the results of this single preventive or therapeutic trial valid?
- Was the assignment of patients to treatments randomised?
- And was the randomisation list concealed?
- Yes
- Were all patients who entered the trial accounted for at its conclusion?
- And were they analysed in the groups to which they were randomised?
- Yes
- Were patients and clinicians kept "blind" to which treatment was being received?
- Interviewers who did the follow-up assessments were blinded
- Aside from the experimental treatment, were the groups treated equally?
- Yes
- Were the groups similar at the start of the trial?
- Yes - although some slight difference between groups in limitation of activities of daily living
Are the valid results of this prognosis study important?
Sample Calculations
| Occurrence of diabetic neuropathy | Relative Risk Reduction (RRR) | Absolute Risk Reduction (ARR) | Number Needed to Treat (NNT) | |
|---|---|---|---|---|
| Usual Insulin Control Event Rate (CER) |
Intensive Insulin Experimental Event Rate (EER) |
(CER - EER)/CER | CER-EER | 1/ARR |
| 9.6% | 2.8% |
(9.6%-2.8%)/9.6% = 71% |
9.6% - 2.8% = 6.8% [4.3% to 9.3%] |
1/6.8% = 15 pts [11 to 23] |
95% Confidence Interval (CI) on an NNT = 1 / (limits on the CI of its ARR)
= +-1.96 sqrt(((CERx(1-CER))/(# of control pts.)) + ((EERx(1-EER))/(# of exper. pts.)))
= +-1.96 sqrt(((0.096x0.904)/730) + ((0.028x0.972)/711))
= ±2.4%
Your Calculations
| Relative Risk Reduction (RRR) | Absolute Risk Reduction (ARR) | Number Needed to Treat (NNT) | ||
|---|---|---|---|---|
| CER | EER | (CER - EER)/CER | CER-EER | 1/ARR |
| 0.10 | 0.04 | 58% | 0.06 | 17 |
Can you apply this valid, important evidence about a treatment in caring for your patient?
Do these results apply to your patient?
- Is your patient so different from those in the trial that its results can't help you?
- no, this patient is similar
- How great would the potential benefit of therapy actually be for your individual patient?
- Method I: f
Risk of the outcome in your patient, relative to patients in the trial. Expressed as a decimal: 1.0
NNT/F
= 17/1
= 17
(NNT for patients like yours) -
Method II: 1 / (PEER x RRR)
Your patient's expected event rate if they received the control treatment:
PEER:______
1 / (PEER x RRR)
= 1/________
= __________
(NNT for patients like yours)
Are your patient's values and preferences satisfied by the regimen and its consequences?
- Do your patient and you have a clear assessment of their values and preferences?
- Needs to be assessed in each patient
- Are they met by this regimen and its consequences?
- Needs to be assessed in each patient
Additional Notes
-Geriatric Assessment - Improves functional status and decreases nursing home admissions
Clinical Bottom Line
Geriatric assessment decreases admissions to long-term nursing homes and improves functional status.Citation
Stuck AE, Aronow HU, Steiner A et al. A trial of annual in-home comprehensive geriatric assessments for elderly people living in the community. NEJM 1995;333:1184-9Clinical Question
In an elderly patient who lives at home, does a comprehensive geriatric assessment decrease the risk of nursing home admission and improve functional status?Search Terms
"geriatric assessment" in Best EvidenceThe Study
- Single-blinded randomised controlled trial without intention-to-treat. patients > 75 years of age who lived at home
- Control group (N = 199; 199 analysed): usual care by their physicians
- Experimental group (N = 215; 215 analysed): annual assessments in their homes from gerontologic nurse practitioners-assessments included medical history, physical exam, lab tests; determinations of functional and mental status, oral health, gait and balance, medications, vision, hearing, social network and support, home safety and external access.
The Evidence
| Outcome | Time to Outcome | CER | EER | RRR | ARR | NNT |
|---|---|---|---|---|---|---|
| long-term nursing home admission | 3 years | 0.101 | 0.042 | 58% | 0.059 | 17 |
| 95% Confidence Intervals | 9% to 100% | 0.009 to 0.109 | 9 to 108 | |||
| admission to acute care hospital | 3 years | 0.467 | 0.460 | 1% | 0.007 | 143 |
| 95% Confidence Intervals | -19% to 22% | -0.089 to 0.103 |
NNT = 10 to INF NNH = 11 to INF |
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Comments
- cost of intervention included in this paper but may differ according to your location.
- these patients had higher education level, lower mortality rate and lower rate of acute care hospital admission -therefore need to compare this to your own population to assess applicability.
- uncertain which components of the geriatric assessment are the most important and have the greatest impact on maintaining independence.
