Improving The Care of Older Adults Full Report

Improving the Care of Older Adults with Common Geriatric Conditions
A Report from the HMO Workgroup on Care Management

A Report from the HMO Workgroup on Care Management
February 2002
This report was written by the HMO Workgroup on Care Management. It does not necessarily reflect the views of the American Association of Health Plans (AAHP), the AAHP Foundation, or The Robert Wood Johnson Foundation. This publication may be freely reproduced and redistributed without permission; however, neither the report nor its contents may be resold. This report may be cited as: HMO Workgroup on Care Management, Improving the Care of Older Adults with Common Geriatric Conditions (AAHP Foundation, Washington, DC, February 2002).
Foreword
The HMO Workgroup on Care Management represents both health plans and group practices that are capitated by health plans for a significant portion of revenues. Health plans and capitated provider groups are referred to, collectively, as Managed Care Organizations (MCOs). Workgroup participants hold senior medical and patient care management positions within their respective organizations, all of which enroll significant numbers of older adults under Medicare capitation, known as Medicare+Choice, contracts. The Workgroups activities are lodged at the AAHP Foundation, and AAHP staff members provide invaluable support. Over the past seven years, the HMO Workgroup on Care Management has met quarterly to discuss ways in which the delivery of care to Medicare beneficiaries can be improved. This report is the seventh to be released. The six other reports released by the Workgroup are:

Identifying High-Risk Medicare HMO Members Planning Care for High-Risk Medicare HMO Members Essential Components of Geriatric Care Provided Through Health Maintenance Organizations Establishing Relations with Community Resource Organizations: An Imperative For Managed Care Organizations Serving Medicare Beneficiaries Geriatric Case Management: Challenges and Potential Solutions in Managed Care Organizations Risk Screening Medicare Members Revisited
We are deeply grateful to The Robert Wood Johnson Foundation for its financial and moral support. The primary writer of this report was Eric A. Coleman, MD, MPH, University of Colorado Health Sciences Center and Kaiser Permanente Colorado Region.
Peter D. Fox Chair
iii
Acknowledgments
The HMO Workgroup on Care Management:
Ellen Aliberti, BSN, MS, CCM
Regional Director, Care Management HealthCare Partners Los Angeles, California
Bonnie Hillegass, RN, MHA

Vice President, Medical Management Sierra Health Services, Inc. Las Vegas, Nevada
Danielle Butin, MPH, OTR

Manager of Health Promotion & Wellness Oxford Health Plans White Plains, New York
Christine Himes, MD
Director, Geriatrics and Long Term Care Group Health Cooperative Seattle, Washington
Jan Clarke, MD, MPH

In-Patient Program Advocate Health Centers Chicago, Illinois
Joy Luque, RN, BSN, CCM

Director, Case Management PacifiCare of California Cypress, California
*Eric A. Coleman, MD, MPH

Associate Professor of Geriatric Medicine University of Colorado Health Sciences Center and Clinical Researcher Kaiser Permanente Colorado Region Denver, Colorado
Paul Mendis, MD
Medical Director Neighborhood Health Plan Boston, Massachusetts
Robert J. Schreiber, MD
Medical Director of Geriatric Services Lahey Clinic Burlington, Massachusetts
Richard D. Della Penna, MD

Regional Elder Care Coordinator So. California Kaiser Permanente San Diego, California
Ingrid Venohr, RN, PhD

Director, Senior Programs Kaiser Permanente Colorado Region Denver, Colorado
Joyce Dubow
Senior Policy Advisor, Public Policy Institute AARP Washington, D.C.
Nancy A. Whitelaw, PhD

Director, Health and Aging Services Research National Council on Aging Washington, D.C., and Adjunct Investigator Center for Health Services Research Henry Ford Health System Detroit, Michigan
Peter D. Fox, PhD

President PDF, LLC Chevy Chase, Maryland
Brian Hayes, MD, CMCE

Senior Medical Director Independence Blue Cross Philadelphia, Pennsylvania
* Served as scientific consultant Served as Convener and Chair
Table of Contents
Section 1
Introduction
Section 2
Physical Inactivity
Section 3
Falls
Section 4
13
Medication-Related Complications
Section 5
21
Dementia
Section 6
29
Depression
Section 7
41
Undernutrition
Section 8
53
Urinary Incontinence
Appendix
63
Illustrative Process and Outcome Measures
69
vii
Section 1
Introduction
Recommendations for Managed Care Organizations
MCOs should:
Conduct periodic screening and assessment for common geriatric conditions and have effective interventions in place for positively identified older members. Ensure that primary care practitioners have the tools, incentives, and resources to facilitate identification and appropriate management of older members with common geriatric conditions. Establish partnerships with community agencies that provide complementary services for older members with common geriatric conditions. Recognize that geriatric conditions often confound treatment of other chronic illnesses. Be open to innovations that are not currently part of their benefit structure but may have a positive impact on quality of life for older members.
Traditionally, most of the focus of geriatric care in Managed Care Organizations (MCOs)1 has been on identifying the relatively small number (3-5%) of older members who account for disproportionate utilization. The main intervention MCOs have offered these high-risk enrollees has been intense, comprehensive case management. More recently, and as will be described in this report, MCOs are beginning to recognize the advantages of broadening this focus to include older members at risk for functional decline and subsequent frail health. These members may not need longitudinal case management but, rather, access to targeted, evidence-based interventions that address specific conditions. The financial advantages of traditional utilization management have largely been realized, and future savings will likely accrue from investing in upstream approaches that prevent costly utilization altogether (e.g., of the hospital or the emergency department). In order to provide excellent geriatric care and simultaneously mitigate downstream cost, MCOs need to establish expertise in improving functional reserve in their older members. Functional reserve refers to the capacity of individuals to withstand a threat to their health and functional status. Persons with limited functional reserve take longer to recover, or may not recover, from their illness to the point that they can manage their care at home. These persons may be frail or may be high-risk for becoming frail (i.e., the pre-frail).
1 Managed care organizations (MCOs) include health maintenance organizations and other health plans with capitated contracts to serve Medicare beneficiaries. They also include providers (e.g., hospitals or group practices) that are capitated by health plans.
Functional decline and accompanying frailty is costly (1). Compared with their counterparts, whose functional status worsened over time, direct costs of care for members who maintained high functional status over the same time period were 62 percent lower (2). Further, many of the benefits with regard to both outcomes and costs can be realized in the relatively short time horizon of 6-12 months (3-6). Cost avoidance achieved from implementing interventions described in this report can be used to further sustain such programs. Reduced functional reserve is frequently multi-factorial, and different combinations of geriatric conditions may contribute to decline in a given individual. Although many conditions threaten functional reserve in older members, seven treatable geriatric conditions serve as the focus of this report:

Physical Inactivity Falls Medication-related Complications Dementia
Depression Undernutrition Urinary Incontinence
These conditions represent common problems that adversely affect function and quality of life. They are frequently underdiagnosed and therefore undertreated, and there are effective interventions available. The seven conditions should not be viewed in isolation since they may interact to potentially enhance or confound treatment (7-10). For example, physical inactivity and urinary incontinence both increase risk for falls; use of high-risk medications is a risk factor for both falls and cognitive dysfunction; and social isolation is a risk factor for depression, undernutrition, and physical inactivity. Conversely, greater physical activity has been shown to improve depressive symptoms and reduce the risk for falls. The Workgroup envisions a tri-partite relationship among the MCO, the primary care practitioner (PCP),2 and the member. MCOs can support the PCP and member towards achieving improved functional outcomes. For example, the MCO can assure that brief and simple-to-use tools to manage these conditions are readily available to PCPs. The MCO can also ensure that programs are available for referral, whether offered by the MCO or in partnership with relevant community-based organizations (11). As discussed in a previous Workgroup report, MCOs can initiate periodic screening and assessment of common geriatric conditions in both newly enrolled and existing members (12). They can also facilitate the availability of evidence-based care pathways for common geriatric conditions that can be accessed by any member of the health care team, or alternatively, by the patient or an informal caregiver. Primary care practitioners need to manage geriatric conditions. However, systems of care are often not in place to provide them with the time, the tools, the incentives, and the support to consistently identify and assess geriatric conditions. PCPs may be reluctant to address these conditions in the absence of effective and accessible treatment programs for appropriate referral, particularly when they face immediate pressures to attend to more acute medical problems. In contrast, MCOs may have, or can develop, the infrastructure for identification and assessment. MCOs can be instrumental in making these programs available and facilitating the referral process. Further, many of the conditions described in this report
2 Primary care practitioner broadly refers to the primary care physician, nurse practitioner, or a medical or surgical specialist to the extent they assume a primary care role. Nurses, who provided asthma-related information, checked on symptoms, and provided assistance as needed. In addition, members in the program could call these nurses at any time to ask questions or request help.
Section 1 Introduction
can be managed by health professionals other than physicians and in locations other than the medical office (e.g., senior centers, self-management groups, physical therapy, and organized incontinence or exercise classes). In order to reduce the threat of care fragmentation, the PCP needs to be continually apprised of the members progress. MCOs can encourage members to take a more active role in their care through ongoing monitoring and positive reinforcement. Strategies to build self-efficacy and self-management skills have been shown to have positive effects on a wide range of health outcomes, including geriatric conditions (13;14). The member has a role in formulating the care plan and bringing in condition-specific materials to share with practitioners. MCO-produced member educational or empowerment materials need to complement MCO-produced PCP education and decision support materials. Thus, the MCO can provide greater self-directed care and can simultaneously prepare PCPs to better manage geriatric conditions. For example, members with urinary incontinence may be encouraged to play a more collaborative role in their care by gathering condition-specific information prior to their visit (e.g., by completing symptom diaries of incontinent episodes), key questions to ask about their condition (e.g., could my incontinence be due to an infection or my medications?), and information regarding specific programs and treatments about which to inquire (e.g., physical therapist or nurse-led incontinence self-management program). Treatment of geriatric conditions often requires that older members change their health-related behavior (15-17). Treatment regimens will more likely be followed when they are tailored to the members personal goals, such as the ability to attend church, enjoy time with family, or return to work. Adherence can be further enhanced through mechanisms that provide positive reinforcement and sustain attempts at behavioral change. MCOs need to account for a members readiness to change when developing new programs. PCPs also need to understand the members readiness to change and individual preferences in order to establish meaningful and obtainable goals. Increasingly, the Center for Medicare and Medicaid Services (CMS) has directed MCOs to include programs that enhance the health status and function of older members in their quality improvement efforts. Nearly all of the interventions for the geriatric conditions discussed in this report lend themselves to continuous quality improvement initiatives such as those required by the National Committee for Quality Assurance (NCQA) and the Quality Improvement Systems for Managed Care (QISMC) regulations applying to MCOs with Medicare and Medicaid enrollees. The goal of this report is not to dictate the practice of medicine. Rather, it is to draw from a composite of evidence-based literature, best practices, and professional judgment to demonstrate how MCOs can implement effective interventions that enhance functional status and quality of life for their older members. Historically, older persons with multiple coexisting problems have been excluded from therapeutic trials. Consequently, for some of the seven conditions, the evidence base is more developed than for others. Many of the recommended interventions do not represent a large investment to the MCO and are not difficult to undertake. In many cases, the role of the MCO is to make it easy for the clinician to do what is best for the member.
Each condition is developed in a separate section that follows the same format: Clinical Vignette, Recommendations for MCOs, Nature of the Problem, Target Population and Risk Factors, Screening and Assessment, Interventions, Implementation Barriers, Economic Impact, and Reference List. Interactions between the conditions are highlighted. Throughout this report, effective programs that leading MCOs have implemented will be featured for each of the seven geriatric conditions. Examples are drawn from both Workgroup members and other MCOs to highlight that such programs are not only possible but have already been successfully implemented and add value to the respective organizations. The Workgroup acknowledges, however, that there is considerable activity in these areas beyond what is reported herein.
Reference List
(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) (17) National Institute on Aging. Physical frailty. 1991. National Institutes of Health. Leveille S, LaCroix A, Hecht J, Grothaus L, Wagner E. The cost of disability in older women and opportunities for prevention. Journal of Womens Health 1992; 1(1):53-61. Leveille S, Wagner E, Davis C, Grothaus L, Wallace J, et al. Preventing disability and managing chronic illness in frail older adults: a randomized trial of a community-based partnership with primary care. Journal of the American Geriatrics Society 1998; 46(10):1191-1198. Burgio K, Locher J, Goode P, Hardin M, McDowell B, et al. Behavioral vs. drug treatment for urge urinary incontinence in older women: a randomized controlled trial. JAMA 1998; 280(23):1995-2000. Stearns S, Bernard S, Fasick S, Schwartz R, Konrad T, et al. The economic implications of self-care: the effect of lifestyle, functional adaptations, and medical self-care among a national sample of Medicare beneficiaries. American Journal of Public Health 2001; 90(10):1608-1612. Rizzo J, Baker D, McAvay G, Tinetti M. The cost-effectiveness of a multifactorial targeted prevention program for falls among community elderly persons. Medical Care 1996; 34(9):954-969. Tinetti ME, Inouye S, Gill TM, Doucette JT. Shared risk factors for falls, incontinence, and functional dependence: unifying the approach to geriatric syndromes. JAMA 1995; 273(17):1348-1353. Singh N, Clements K, Fiatrone M. A randomized controlled trial of progressive resistance training in depressed elders. Journal of Gerontology A Biological and Medical Sciences 1997; 52A(1):M27-M35. Dugan E, Cohen S, Bland D, Preisser J, Davis C, et al. The association of depressive symptoms and urinary incontinence among older adults. Journal of the American Geriatrics Society 2000; 48(4):413-416. Wolf SL, Barnhart HX, Kutner NG, McNeely E, Coogler C, Xu T. Reducing frailty and falls in older persons: an investigation of Tai Chi and computerized balance training. Journal of the American Geriatrics Society 1996; 44(5):489-497. HMO Workgroup on Care Management. Establishing relations with community resource organizations: an imperative for managed care organizations serving Medicare beneficiaries. 1-26. 1999. Washington D.C., AAHP Foundation. The HMO Workgroup on Care Management. Risk screening Medicare members revisited. 1-37. 2000. Washington D.C., AAHP Foundation. Lorig K, Sobel DS, Stewart A, Brown B, Bandura A, et al. Evidence suggesting that a chronic disease self-management program can improve health status while reducing hospitalization. Medical Care 1999; 37(1):5-14. Reuben D, Frank J, Hirsch S, McGuigan K, Maly R. A randomized clinical trial of outpatient comprehensive geriatric assessment coupled with an intervention to increase adherence to recommendations. Journal of the American Geriatrics Society 1999; 47(3):269-276. Nigg CR, Burbank PM, Padula C, Dufresne R, Rossi JS, et al. Stages of change across ten health risk behaviors for older adults. Gerontologist 1999; 39(4):473-482. Prochaska JO, Velicer WF. The transtheoretical model of health behavior change. American Journal of Health Promotion 1997; 12(1):38-48. Simons-Morton DG, Mullen PD, Mains DA, Tabak ER, Green LW. Characteristics of controlled studies of patient education and counseling for preventive behaviors. Patient Education and Counseling 1992; 19(2):175-204.
Section 1 Introduction
Section 2
Physical Inactivity
Clinical Vignette
In 1998, Group Health Cooperative was faced with becoming the highest priced Medicare+Choice plan in Washington state. Recognizing an opportunity to combine a member retention strategy with a clinical imperative for senior health, the health plan decided to add a covered physical activity benefit, partnering with senior centers and local health clubs. The strategy has increased member retention and decreased utilization. Those members who took advantage of the added benefit experienced 1.5 fewer outpatient clinic visits over one year compared with those who did not. Furthermore, the 14 percent of members currently using the benefit have become some of the most loyal and most vocal advocates, praising Group Health Cooperative in the community. Finally, Group Health Cooperative has received positive publicity from the local press with numerous articles featuring their exercising seniors.

MCOs should:
Promote physical activity for members irrespective of age, health, or functional status. Physical activity is particularly important for members with chronic illness at high-risk for functional dependence and those contemplating elective surgery, such as knee replacement. Increase awareness of the benefits of physical activity among older members and encourage them to discuss physical activity with their primary care practitioner. Provide both practitioners and members with specific tools and guidance to promote regular physical activity. Establish partnerships with community-based agencies to ensure that physical activity programs are available to their members. MCOs should also participate in state- or city-wide initiatives designed to promote physical activity.
Nature of the Problem

Lack of regular physical activity3 is a major under-recognized risk factor for chronic health problems, loss of functional reserve, and disability. Either alone or through its contribution to prevalent and costly chronic illnesses, physical inactivity extols significant burden in terms of morbidity and mortality (1). Physical deconditioning, through its adverse effect on physical function, is a contributing factor for extended hospital length-of-stay and need for subsequent post-hospital care in skilled nursing facilities (2-5). Regular physical activity has been shown to extend life, reduce disability, and improve quality of life in older adults (6-10). It reduces risk for cardiovascular disease, osteoarthritis, osteoporosis, obesity, diabetes, and insomnia. In addition, it significantly reduces risk for three of the conditions featured in this report; falls, depression, and incontinence (6;8;11-19). Consequently, because of the high prevalence of these conditions, older persons potentially have the most to gain from regular physical activity (6;7;20;21). Thus, if there is one thing that MCOs can do to improve health outcomes in older memberswhether they are robust and healthy or frail and immobileit is to encourage a program of regular physical activity. The Surgeon General recommends that nearly all persons should accumulate 30 minutes or more of moderate intensity physical activity over the course of most days (6;22). Currently, however, older adults are the most sedentary segment of the adult population (6). Fewer than half of men 70 years of age and older engage in physical activity three or more times per week. In women, the proportion is even lower with fewer than one-third participating in physical activity three or more times per week (23).
Target Population and Risk Factors

MCOs should promote physical activity for members irrespective of age, health, or functional status. Traditionally, MCOs have focused their attention on healthier members and have placed considerably less emphasis on reducing physical inactivity among older members with multiple chronic illnesses, the pre-frail, or the frail. Scientific evidence strongly supports implementation of programs that promote physical conditioning for all members throughout the spectrum from healthy to frail (6-8;24-26). For example, recent studies have demonstrated the value of strength training in frail 80- and 90-year-old nursing home residents (20). Regular physical activity in older adults with chronic illness can potentially reverse loss of mobility (6). Older members with degenerative joint disease of the knees who undergo knee replacement can improve their post-operative recovery through participation in a structured exercise program prior to surgery (27). The minority of community-dwelling enrollees who have particularly high health care costs are another important group for targeted programs that promote physical conditioning.
3 The following elements are aspects of physical activity: cardio respiratory (aerobic) endurance, muscle strength and endurance, balance, and stretching. Physical activity is regular if activities are performed most days of the week (1).
Section 2 Physical Inactivity
Screening and Assessment

Physical activity levels of new members can be determined by a mailed screening questionnaire. Taken a step further, the assessment of physical activity can be considered an additional vital sign for all older members, performed at each visit irrespective of health or functional status (1). Consistent with the Surgeon Generals recommendations for promoting physical activity, a commonly used screening question asks, How many days in the past week have you accumulated 30 minutes or more of moderate exercise (for example, walking, gardening, cleaning)? (6). Two more elaborate tools have been used within MCO populations (28). PASE, or the Physical Activity Scale for the Elderly, measures total leisure and work activity through a weighted scoring of hours per activity in the previous 7 days (29). PACE, or Physician-based Assessment and Counseling for Exercise, measures attitudes and behaviors related to physical activity (30). In assessing older members for participation in a physical activity program, a question that often arises is whether a medical evaluation is needed, such as exercise treadmill testing, to assess the likelihood of adverse cardiac events. For older members who have no active cardiopulmonary symptoms embarking on a moderate-intensity program (as opposed to a vigorous one that causes the person to breathe hard and sweat profusely), formal testing is generally not necessary and is not supported by the current scientific evidence (8;31-34). Furthermore, recommending additional steps such as exercise treadmill testing could deter participation by portraying physical activity as potentially hazardous, when in fact just the opposite message needs to be conveyed. Nevertheless, formal instruments, such as the Physical Activity Readiness Questionnaire (PAR-Q) have been developed to identify persons who may benefit from exercise treadmill testing and ongoing physician monitoring (35). An evaluation by a physical or occupational therapist prior to initiating a program of regular physical activity may be appropriate for some older members, for example, those with impaired balance or mobility who are high-risk for falls.
Interventions
The Surgeon Generals national goal for each person to accumulate 30 minutes or more of moderate intensity physical activity during the course of most days can be achieved in multiple ways (6;22).4 In this context, the emphasis is on physical activity rather than exercise per se. Physical activity is a broader term that includes activities such as walking, climbing stairs, or regular gardening. A program may emphasize strength, aerobic, balance, flexibility training, or it may be multifaceted. In general, however, the recommendation is intended to convey the message that any type of physical activity is better than none. The initial goal may be to move from no activity to minimal activity, followed by incremental gains as tolerated. An individual conditioning program should be tailored to the members abilities, preferences, and living environment. An older member suffering from osteoarthritis of the knee may benefit most from an emphasis on flexibility and strength training. In contrast, a frail older member with impaired mobility and falls living in an assisted living environment may benefit from a balance program such as
The activity or activities do not necessarily need to be performed continuously.
group Tai Chi. This activity has been shown to reduce the risk of multiple falls, fear of falling, and improve ability to perform activities of daily living (14;36). Informal walking programs offered at local shopping malls are a good way to promote physical activity in environments where the weather may not always be conducive. Tailoring of a program of physical activity also entails deciding whether the physical activity is performed individually or within a group, and whether it is based at home or in a community setting (32). Participation in a structured group exercise program (e.g., at a healthcare facility or in a community senior center) versus a home-based program is a matter of personal preference. Comparable results can be achieved in either (12;37;38). The group setting, however, affords additional benefits by creating an environment for peer support, self-efficacy, and increased socialization that can counteract the negative effects of social isolation and associated depression (29;39;40). Also, members who exercise in a group setting may feel a greater sense of personal safety that might reduce an additional barrier, namely fear of injury. For members who prefer the convenience or privacy of a home-based program, protocols have been developed that use resistance bands, light weights, stationary bicycles, or common household objects such as a chair or a towel (37;41). The National Institute on Aging, among others, has produced a low-cost ($7.00) self-guided home video that begins with 6 minutes of safety tips followed by 40 minutes of balance, strength, and stretching exercises.5 Multiple studies have shown that PCPs are an important source of motivation for members contemplating the initiation of a physical activity (42;43).6 Every clinical encounter represents an opportunity to reinforce the benefits of regular physical activity. Thus, MCOs should provide both PCPs and members with specific tools and guidance to promote regular physical activity. MCOs can offer PCPs continuing medical education classes on physical activity counseling and prescription writing. MCOs can also establish partnerships with community programs to facilitate PCP referral of interested members.7 For example, Oxford Health Plan gives physicians prescription pads that list Oxfordsponsored community walking clubs and the name and phone number of the leader. Members are also encouraged to lead walking programs on their own by acting as a coach for peers in their neighborhood. Similarly, MCOs can encourage members to discuss physical activity with their PCPs, provide members with information about specific types of physical activity programs and their respective benefits (e.g., strength, balance, aerobic), and direct them to available community resources (e.g., senior centers) where they can pursue such programs. For example, PacifiCare provides members with information regarding the benefits of physical activity and an up-to-date listing of available community physical activity programs on their web site. Older members at Group Health Cooperative are asked yearly about their physical activity as one component of the Lifetime Health Monitoring questionnaire.8 The underlying premise is that everyone can benefit from regular physical activity, particularly persons with chronic illness or functional
5 6
The video can be obtained by calling 1-800-222-2225 or online at http://www.nih.gov/nia.
Although a discussion of physical activity counseling and motivation is beyond the scope of this report, the reader is referred to several excellent resources (8;32;42-45).
7 8
Please see an earlier Workgroup report (46). This annual questionnaire comprises an important component of a Group Health Cooperative members overall health promotion and disease prevention care plan.
impairment. Primary care practitioners are encouraged to assess physical capacity, develop an individualized written exercise prescription, and direct patients to either a community- or home-based exercise program. One community-based program in particular, the Lifetime Fitness Program, began in 1993 and is now offered in nearly 30 locations in the Seattle metropolitan area. It offers low-cost, one-hour supervised classes that focus on strength training (with wrist and ankle weights), aerobics, balance, and flexibility. Positive outcomes have included improved balance and flexibility as well as improved overall functional status in members who attended at least two classes per week (12). In addition, Group Health Cooperative has contracted with health clubs throughout the Seattle area to provide senior-oriented exercise classes. Out of approximately 60,000 older Group Health Cooperative members, 9,513 have visited a network contract health club and 3,206 attend the facility at least twice weekly. These classes are a covered benefit for Group Health Cooperative Medicare members. Health Partners, a mixed group model and IPA MCO serving 800,000 members in Minnesota, encourages members to participate in a wide variety of programs tailored to their interest and motivation for behavioral change. Programs include a mall walking program at the Mall of America (currently 5000 members are enrolled), reduced monthly fees for joining a contract local fitness club, a clinicbased fitness program, and an innovative self-directed walking program entitled, 10,000 Steps. Nearly 10,000 individuals have participated in the 10,000 Steps program. It is based on the premise that inactive people take 2,000 to 4,000 steps per day, whereas active people take over 10,000 steps per day. Inactive people need positive reinforcement to increase their level of activity in order to gain the same health benefits. Participants in the program are issued a pedometer (i.e., step counter) that provides positive reinforcement, a personal action planner designed to encourage them to initiate and sustain participation, a log to keep track of steps, biweekly mailed motivational cards for eight weeks followed by bimonthly cards for six months, and an opportunity to enter drawings and win prizes (47). This program has been implemented in various settings, including primary care clinics, disease management programs, worksites, and in community programs as part of a state-wide initiative sponsored by the Department of Health.
Implementation Barriers
There are multiple barriers to improving physical activity levels in older members. Motivation and adherence barriers can be counteracted through PCP encouragement, transportation, and exercising with a partner (8;32;42-45). Further, a lack of knowledge regarding nearby community physical activity programs is common. Fear of crime can deter participation in outdoor programs such as walking. Because of the loss of a spouse, sibling, or friend (and associated social isolation), many older members do not have a partner to participate in a regular conditioning program. Weather that is not conducive to physical activity (e.g., excessive cold or heat) may also preclude regular outdoor exercise. Finally, the myth of the need to take it easy in older age is far from eradicated in the minds of many older members.
At the level of the MCO, the geographic distribution of a plans membership may complicate the offering of MCO-developed and run physical activity programs. Instead, MCOs may choose to partner with community-based organizations (e.g., senior centers, parks and recreation, YMCA/YWCA). Few PCPs have had formal training in prescribing and monitoring a physical activity program, especially for their older members. Many PCPs feel that they lack the time, prescribing skills, and specific tools that they need to encourage their patients to become more active (44;45;48). The MCO can play a pivotal role in sensitizing PCPs to the central importance of physical activity in older adults, thereby reducing the possibility that negative attitudes do not create barriers to counseling. MCOs can also facilitate the PCPs role in promoting regular physical activity by providing them with a listing of available community resources, tear-off sheets on exercise tips, and a prescription pad to assist their patients in initiating an exercise program to prompt immediate referral.
Economic Impact
Deconditioning, through its adverse effect on physical function, is often a contributing factor to prolonged hospital length of stay or post-hospitalization admission to a skilled care facility (2-5). Alternatively, physical conditioning is one of the most effective strategies for building physiologic reserve (i.e., pre-hab), thereby proactively reducing hospital length-of-stay or obviating the need for post-hospital skilled care. In a study by Buchner and colleagues, older community-dwelling adults who were randomized to receive a strength and endurance training intervention had fewer high cost hospitalizations (more than $5,000) and outpatient visits compared with those who were randomized to a comparison group (21). Older women who walk more than four hours per week reduce their risk of hospitalization due to cardiovascular conditions (49). Health Partners has examined the economic impact of encouraging sedentary members to become physically active one day per week. Based on conservative analyses, they estimate a 4.7 percent reduction in annual costs for each member who achieves this modest increment (50). These findings have been instrumental in decisions to expand their efforts to promote physical activity for members cared for in primary care, disease management, weight management programs, and in community settings such as walking programs offered in local shopping malls. Enrollees who are candidates for elective joint replacement illustrate the potential economic benefits of physical activity. A physical therapist-led strengthening program focusing on the quadriceps and hamstring muscles in the legs has been shown to delay or prevent the need for subsequent elective knee joint replacement surgery. The cost of the program is estimated around $500 to $1,000 for the physical therapy visits, compared to the cost of knee replacement, estimated around $30,000 (27;51).9 Cost savings due to the positive influence of physical activity on improved management of chronic illnesses such as hypertension, diabetes, and osteoarthritis are difficult to quantify. For example, older members with adult-onset diabetes who exercise regularly may no longer require pharmacologic therapy or may have fewer complications requiring hospitalization. Hu and colleagues demonstrated that women with diabetes who engaged in regular physical activity had fewer cases of heart disease and stroke (52).
These costs do not account for the complications associated with surgery.
10
Reference List
(1) (2) (3) (4) (5) (6) (7) (8) (9) Robert Wood Johnson Foundation. National Blueprint for Increasing Physical Activity Among Adults Age 50 and Older. 2000. Princeton, New Jersey. Stearns S, Bernard S, Fasick S, Schwartz R, Konrad T, et al. The economic implications of self-care: the effect of lifestyle, functional adaptations, and medical self-care among a national sample of Medicare beneficiaries. American Journal of Public Health 2001; 90(10):1608-1612. Kane R, Finch M, Blewett L, Chen Q, Burns R, Moskowitz M. Use of post-hospital care by Medicare patients. Journal of the American Geriatrics Society 1996; 44(5):242-250. Inouye S, Wagner D, Acampora D, Horowitz R, Cooney L, et al. A predictive index for functional decline in hospitalized elderly medical patients. Journal of General Internal Medicine 1993; 8:645-652. Hoenig H, Nusbaum N, Brummel-Smith K. Geriatric rehabilitation: state of the art Journal of the American Geriatrics Society 1997; 45(11):1371-1381. U.S. Department of Health and Human Services CDC. Physical activity and health: a report of the Surgeon General. Executive summary. 9-14. 1996. Buchner D. Preserving mobility in older adults. Western Journal of Medicine 1997; 167(4):258-264. American College of Sports Medicine. Exercise and physical activity for older adults. Medical Science Sports Exercise 1998; 30(6):992-1008. Guralnik J, LaCroix AZ, Abbott R, Berkman L, Satterfield S, et al. Maintaining mobility in late life: I demographic characteristics and chronic conditions. American Journal of Epidemiology 1993; 137(8):845-857.
(10) LaCroix A, Guralnik J, Berkman L, Wallace R, Satterfield S. Maintaining mobility in late life: II smoking, alcohol consumption, physical activity, and body mass index. American Journal of Epidemiology 1993; 137(8):858-869. (11) Singh N, Clements K, Fiatrone M. A randomized controlled trial of progressive resistance training in depressed elders. Journal of Gerontology A Biological and Medical Sciences 1997; 52A(1):M27-M35. (12) Wallace JI, Buchner DM, Grothaus L., Leveille S, Tyll L, et al. Implementation and effectiveness of a community-based health promotion program for older adults. Journal of Gerontology A Biological and Medical Sciences 1998; 53A(4):M301-M306. (13) Gardner M, Robinson C, Campbell J. Exercise in preventing falls and fall related injuries in older people: a review of randomised controlled trials. British Journal of Sports Medicine 2000; 34:7-17. (14) Wolf SL, Barnhart HX, Kutner NG, McNeely E, Coogler C, Xu T. Reducing frailty and falls in older persons: an investigation of Tai Chi and computerized balance training. Journal of the American Geriatrics Society 1996; 44(5):489-497. (15) Burgio K, Locher J, Goode P, Hardin M, McDowell B, et al. Behavioral vs. drug treatment for urge urinary incontinence in older women: a randomized controlled trial. JAMA 1998; 280(23):1995-2000. (16) Camacho T, Roberts R, Lazarus N, Kaplan G, Cohen R. Physical activity and depression: evidence from the Alameda County Study. American Journal of Epidemiology 1991; 134(2):220-231. (17) Farmer ME, Locke B, Moscicki E, Dannenberg A, Larson D, Radloff LS. Physical activity and depressive symptoms: the NHANES I epidemiologic follow-up study. American Journal of Epidemiology 2001; 128(6):1340-1351. (18) Ettinger Jr W, Burns R, Messier S, Applegate W, Rejeski W, Morgan T et al. A randomized trial comparing aerobic exercise and resistance exercise with a health education program in older adults with knee osteoarthritis. The Fitness Arthritis and Seniors Trial (FAST). JAMA 1997; 277(1):25-31. (19) Coleman EA, Buchner DM, Cress ME, Chan BKS, DeLateur B. The relationship of joint symptoms with exercise performance in older adults. Journal of the American Geriatrics Society 1996; 44(1):14-21. (20) Fiatrone M, Marks E, Ryan N, Meredith C, Lipsitz L, Evans W. High-intensity strength training in nonagenarians: effects on skeletal muscle. JAMA 1990; 263(22):3029-3034. (21) Buchner D, Cress M, DeLateur B, Esselman P, Margherita A, Price R et al. The effect of strength and endurance training on gait, balance, fall risk, and health services use in community-living older adults. Journal of Gerontology A Biological and Medical Sciences 1997; 52(4):M218-M224. (22) Pate R, Pratt M, Blair S, Haskell W, Macera C, Bouchard C et al. Physical activity and public health: a recommendation from the centers for disease control and prevention and the American College of Sports Medicine. JAMA 1995; 273(5):402-406. (23) Crespo C, Keteyian S, Heath G, Sempos C. Leisure-time physical activity among U.S. adults. Archives of Internal Medicine 1996; 156(1):93-98.
(24) Wagner EH. Preventing decline in function: evidence from randomized trials around the world. Western Journal of Medicine 1997; 167(4):295-298. (25) Larson E. Exercise, functional decline and frailty. Journal of the American Geriatrics Society 1991; 39:635-636.
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(26) (27) (28) (29) (30) (31) (32) (33) (34) (35) (36) (37) (38) (39) (40) (41) (42) (43) (44) (45) (46) (47) (48) (49) (50) (51) (52)
Institute of Medicine. The second fifty years: promoting health and preventing disability. Berg R, Cassells J, editors. 1990. Washington D.C., National Academy Press. Deyle G, Henderson N, Matekel R, Ryder M, Garber M, Allison S. Effectiveness of manual physical therapy and exercise in osteoarthritis of the knee. A randomized, controlled trial. Annals of Internal Medicine 2000; 132(3):173-181. Leveille S, Wagner E, Davis C, Grothaus L, Wallace J, et al. Preventing disability and managing chronic illness in frail older adults: a randomized trial of a community-based partnership with primary care. Journal of the American Geriatrics Society 1998; 46(10):1191-1198. Washburn RA Smith KW Jette AM, Janney CA. The physical activity scale for the elderly (PASE): development and evaluation. Journal of Clinical Epidemiology 1993; 46(2):153-162. Cardiovascular Health Branch, editor. Project PACE. Physician Manual. Atlanta, GA: Centers for Disease Control, 1992. Gill T, DiPietro L, Krumholz H. Role of exercise stress testing and safety monitoring for older persons starting an exercise program. JAMA 2000; 284(3):342-349. King AC, Rejeski WJ, Buchner DM. Physical activity interventions targeting older adults. A critical review and recommendations. American Journal of Preventive Medicine 1998; 15(4):316-333. Buchner DM, Coleman EA. Exercise considerations for older adults. Physical Medicine and Rehabilitation Clinics of North America 1994; 5(2). National Institute on Aging. Exercise: a guide from the National Institute on Aging. NIH 99-4258. 1999. Thomas S, Reading J, Shepherd RJ. Revision of the Physical Activity Readiness Questionnaire (PAR-Q). Canadian Journal of Sports Science 1992; 17(4):338-345. Kutner N, Barnhart H, Wolf S, McNeely E, Xu T. Self-report benefits of Tai Chi practice by older adults. Journal of Gerontology 1997; 52(5):P242-P246. King A, Haskell W, Taylor C, Kraemer H, DeBusk R. Group vs home-based exercise training in healthy older men and women: a communitybased clinical trial. JAMA 1991; 266(11):1535-1542. Wagner EH, LaCroix A, Grothaus L, Leveille SG, Hecht JA, et al. Preventing disability and falls in older adults: a population-based randomized trial. American Journal of Public Health 1994; 84(11):1800-1806. Lorig K, Sobel DS, Stewart A, Brown B, Bandura A, et al. Evidence suggesting that a chronic disease self-management program can improve health status while reducing hospitalization. Medical Care 1999; 37(1):5-14. Beck A, Scott J, Williams P, Robertson B, Jackson D, et al. A randomized trial of group outpatient visits for chronically ill older HMO members: the cooperative health care clinic. Journal of the American Geriatrics Society 1997; 45(5):543-549. Jette A, Harris B, Sleeper L, Lachman M, Heislein D, et al. A home-based exercise program for nondisabled older adults. Journal of the American Geriatrics Society 1996; 44:644-649. Andersen R, Blair S, Cheskin L, Barlett S. Encouraging patients to become more physically active: the physicians role. Annals of Internal Medicine 1997; 127(5):395-400. Christmas C, Andersen R. Exercise and older patients: guidelines for the clinician. Journal of the American Geriatrics Society 2000; 48(3):318-324. Kohrt W, Spina R, Holloszy J, Ehsani A. Prescribing exercise intensity for older women. Journal of the American Geriatrics Society 1998; 46:129-133. Eckstrom E, Hickam D, Lessler D, Buchner D. Changing physician practice of physical activity counseling. Journal of General Internal Medicine 1999; 14(6):376-378. HMO Workgroup on Care Management. Establishing relations with community resource organizations: an imperative for managed care organizations serving Medicare beneficiaries. 1-26. 1999. Washington D.C., AAHP Foundation. Lindberg R. Active living: on the road with the 10,000 steps program. Journal of the American Dietetic Association 2000; 100(8):878-879. Pretrella R, Wight D. An office-based instrument for exercise counseling and prescription in primary care. The step test exercise prescription (STEP). Archives of Family Medicine 2000; 9(4):339-344. Leveille S, LaCroix A, Hecht J, Grothaus L, Wagner E. The cost of disability in older women and opportunities for prevention. Journal of Womens Health 1992; 1(1):53-61. Pronk N, Goodman M, OConnor P, Martison B. Relationship between modifiable health risks and short-term health care charges. JAMA 1999; 282(23):2235-2239. Knee pain: early intervention can boost outcomes, cut costs. Senior Care Management May, 73-77. 2000. Hu FM, Stampfer J, Solomon C, Liu S, Colditz G, et al. Physical activity and risk for cardiovascular events in diabetic women. Annals of Internal Medicine 2001; 134(2):96-105.
12
Section 3
Falls
Clinical Vignette
Mrs. D. is a 76-year-old woman with obesity, macular degeneration, Type II diabetes, asthma, and degenerative joint disease who has experienced two non-injurious falls over the past six months. During a telephone call initiated by an Oxford Health Plan outreach worker, Mrs. D. reported feeling depressed over her inability to perform basic daily activities unassisted, such as using the shower and toilet, doing laundry, and cooking. The outreach worker enrolled Mrs. D. into Oxfords Activity and Safety Program, and both a physical and an occupational therapist visited her. The therapists ordered adaptive equipment that included a tub bench, grab bars, trolley walker, and a toilet safety frame. Mrs. D. was taught how to use the adaptive equipment, and she subsequently expressed to the therapists that she has more energy, requires less frequent use of her inhaled asthma medications, and relies less on her husband for help with household chores. Approximately two months after enrollment into the program, Mrs. D. proudly reported that, for the first time in two years, she was able to serve dinner to her family without help. Since enrollment in the Activity and Safety Program, she has remained free of falls.

MCOs should:
Adopt mechanisms to identify older members who have fallen in the past year or who are at high risk for falls and associated injuries, given that over 30 percent of community dwelling older adults fall at least once each year. Heighten awareness among members and providers of the significance of falls and provide interventions tailored to their level of risk. Ensure that interventions are available that address the following four risk areas: high-risk medications, deconditioning, home and environmental safety, and visual impairment. Participate in state-wide initiatives aimed at reducing fall-related injuries.
13

More than 30 percent of community dwelling older adults fall at least once each year, 50 percent of whom do so repeatedly (1-3). A fall in an older member often represents a sentinel event, heralding the beginning of a decline in function. Multiple falls are a marker of physical frailty since falls and associated fear of falling frequently lead to reduced activity, social isolation, and, consequently, impaired function (1;2;4). This downward spiral may ultimately lead to loss of independence and nursing home placement (4). Not all falls result in injury and not all injuries result in healthcare utilization. However, because of the large number of falls, the overall impact on utilization is substantial. Approximately 30-55 percent of falls result in minor injury and about 5 percent of falls result in a fracture (1;5;6). Approximately eight percent of persons older than age 70 seek emergency care for a fall-related injury and 30-40 percent of these emergency visits result in hospitalization with an average length of stay ranging from 8-15 days (2;7-9). The Lahey Clinic in Massachusetts closely examined emergency visits in members over age 65 and found that 45 percent of emergency visits were fall-related in 1997-8. Older patients with fallrelated injuries are also more likely to require continued skilled care in a nursing facility following hospitalization (9-12). Further, complications caused by falls are the leading cause of death from injury in persons over age 65 (2;13). Fortunately, proven interventions designed to reduce risk factors for falls have been shown to be effective as well as cost-effective (14).

Most falls are attributable to multiple factors and providers should search for more than one possible etiology. Risks for falls are commonly categorized into (1) intrinsic factors, referring to characteristics of the individual faller, and (2) extrinsic factors, referring to the individuals environment (1;13;15). Intrinsic factors include physical deconditioning, gait disturbance, vestibular dysfunction, visual deficits, and certain underlying medical conditions such as Parkinsons disease, dementia, stroke, macular degeneration, and urinary incontinence. Extrinsic factors include high-risk medications, use of alcohol, environmental hazards (e.g., throw rugs, extension cords, poor lighting, and slippery floors), and lack of sturdy shoes with good traction (16). The most important risk factors on which a MCO should focus are muscle weakness (five-fold risk for falls compared with those without such weakness), balance or gait deficits (three-fold risk), and vision deficits (two and a half-fold risk) (4). Medications are an additional risk factor to consider (17). Classes of medications that are associated with a particularly high risk for falling include: psychotropic drugs,10 associated with a 73 percent increased risk for falls; medications that suppress abnormal heart rhythms, associated with a 59 percent increased risk; Digoxin, associated with a 22 percent increased risk; and diuretics, associated with an eight percent increased risk (17). Diphenhydramine (Benadryl) and other over-the-counter medications can also contribute to falls as a result of drowsiness, confusion, or interaction with other medications. Finally, environmental factors, including poor lighting or the absence of assistive devices such as grab bars in the bathroom are also important risk factors (16). Each of these individual risk factors can have either additive or synergistic effects when combined (4).
10
This category includes anti-psychotics, tricyclic antidepressants, and benzodiazepines.
14
Section 3 Falls

Older persons who fall repeatedly are at highest risk for future falls and are most likely to benefit from targeted intervention (4;18;19). High-risk members can be identified by questionnaires administered either by mail or in the waiting room of a PCPs office. PCPs, specialists, and emergency department staff are additional sources for identification of high-risk members (20). The most commonly employed screening question for falls inquires about the number of falls in a six-month time interval (21).11 Administrative data are another way to identify older members who fall. For members enrolled in its Medicare product, Independence Blue Cross monitors emergency department utilization that does not result in a hospitalization. A case-manager telephones members to conduct a detailed assessment to determine the next course of action. Determining the need for referral to a falls prevention program is a particular focus of this assessment. Further assessment after a positive screen often necessitates a gait evaluation. Although more sophisticated tools exist, two simple assessments are adequate for most situations (22). The first one, the timed Up & Go, is a test of functional mobility for older members (23). The PCP, nurse, or medical assistant can administer it when the older member is called in from the waiting room, or the receptionist can even administer it before the encounter. During this test, the patient is observed and timed while rising from an armchair, walking 10 feet, turning, walking back, and sitting down again. Patients who cannot perform the test within 20 seconds should be evaluated further (i.e., by a physical therapist) to identify specific problems with gait and balance. The second tool, functional reach, is a measure of balance that can identify persons who are likely to fall (24). Functional reach, the maximal distance one can reach forward from a standing position without stepping, is measured using a leveled yardstick secured to the wall at shoulder height. Patients who cannot reach more than 10 inches are at increased risk of falling (25). Other critical components of the assessment besides the gait evaluation include measuring the members blood pressure and heart rate as they change positions from lying to sitting to standing and conducting a comprehensive medication evaluation. The medication evaluation can be performed by the PCP or by a clinical pharmacist. Particular attention should be paid to medications associated with confusion (e.g., benzodiazepines, Benadryl or diphenhydramine), those that inadvertently lower blood pressure upon standing (e.g., antihypertensives, diuretics, tricyclic antidepressants such as Doxepin, and Amitriptyline), and medications that suppress abnormal heart rhythms (e.g., Digoxin) (17). An evaluation of alcohol consumption is an important component of the medication evaluation. Environmental assessments focus on home safety. They are most commonly conducted by a nurse or occupational therapist employed by a home care agency and are designed to reduce hazards and make the home more suited to members functional level.
11
Longer time intervals are associated with reduced reporting accuracy.
15
Interventions
The falls intervention literature strongly supports the initiation of a multi-factorial falls reduction program, particularly one that targets multiple risk factors in individuals who have experienced repeated falls (19;26;27). Elements of a multi-factorial falls program may address strength and balance, home safety modification, instruction in the use of a cane or walker, and high-risk medication reduction. Although not all older members who fall have correctable contributing factors, a significant number do. Interventions to reduce falls can be categorized into physical activity, environmental interventions, assistive devices, and medication review. Although physical activity programs designed to build physiologic reserve are the cornerstone of any falls reduction program, they are most effective when they are part of a multi-component risk reduction approach (19;28;29). Physical activity programs, particularly those emphasizing balance and lower extremity strengthening, are associated with a 10-20 percent reduction in falls (30). These programs may be conducted in either a group or individual format. Older adults with repeated falls may require supervision by a physical therapist or trained exercise leader. Environmental interventions usually entail a home safety assessment, commonly conducted by a nurse, or a physical or occupational therapist from a home care agency. The assessment focuses on reducing hazards such as throw rugs, extension cords, poor lighting, dangerous stairwells and shoes that increase the risk of falling. It also attempts to make the home more suited to the members functional level, such as installation of a raised toilet seat, a shower chair, or grab bars near the toilet and tub. With a home self-assessment guide and access to durable medical equipment, some members and their families can improve the safety of their home without the need for a visit from a healthcare professional. In either case, the involvement of a concerned family member or friend can help ensure that the safety recommendations are followed. Through partnerships with community agencies, MCOs can help members identify low-cost installers of equipment to promote home safety (e.g., grab bars in the bathroom). Environmental safety can also be promoted among older adults population-wide. For example, the state of Minnesota has initiated a state-wide campaign aimed at reducing fall-related injury. MCOs can enhance their efforts through partnering with relevant state and local agencies. Referral to physical and occupational therapy is often the most efficient way for members to obtain and learn how to use assistive devices, such as a single-point cane, a four-point cane, or a walker. Assistive devices can help the older member compensate for a gait or balance disturbance. More appropriate footwear may also be prescribed. The member may also need training from a therapist to learn how to get up safely once a fall has occurred. Sierra Health Services in Nevada has designed and implemented an extended physical therapy benefit to improve balance, gait and function. Services include a continuum of different levels of supervised therapy. Examples of services include customized individual physical therapy provided in the home, individualized therapy offered in an outpatient facility, supervised group exercise classes, and supervised pool exercise classes. Evaluation of members function before and after participation has revealed significant improvements in balance, gait stability, and physical function.
16
Section 3 Falls
For older persons living alone who are frail or otherwise could not get back up after a fall, a home alert lifeline necklace may be life saving. One push of the button on the necklace can summon help and reduce some of the complications of falls. These devices are available from home health agencies for a monthly fee. PCP encouragement can be instrumental in assuring that members obtain this device and wear it on a regular basis. Either the PCP or a clinical pharmacist can conduct a comprehensive medication review. To prevent fall-related complications, the overall goal is to reduce use of high-risk medications and to reduce the risk for osteoporosis using proven treatment such as calcium and vitamin D replacement, estrogens, and bisphosphanates (e.g., Alendronate). Sierra Health Services, the Lahey Clinic, Group Health Cooperative, and Kaiser Permanente, Colorado Region, have all invested in clinical pharmacists to assist practitioners and members in their efforts to reduce high-risk medication use. Many MCOs have adopted strategies to reduce falls among their older members. In collaboration with researchers from Yale, Oxford Health Plan is evaluating the effectiveness of a multi-component risk reduction demonstration program in selected boroughs of New York City. In accordance with the protocol, screened members are identified to participate if they report having fallen over the past six months or if they are worried about falling (i.e., fear of falling). Members identified using this approach receive an in-home comprehensive assessment from an occupational therapist and a physical therapist. The goals for these visits are to improve gait, balance, and strength, and to teach compensatory strategies for any functional impairment. Members are also counseled how to access vision and podiatry services. A registered nurse may conduct an in-home falls risk assessment if the member is 1) currently prescribed a targeted high-risk medication; 2) has a history of falls associated with dizziness; or 3) the members blood pressure has been observed to drop upon standing. Results from this study are expected in December 2002. The Lahey Clinic in Massachusetts offers high-risk members a multidisciplinary fall risk prevention clinic. This clinic is staffed by a geriatrician, a physiatrist (a physician who specializes in rehabilitative medicine), and a physical therapist. Following an evaluation by the physical therapist, the team works with primary care practitioners to implement a falls-reduction care plan with follow-up monitoring. Independence Blue Cross has formed a partnership with its local Area Agency on Aging to conduct home safety evaluations for Medicare members. For members who need home adaptation, it works with a local agency, Children of Aging Parents. Senior Buena Care, a PACE (Program of All-Inclusive Care to the Elderly) in East Los Angeles teaches members how to get up after a fall. Kaiser Permanente, Colorado Region, has developed a falls prevention video entitled, No More Falls, which is available in the public domain.
Many practitioners are not fully aware of the significant threat falls pose to older members or are unfamiliar with effective interventions. Typically, the focus of the evaluation is on the effect of the fall rather than the underlying cause. The first step to implement an effective falls intervention program is to increase awareness for the hazards of falls amongst the wide range of practitioners that come into
17
contact with older members (e.g., PCPs, ambulatory care nurses, emergency physicians and nurses, orthopedic surgeons, physiatrists, physical therapists, home care nurses, and case managers). The second step is to encourage them to be proactive. MCOs can play an important role in providing education and simple evaluation tools (e.g., pocket cards with algorithm for diagnosis and treatment of falls). Another barrier to implementing intervention programs for falls is that this condition currently is not readily assessed from diagnoses that are coded in administrative data. Often it is only the manifestation of the fall (e.g., contusion, dizziness, syncope, laceration, etc.) that is coded. The Lahey Clinic found that the underlying fall was coded in only 47 percent of cases. Finally, older members may be reluctant to participate in a falls intervention program. They may minimize their problem out of fear that admitting the problem could result in loss of independence. Some older persons also refuse a home safety evaluation for this same reason. Oxford Health Plan refers to its fallsreduction program as an Activity and Safety Program to enhance acceptance. Further, some of the interventions described in the previous section involve out of pocket costs (e.g., installation of grab bars in the toilet or a home alert lifeline necklace). Transportation to physical therapy appointments or exercise programs can represent a significant barrier to adherence and subsequent improvement. MCOs can work with members to raise awareness for the fact that falls are often preventable and that, by seeking help, these older members stand to gain rather than lose their independence.
Economic Impact
An estimated eight percent of people over the age of 70 visit an emergency room each year as a result of a fall, about one-third of whom will be hospitalized (4). Further studies have confirmed that, compared with non-fallers, recurrent fallers have significantly higher rates of hospital, emergency department, home health, and skilled nursing facility use (10;14). The economic impact of multiple-risk factor reduction programs has been rigorously evaluated in two randomized trials. Rizzo and colleagues conducted a cost-effectiveness analysis of a multi-factorial risk reduction program (14). Over the subsequent 12 months, health care costs were reduced by an average of $2,000 per subject compared to a program cost of $925. Savings were primarily attributed to a reduction in hospitalization. The program was found to be even more cost-effective when targeted at older adults with at least four risk factors.12 Moreover, these savings were realized within the year of program implementation. Salkeld and colleagues conducted a randomized trial to evaluate the effectiveness of home modification for preventing falls in a population of older adults (31). The main intervention involved an in-home assessment of potential environmental hazards followed by home modification. The authors examined changes in resource use within and between the hospital, home, and community sectors. For subjects who had fallen in the year prior to randomization (i.e., the high-risk group), the authors were able to demonstrate cost savings over the subsequent 12 months of follow-up. This study strongly suggests that in order to be cost-effective, interventions must target those older members at greatest risk.
12 Risk factors included sedative use, use of at least four prescription medications, postural hypotension, unsafe tub or toilet transfers, the presence of environmental fall hazards, and impaired strength, balance, or gait.
18
Section 3 Falls
These analyses demonstrate three important lessons. First, both of these studies point to the potential of community partnerships for delivering high quality cost-effective care, such as with senior centers, meals on wheels, Visiting Nurses Association, physical activity programs and local Area Agencies on Aging (32). Second, both studies demonstrated the importance of targeting resources to members with the highest risk for adverse events. Finally, falls prevention programs can lead to favorable economic outcomes, with gains realized within a year.
Reference List
(1) (2) (3) (4) (5) (6) (7) (8) (9) Tinetti ME, Speechley M, Ginter SF. Risk factors for falls among elderly persons living in the community. New England Journal of Medicine 1988; 319(26):1701-1707. Sattin R. Falls among older persons: a public health perspective. Annual Review of Public Health 1992; 13:489-508. Rubenstein LZ, Robbin AS, Schulman BL, et al. Falls and instability in the elderly. Journal of the American Geriatrics Society 1988; 36(266):278. Rubenstein LZ. Approaching falls in older persons. Annals of Long-Term Care 2000; 8(8):61-64. King M, Tinetti M. Falls in community-dwelling older persons. Journal of the American Geriatrics Society 1995; 43(10):1146-1154. Nevitt MC, Cummings SR, Kidd S, Black D. Risk factors for recurrent non-syncopal falls. JAMA 1989; 261:2663-2668. Grisso JA, Schwartz DF, Wolfson V, et al. The impact of falls in an inner-city elderly African-American population. Journal of the American Geriatrics Society 1992; 40:673-678. Sjogren H, Bornstig U. Injuries among the elderly in the home environment. Journal of Aging Health 1991; 3(107):125. Alexander BH, Rivara FP, Wolf ME. The cost and frequency of hospitalization for fall-related injuries in older adults. American Journal of Public Health 1992; 82(1020):1023.
(10) Kiel D, OSullivan P, Teno J, Mor V. Health care utilization and functional status in the aged, following a fall. Medical Care 1991; 29(3):221-228. (11) Wolinsky FD, Johnson RJ, Fitzgerald JF. Falling, health status, and the use of health services by older adults: a prospective study. Medical Care 1992; 30(7):587-597. (12) Tinetti, ME, Liu WL, Claus EB. Predictors and prognosis of inability to get up after falls among elderly persons. JAMA 1993; 269(65):70. (13) Rubenstein L, Robbin A, Josephson K, Schulman B, Osterweil D. The value of assessing falls in an elderly population: a randomized clinical trial. Annals of Internal Medicine 1990; 113(4):308-316. (14) Rizzo J, Baker D, McAvay G, Tinetti M. The cost-effectiveness of a multifactorial targeted prevention program for falls among community elderly persons. Medical Care 1996; 34(9):954-969. (15) Cutson T.M. Falls in the elderly. American Family Physician 1994; 49(149):156. (16) Sattin RW, Rodriguez JG, DeVito CA, Wingo PA, and the Study to Assess Falls Among the Elderly (SAFE) Group. Home environmental hazards and the risk of fall injury events among community-dwelling older persons. Journal of the American Geriatrics Society 1998; 46:669-676. (17) Leipzig RM, Cummings RG, Tinetti ME. Drugs and falls in older people: a systematic review and meta-analysis: II. cardiac and analgesic drugs. Journal of the American Geriatrics Society 1999; 47(1):40-50. (18) Rizzo JA, Baker D I, McAvay G, Tinetti ME. The cost-effectiveness of a multifactorial targeted prevention program for falls among community elderly persons. Medical Care 1996; 34(9):954-969. (19) Gillespie LD, Gillespie WJ, Cumming R, Lamb SE, Rowe BH. Interventions for preventing falls in the elderly. The Cochrane Database of Systematic Reviews 2000; 3:1-51. (20) Baraff L, Della P, Sanders W. Practice guideline for the ED management of falls in community-dwelling elderly persons. Annals of Emergency Medicine 1997; 30(4):480-492. (21) Buchner D, Cress M, Wagner E, DeLateur B, Price R, Abrass I. The Seattle FICSIT/MoveIt study: the effect of exercise on gait and balance in older adults. Journal of the American Geriatrics Society 1993; 41(3):321-325.
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Tinetti ME. Performance-oriented assessment of mobility problems in elderly patients. Journal of the American Geriatrics Society 1986; 34(2):119-126. Podsiadlo D, Richardson S. The timed Up & Go: A test of basic functional mobility for frail elderly persons. Journal of the American Geriatrics Society 1991; 39:142-148. Duncan PW, Weiner DK, Chandler J, Studenski S. Functional reach: a new clinical measure of balance. Journal of Gerontology 1990; 45(6):M192-M197. Duncan PW, Studenski S, Chandler J, Prescott G. Functional reach: predictive validity in a sample of elderly male veterans. Journal of Gerontology 1992; 47(3):M93-M98. Tinetti ME, Speechley M. Prevention of falls among the elderly. New England Journal of Medicine 1989; 320.(16):1055-1059. U.S. Preventive Services Task Force. Guide to clinical preventive services: report of the U.S. Preventive Services Task Force. 1996. Baltimore, Williams and Wilkins. Gregg EW, Pereira MA, Caspersen CJ. Physical activity, falls, and fractures among older adults: a review of the epidemiologic evidence. Journal of the American Geriatrics Society 2000; 48:883-893. Gardner M, Robinson C, Campbell J. Exercise in preventing falls and fall related injuries in older people: a review of randomised controlled trials. British Journal of Sports Medicine 2000; 34:7-17. Province M, Hadley E, Hornbrook M, Lipsitz L, Miller J, et al. The effects of exercise on falls in elderly patients: a preplanned meta-analysis of the FICSIT trials. JAMA 1995; 273(17):1341-1347. Salkeld G, Cumming RG, ONeill E, Thomas M, Szonyi G, Westbury C. The cost effectiveness of a home hazard reduction program to reduce falls among older persons. Journal of the American Geriatrics Society 2000; 24(3):265-271. HMO Workgroup on Care Management. Establishing relations with community resource organizations: an imperative for managed care organizations serving Medicare beneficiaries. 1-26. 1999. Washington D.C., AAHP Foundation.
20
Section 3 Falls
Section 4
Clinical Vignette
Mrs. J.K. is a 70-year-old female new Lahey Clinic patient who reported a sensation of dizziness and a history of repeated falls. She had recently fallen and had suffered a compound fracture of her humerus. At the time of her first appointment, she was taking 14 different prescribed medications for her multiple chronic illnesses, which included coronary artery disease, diabetes, asthma, depression, anxiety, and a recent stroke. She was living in an assisted living environment and used a wheeled walker due to gait instability. Her primary care physician suspected that part of Mrs. J.K.s instability might be attributable to adverse effects of her medications. Together they reviewed all of her medications and found that an error had been made in the dosage of her antidepressant, resulting in her receiving several times the recommended dose. Mrs. J.K. improved significantly after her primary care physician adjusted her antidepressant and reduced her total number of prescribed medications to nine. She enrolled in a physical activity program and regained her strength. She also participated in community activities that she had previously given up and was able to return to independent living.

MCOs should:
Implement programs targeting medication-related complications for older members irrespective of whether they offer a pharmacy benefit. Such programs should target overuse, under-use, and misuse of medications. Improve compatibility of internal and external data systems to maximize the potential use of administrative data (diagnosis, pharmacy, and utilization) for targeted interventions. Employ pharmacists in a liaison role between pharmacy benefit managers, practitioners, and members. Provide educational materials and tools to practitioners and members designed to reduce medicationrelated complications.
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The likelihood of medication-related complication increases with the number of medications consumed, both prescribed and over-the-counter. Older patients received a disproportionate number of prescribed medications and therefore represent a particularly high-risk group (1-3). Approximately 14 to 24 percent of community-dwelling older adults take medications believed to be inappropriate (1-5). Medication-related complications contribute to common geriatric conditions such as falls, depression, cognitive impairment, and undernutrition (1;6-8). Medication-related complications are an important factor in hospitalization of older adults. Different studies have reported rates that range from 10 to 31 percent of all hospitalizations and up to 45 percent of all hospital re-admissions (1;9-12). Patients who suffer adverse drug reactions in the hospital have longer lengths of stay, with an associated additional cost of $3,224 per episode (13). Medicationrelated complications are also a contributing factor in the 32,000 hip fractures reported each year (1). Medication-related complications also contribute to higher utilization in settings other than the hospital. In one study, 63 percent of older adults experiencing a medication-related complication resulted in a visit to their physicians office and 10 percent resulted in a visit to the emergency department (14). Although not all of these encounters were avoidable, the fact that medication-related complications increase utilization is well established. The term medication-related complications is used in this report because it incorporates the range of potential problems older members experience, including underuse, overuse, and misuse. Specific examples include polypharmacy; the use of high-risk medications; suboptimal dosing; or underuse of medications for conditions such as congestive heart failure, depression, and chronic pain. The recommendations included in this report are consistent with national efforts to reduce medication errors and improve patient safety (15).

The risk of medication-related complications not only increases with the number of prescribed medications, it also increases with age as a result of reduced physiologic reserve. Aging is associated with a decline in the ability of the liver and kidneys to metabolize medications and eliminate them from the body. In addition, age-related changes in the distribution of fat and muscle throughout the body also contribute to older adults sensitivity to adverse effects of certain medications. This sensitivity is heightened with concurrent use of alcohol. Because of these age-related changes in physiologic reserve and fat distribution, older adults often have a narrow therapeutic window between benefit and harm. Virtually any medication can lead to an adverse event. Medication-related complications increase with the number of medications taken (including both prescribed and over-the-counter) due to problems of confusion over the regimen, non-adherence, and harmful drug-to-drug interaction (1). In addition, improper consumption of a single medication can pose a risk (e.g., long-acting benzodiazepines) (5;16;17). In some cases, the potential risks of the medication outweigh the potential benefits.
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Section 4 Medication-Related Complications
Older members making transitions between sites of care (e.g., those who receive short-term care in skilled nursing facilities after being hospitalized) are an often overlooked population at risk for medication-related complications. Their medication regimens require close coordination between prescribers in the hospital, skilled nursing facility, and outpatient settings to avoid inadvertent discontinuation and duplication. Furthermore, the hospital, skilled nursing facility, and community pharmacies may all have different formularies. These different formularies can confound attempts made by the older patient or the PCP to fully comprehend the regimen following discharge. Because practitioners are prescribing medication regimens that are increasingly complex, older adults with low literacy skills or cognitive impairment are particularly at risk for complications. Similarly, older patients who cannot afford to purchase their medications are also at risk for medication-related complications, particularly due to non-adherence.

The multiple approaches for characterizing high-risk older members have implications for screening and assessment strategies. The initial step, choosing the target population, is determined by the focus of the program, available resources, and the nature of the subsequent intervention. Strategies can target a wide range of potential medication-related complications or focus on those that are associated with certain adverse events, such as falls or confusion. Alternatively, a MCO can identify a cluster of practitioners who care for a substantial proportion of older members and screen older members within just those practices. Analysis of pharmacy records, particularly claims files or other administrative data can serve to identify high-risk patients. Access to such data facilitates the periodic screening of the entire population of older members. Most MCOs have arrangements that allow access to claims files for their Pharmacy Benefits Manager (PBM). This data can be linked to health plan utilization data to create a more complete understanding of members needs. Rather than focus on the number of prescribed medications, PacifiCare uses pharmacy claims data to examine the total number of prescribed pills to be taken daily to identify members who are potentially at risk for complications. Pharmacy claims data also facilitates screening programs that target specific high-risk medications. For example, Kaiser Permanente, Southern California Region, uses administrative data to identify older members taking long-acting sedatives (e.g., benzodiazepines) and four selected antidepressants (e.g., primary tricyclic antidepressants) based on evidence for their association with confusion, falls, and functional decline. Of the 300,000 Medicare members in this Region, 10 percent were identified as taking at least one high-risk medication and were candidates for further assessment. However, screening using administrative data has limitations. The data may not capture whether members are in fact taking their medications as prescribed or whether they obtain medications from non-plan sources (e.g., from a non-contracted community pharmacy, a Veterans Hospital pharmacy, or friends or family members). In addition, administrative data do not generally reflect use of vitamins, herbal supplements, or other over-the-counter medications.
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MCOs that lack access to administrative pharmacy data can still conduct effective screening programs. For example, they can ask new members to complete questionnaires designed to target older members taking more than a predefined threshold number of prescribed medications or those taking a few specific types of high-risk medications. The most commonly employed screening question for medication problems asks about the number of prescribed medications taken. Many plans view taking 5 or 6 distinct prescribed medications as an indicator of potential risk (3;10). However, the absolute number of prescribed medications does not provide insight into the types of medications taken or that the medication is essential to optimize control of a chronic illness. Although a questionnaire may be the preferred method for screening new members, periodic PCP medication review may be more efficient for existing members.
Interventions
For members identified as being at high-risk, potential risk-reduction strategies include interventions conducted by clinical pharmacists, changes to the medication formulary, and enhancements of the roles of PCPs with or without accompanying empowerment of older members. Each of these three strategies is discussed below. Many successful interventions for reducing the prevalence of medication-related complications have utilized the expertise of clinical pharmacists. In a recent randomized trial, clinical pharmacists review of medication regimens in community-dwelling older patients was found to reduce inappropriate prescribing and adverse drug events by approximately 25 percent (18). In another intervention, pharmacists with training in geriatrics telephoned prescribing physicians about modifying potentially adverse drug regimens detected using a computerized surveillance data system. When the prescribing physician was reached, 24 percent of all medication regimens of concern were switched to a more appropriate alternative. This intervention resulted in a change to a lower risk alternative in 40 percent of older adults on long-acting benzodiazepines, medications shown to be strongly associated with falls and confusion (19). Newly enrolled Medicare+Choice members at Kaiser Permanente, Colorado Region, receive a new member phone call by a clinical pharmacist shortly after enrollment and before their first primary care physician visit. During this call, the pharmacist explains the formulary system, the members co-pays and cost obligation, and reviews all previously prescribed and over-the-counter medications taken. In conducting the review, the pharmacist identifies problems associated with polypharmacy, potential adverse drug reactions, and certain high-risk medications. The pharmacist also explains conversions from non-formulary to formulary medications, suggests safer alternatives to high-risk medications, and introduces the member to special programs of relevance, such as a pharmacist-run clinic to monitor anticoagulation medications. Kaiser Permanente, Southern California Region, takes advantage of both their cadre of clinical pharmacists and their administrative pharmacy data system. As discussed earlier, this program focuses on long-acting sedatives (benzodiazepines) and four selected antidepressants (primary tricyclic antidepressants), reflecting the strong evidence for their association with confusion, falls, and functional decline. Use of these medications at any dose triggers an alert.
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Approximately 10 percent of members over age 65 were prescribed these classes of medication in 1999. The clinical pharmacists have developed an automated system whereby an alert is faxed to the primary care practitioner the night before the member has a scheduled appointment. The fax calls attention to the potential adverse effects associated with prescribing the medication in older patients and suggests safer alternatives. Although data are not yet available to evaluate this program, their use of similar just in time prescribing approaches at Kaiser Permanente, Southern California Region, have led to more appropriate prescribing and cost reduction in conditions such as congestive heart failure and diabetes. A second strategy is to make changes in formulary composition. This approach can entail removing medications from the formulary that pose particularly high risk for older members, thereby creating a Seniors Only formulary. Such a formulary might remove long-acting benzodiazepines such as Valium or tricyclic antidepressants such as Amitriptyline. Group Health Cooperative has adopted such a program. However, prescribing practitioners are allowed to override the formulary in order to maintain an older patient on a medication that has been identified as high-risk. For this approach to be effective, it is important that safer alternatives to high-risk medications be available on the formulary. To reduce medication-related complications resulting from transitions between care settings that have different formularies, another intervention is to foster continuity across sites. Kaiser Permanente, Colorado Region, builds into agreements with contracted skilled nursing facilities that its members in long-term care settings receive medications through the Kaiser formulary. Independence Blue Cross contracts with the Visiting Nurse Association for nurse-conducted medication reviews for Medicare members returning home from the hospital for one of 14 specific discharge diagnoses.13 The goal of this review is to ensure that members have received the appropriate medications for their conditions from the hospital formulary and to reconcile any potential confusion or duplication between members pre- and post-hospital medication regimens. MCOs can also work with PCPs to enhance their role in reducing medication-related complications. For example, one study demonstrated that a practitioner-led comprehensive review of older members medications (often referred to as a brown bag session) led to more appropriate medication regimens (10). The MCO provided practitioners with clinical practice guidelines on polypharmacy and laminated pocket cards that included a list of potentially contraindicated medications and suggested safer alternatives. Harvard Pilgrim and other MCOs offer a similar brown bag program for its members. These programs strive to discontinue non-essential medications and reduce prescribing or dispensing errors. MCOs can also provide ongoing education for practitioners to improve prescribing strategies for older patients. PacifiCare has found physician profiling to be particularly effective. At any one time, two to three high-risk medications serve as the focus for the educational effort. Physicians are informed of the program, given the specific evidence-based rationale for the recommendations, and provided with strategies for medication discontinuation and a list of safer alternatives. The physicians are subsequently given periodic profiling reports that portray their performance in reducing prescribing of these medications relative to their peers.
13 Examples of these diagnoses include congestive heart failure, chronic obstructive pulmonary disease, end-stage renal disease, coronary artery bypass surgery, abdominal aortic aneurysm, prostatectomy, and hysterectomy.
25
Harvard Pilgrim has developed a similar initiative to reduce the use of particular high-risk medications directed at network physicians. In partnership with its pharmacy benefits manager (PBM), Harvard Pilgrim searches administrative pharmacy data to identify patients who have been prescribed medications thought to pose substantial risk to older adults, referred to as the gray list. Physicians are mailed patient-level data on their prescribing patterns in addition to evidence-based information on safer alternatives. There were 867 older patients prescribed gray list medications in 1997. Only 39 patients were prescribed these medications in 2001, a 96 percent reduction. MCOs can enhance their members role in reducing medication-related complications. For example, they can support members role in managing their own medications, particularly when they receive care in other settings such as the hospital or skilled nursing facility. This might include providing them with a complete medication list that can be conveniently placed in a purse or wallet. MCOs can also provide additional pharmacy services to help their older members adhere to their medication regimens or discontinue particular classes of high-risk medications. Alternatively, MCOs can direct members to programs that provide medications for free or a reduced price. For example, members may be eligible to receive medications through the state Medicaid program, the local Veterans Administration hospital, or programs available through pharmaceutical companies. The pharmaceutical industry has successfully created demand for medication use via direct-toconsumer advertising. Opportunity exists for MCOs to take similar steps to assure appropriate medication utilization or to encourage changes in prescribing to safer alternatives. MCOs can use the forum of a periodic newsletter, lectures, or waiting room posters to advertise to older members and encourage them to discuss risk reduction approaches with their PCP. The advertisement could also emphasize that not all medical problems require a prescription. Because of cognitive difficulty, some older members may not be able to assume an active role in their medication management. Kaiser Permanente, Southern California Region, uses new member screening data to identify members who may have difficulty following medication instructions due to cognitive impairment. Members who are identified as having a severe memory impairment receive a cognitive functional assessment and an intervention involving the primary care practitioner and pharmacist aimed at discontinuing medications known to cause confusion and simplifying the overall medication regimen. This program also assists these members with identifying a capable person to oversee the administration of their medications.
Barriers to MCOs implementing interventions designed to reduce medication-related complications occur at the level of data systems, practitioners, and members. Not having access to members pharmacy data because prescription drugs are not a covered benefit is a barrier to many of the interventions discussed. Some of the more effective interventions have merged different data sources to further enhance identification and monitoring of outcomes. Combining disparate data systems, such as pharmacy data, diagnostic data, and utilization data sources can be difficult outside of a fully integrated delivery system. Further, tracking medication use in older patients making transitions across different settings may require access to different pharmacy databases.
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Many successful interventions have relied on pharmacists who suggest management strategies to prescribing practitioners. However, practitioners do not always positively receive such suggestions. Practitioners may not be comfortable switching to recommended alternatives or changing a medication prescribed by another practitioner (i.e., a specialist or practice partner). There are steps that can be taken to improve receptivity. These include limiting the suggestions to categories of medications for which practitioners have given prior input, providing the rationale for suggestions with references from credible sources, targeting the prescribing practitioner, and providing information in a way that is minimally intrusive to clinic flow (e.g., a fax the day a patient is to be seen in the ambulatory clinic). Older members may be reluctant to discontinue particular high-risk medications, even when recommended to do so by their PCP. Members may not have a drug benefit and thus may not be able to afford the prescribed medication. Members with a drug benefit may be concerned about exceeding their annual pharmacy benefit.
Economic Impact
Although empiric evidence for potential cost savings from interventions designed to reduce medicationrelated complications is limited, it is the Workgroups judgment that significant opportunity exists for cost-effective interventions. In order to better understand factors associated with prolonged length of stay, Group Health Cooperative reviewed records for surgical patients who received post-hospital care in a subacute facility. Overuse of sedating pain medications in both the hospital and the subacute facility accounted for the majority of cases. Through their contribution to delirium and constipation, use of these medications were found to interfere with participation in rehabilitation and thereby delay discharge. This problem is currently being addressed through an educational initiative that targets prescribing practices of hospitalists and surgeons. All of the PACE (Program of All-Inclusive Care for the Elderly) sites have a mandatory medication review by a clinical pharmacist every 30 days. As a result of this intervention, the PACE site at Henry Ford Health Care System reduced pharmacy expenditures from $178 to $118 per member per month, a 34 percent decline. Kaiser Permanente, Mid-Atlantic Region, has initiated a hospital-based pharmacy rounding service at two contract hospitals. Pharmacists review patient charts, assess optimal drug therapy, identify candidates for home intravenous therapy, facilitate timely discharge, and serve as a resource to PCPs and nurses. Receptivity to their recommendations has been high, with an acceptance rate approaching 99 percent. This program has achieved savings of $523,907 for a $57,643 investment (20). The savings have come from using alternative medication therapies, optimizing dosing, discontinuing unnecessary medications, and reducing hospital days (e.g., expedited transition from intravenous to oral medication delivery, facilitating earlier discharge home with support to continue therapy, and reducing adverse drug reactions). Kaiser Permanente, Mid-Atlantic Region, is currently expanding this service to their contract skilled nursing facilities.
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Reference List
(1) (2) (3) (4) (5) (6) (7) (8) (9) Government Accounting Office. Prescription drugs and the elderly. GAO/HEHS-95-152, 1-30. 1995. Golden AG, Preston RA, Barnett SD, Llorente M, Hamdan K, Silverman MA. Inappropriate medication prescribing in homebound older adults. Journal of the American Geriatrics Society 1999; 47:948-953. Nolan L, OMalley K. Prescribing in the elderly part I: sensitivity of the elderly to adverse drug reactions. Journal of the American Geriatrics Society 1988; 36(2):142-149. Wilcox SM, Himmelstein DU, Woolhandler S. Inappropriate drug prescribing for the community-dwelling elderly. JAMA 1994; 272(4):292296. Stuck A, Beers M, Steiner A, Aronow H, Rubenstein L, Beck J. Inappropriate medication use in community-residing older persons. Archives of Internal Medicine 1994; 154:2195-2200. Herings RMC, Stricker BHC, DeBoer B, Bakker A, Sturmans F. Benzodiazepines and the risk of falling leading to femur fractures. Archives of Internal Medicine 1995; 155:1801-1807. Chutka DS, Evans JM, Fleming KC, Mikkelson KG. Drug prescribing for elderly patients. Mayo Clinical Proceedings 1995; 70:685-693. Katz IR, Sands LP, Bilker W, DiFilippo S, Boyce A, DAngelo K. Identification of medications that cause cognitive impairment in older people: the case of oxybutinin chloride. Journal of the American Geriatrics Society 1998; 46:8-13. Bero L, Lipton H, Bird J. Characterization of geriatric drug-related hospital readmissions. Medical Care 1991; 29(10):989-1003.
(10) Fillit H, Futterman R, Orland B, Chim T, Susnow L, et al. Polypharmacy management in Medicare managed care: changes in prescribing by primary care physicians resulting from a program promoting medication reviews. American Journal of Managed Care 1999; 5:8587-594. (11) (12) (13) (14) (15) (16) (17) (18) (19) (20) Gerety M, Soderholm-Difatte V, Winograd C. Impact of prospective payment and discharge location on the outcome of hip fracture. Journal of General Internal Medicine 1989; 4(5):388-391. Culler S, Parchman M, Przybylski M. Factors related to potentially preventable hospitalizations among the elderly. Medical Care 1998; 36(6):804-817. Bates D, Spell N, Cullen D, Burdick E, Laird N, et al. The costs of adverse drug events in hospitalized patients. JAMA 1997; 277(4):307-311. Hanlon J, Schmader K, Koronkowski M, Weinberger M, Landsman P, et al. Adverse drug events in high risk older outpatients. Journal of the American Geriatrics Society 1997; 45(8):945-948. Agency for Health Care Quality Research. Medical errors: the scope of the problem. 1-4. 2000. Rockville, MD. Beers M. Explicit criteria for determining potentially inappropriate medication use by the elderly: an update. Archives of Internal Medicine 1997; 157(14):1531-1535. Coleman E, Grothaus L, Sandhu N, Wagner E. Chronic care clinics: a randomized controlled trial of a new model of primary care for frail older adults. Journal of the American Geriatrics Society 47(7), 775-783. 1999. Hanlon J, Weinberger M, Samsa G, Schmader K, Uttech K, Lewis I et al. A randomized, controlled trial of a clinical pharmacist intervention to improve inappropriate prescribing in elderly outpatients with polypharmacy. American Journal of Medicine 1996; 100(4):428-437. Monane M, Matthias D, Nagle B, Kelly M. Improving prescribing patterns for the elderly through an online drug utilization review intervention: a system linking the physician, pharmacist and computer. JAMA 1998; 280(14):1249-1252. Yee DK, Veal JH, Trinh B, Bauer S, Freeman CH. Involvement of HMO-based pharmacists in clinical rounds at contract hospitals. American Journal of Health System Pharmacy 1997;54:670-673.
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Section 5
Dementia
Clinical Vignette
Mr. N.L. is a 78-year-old married man with progressive memory loss who presented to the Lahey Clinic. His wife reported that Mr. N.L. had been experiencing increasing difficulty carrying out basic functional tasks such as dressing and bathing and had developed a fear of being left alone. As his sole caregiver, his wife was becoming depressed and overwhelmed. His children, from a previous marriage, have refused to help in his care. Following a complete evaluation by his primary care physician, Mr. N.L. was diagnosed with Alzheimers Disease. His physician initiated treatment with a dementia medication (an acetylcholinesterase inhibitor) and made a referral to a local senior service agency to facilitate obtaining additional services for the member and his wife. A referral was also made to a local senior day care center, and Mr. N.L. agreed to attend three days per week. During this time, his wife has attended caregiver support groups offered at the local chapter of the Alzheimers Association. This respite has not only helped his wife better understand and manage her husbands condition, it has also led to an improvement in her depression. In appreciation for the care and assistance her husband has received, she made a philanthropic contribution to the clinic in the form of an ongoing annuity.

MCOs should:
Work with practitioners and members to increase awareness of dementia to facilitate early identification and appropriate management. Enhance practitioners ability to diagnosis and manage dementia by providing education, facilitating linkages to community agencies and caregiver support groups, and increasing awareness of the negative effect of dementia on the management of comorbid conditions to promote the highest level of functional independence possible. Involve the members family and caregivers as an integral part of the care team and provide education and community linkages to support their efforts. Encourage practitioners to communicate with not only the member with dementia, but also with his or her family and caregivers to facilitate the execution of the care plan.
29
Encourage members with dementia and their families to participate in planning regarding advanced directives for health decisions as well as for financial and legal matters. Partner with local agencies serving older adults with dementia and their caregivers to assure that appropriate services are available in the community.

The growing population of older members with dementia presents formidable challenges to MCOs. The progressive cognitive deterioration associated with dementia interferes with self-care activities, management of other comorbid conditions, and personal safety. As a result of this cognitive decline, older members experience problems following treatment instructions, reporting symptoms, taking medications appropriately, keeping appointments, and participating in rehabilitation programs (1;2). Dementia also exacts a significant toll on the health of family caregivers, many of whom may already be in poor health and may also be members of the same MCO (3-6). Multiple studies have documented that older persons with dementia experience higher total costs of care compared to those without dementia. Taylor and colleagues found that, in 1994, average total costs (including inpatient, ambulatory, home health, skilled nursing facility, hospice, and durable medical equipment) for persons with dementia were $6,021 versus $2,310 for persons without the diagnosis (7). Gutterman and colleagues reported mean total annual costs that were approximately 1.5 times higher in Medicare MCO patients with dementia compared to those without dementia (8). Per capita Medicare expenditures for patients with dementia have been found to be nearly twice the average for all Medicare beneficiaries, with inpatient care accounting for 63 percent of expenditures (9). Weiler and colleagues demonstrated that persons with dementia were twice as likely to be hospitalized compared to persons without dementia (10). Similarly, older persons with dementia frequently have a longer mean length of stay (11). The higher rate of inpatient utilization is commonly attributed to the role of dementia in complicating the care of other acute and chronic conditions and prolonging discharge planning (12). However, not all studies have demonstrated this relationship. McCormick and colleagues compared Group Health Cooperative members without dementia to those with dementia and found that the latter had lower costs during the last 3 years preceding death (13). The relationship between dementia and cost of care may depend on which stage of the condition is examined (i.e., early versus late dementia). By adversely affecting the management of other comorbid conditions, such as heart failure, chronic pulmonary disease, and cerebrovascular disease, dementia can contribute to higher costs of care. In one study, 93 percent of persons with dementia had at least one comorbid condition, and 61 percent had 3 or more (14). Newcomer and colleagues found that mean annualized Medicare expenditures for congestive heart failure patients with dementia were $16,067 compared with $6,463 for congestive heart failure patients without dementia (15). Similar cost relationships were found for heart attack, stroke, diabetes, chronic lung disease, and hip fracture (8;15). Coexistent depression and dementia has also been associated with significantly higher utilization than depression without dementia (16). These findings reflect, in part, the fact that persons with dementia have difficulty reporting symptoms and following prescribed treatment regimens. Such delays in reporting exacerbation of comorbid conditions may lead to situations that require greater treatment intensity to stabilize the problem, such as
30
Section 5 Dementia
an emergency department visit or hospital admission. Persons with dementia are also more likely to experience falls and associated fractures, medication-related complications, and undernutrition. Thus, whether due to independent effects on utilization and costs or negative effects on the management of other prevalent and costly comorbid conditions, there are powerful financial incentives for identifying and treating dementia in MCOs. Current estimates suggest that 5-10 percent of persons over age 65, and nearly 50 percent of persons over age 85, are afflicted with dementia (3). Alzheimers disease is the most common cause of dementia in the United States, accounting for at least two-thirds of all cases. Vascular dementia is the second most common etiology.14 Dementia is often unrecognized or misdiagnosed, particularly in its early stages. A two- to three-year delay in diagnosis is not uncommon (17). In one study, 65 percent of patients with probable dementia and 82 percent of patients with mild cognitive impairment did not have an assessment documented in their medical record (17). Harvard Pilgrim found that primary care physicians were unaware of the diagnosis of dementia in 50 percent of cases. Correct recognition can prevent costly and inappropriate treatment resulting from misdiagnosis and give patients and their families time to prepare for the challenging financial, legal, and medical decisions that lie ahead (3).

Although dementia is not an inevitable consequence of growing older, advanced age remains an important risk factor. Increasing scientific evidence suggests that in a minority of cases there may be a familial predilection, pointing to the importance of obtaining a family history for dementia in older patients (3). Other risk factors include prior history of stroke or transient ischemic attacks, Parkinsons disease, alcoholism, or head injury severe enough to cause loss of consciousness.

Early diagnosis is critical to improving management of members with dementia. Given the increasing prevalence of dementia with advancing age, an argument could be made to screen all members greater than 75 years of age. Screening programs can also be developed that encourage members and caregivers to seek care in the setting of particular trigger symptoms. Additional tools have been developed to facilitate screening by any member of the healthcare team, including the PCP, nurse, case manager, or receptionist. PCPs should be aware of particular situations that might indicate the presence of dementia, including confusion over medications, one or more episodes of delirium, unexplained falls, or a motor vehicle crash. Kaiser Permanente, Southern California Region, asks all new members, During the past few months, have you had increasing problems with severe memory loss? Kaiser researchers have compared the utility of this single question with more rigorous dementia screening instruments as well as review of
14
Vascular dementia is also referred to as multi-infarct dementia. Alzheimers disease and vascular dementia can manifest concurrently.
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the medical record. Among those new members who answered affirmatively to the single question, 89 percent were subsequently found to meet criteria for cognitive impairment or dementia. The Alzheimers Association has developed a 10-item Warning Signs of Dementia (Table 1) which consists of a list of common trigger symptoms that are suggestive for dementia. These symptoms are similar to those included in the screening guidelines developed by the Agency for Health Care Policy Research (AHCPR)(3). Both the Alzheimers Association and the AHCPR trigger symptoms were designed to promote greater awareness for dementia by the healthcare team. Further assessment for dementia is recommended when health care providers detect positive answers to either these trigger symptom questionnaires or evidence of more global cognitive impairment.
Table 1. Warning Signs for Alzheimers Disease (Developed by The Alzheimers Association)
Have you noticed changes like these in someone you know? Forgets things more often. Has problems doing familiar things. Puts things in strange places. Forgets common words or uses wrong words. Has frequent problems with complicated tasks. Has a major change in personality (confused, suspicious, or afraid). Is confused about where they are (or what time of day it is). Has lost interest in doing things (or loses interest quickly if not encouraged). Has sudden change in mood or behavior. Does things that dont seem to make sense. Positive findings in any of these areas generally indicate the
need for further assessment for the presence of dementia. Similar screening tools have been developed that rely on self-report from family members and caregivers. The Alzheimers Association, in collaboration with the National Chronic Care Consortium, has developed a 5-item questionnaire15 to be completed by a family member or caregiver (Table 2). The Memory Problems Checklist is another such instrument that has been validated against more formal tests of cognition (18). An affirmative response to 5 of the 11 questions suggests the presence of dementia and the need for further assessment.
Table 2. Family Questionnaire (Jointly developed by The Alzheimers Association and National Chronic Care Consortium)
In your opinion, does the person in question have problems with any of the following? (Please circle the appropriate answer) Repeating or asking the same things over and over? Remembering appointments, family occasions, holidays? Writing checks, paying bills, balancing the checkbook? Deciding what groceries or clothes to buy? Taking medications according to instructions? not at all not at all not at all not at all not at all mild mild mild mild mild severe severe severe severe severe
Relationship to patient _____________________ (spouse, son, daughter, brother, sister, grandchild, friend, etc.)
15
Formal validation studies to determine criteria for a positive screen are pending at the time of this report.
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Section 5 Dementia
Administrative records are generally not a reliable means for identifying persons with dementia as the diagnosis is infrequently and inconsistently coded in the hospital, emergency department, or ambulatory settings (9;15). Following a positive screen, a detailed evaluation is appropriate. In most cases this entails a more comprehensive mental status test. No single test has been found to be clearly superior. The Folstein Mini-Mental Status Evaluation (MMSE) is the most widely recognized and has been tested in individuals with different education, socioeconomic, and cultural backgrounds (19). Other tests include the Blessed Orientation-Memory-Concentration and the Short Portable Mental Status Questionnaire (20;21). In practice, PCPs may not have adequate time or resources to administer the more comprehensive assessments (e.g., the MMSE), which has prompted the development of shorter evaluations (22). These include the Clock Drawing test and the Time and Change test (23;24). These tests are brief and simple and have been shown to correlate with more rigorous evaluations including the MMSE (24;25). The Clock Drawing test entails asking the patient to draw the face of a clock and place the hands at a pre-designated time. There are several scoring systems, the most commonly employed of which is the Simple Scoring System. It entails awarding a point for: the approximate drawing of a clock face, the presence of numbers in sequence, the correct spatial arrangement of numbers, the presence of clock hands, clock hands that approximately show the correct time, and clock hands that depict the exact time. Missing one or more points is indicative of cognitive impairment. A formula has been developed to convert this clock-drawing score to a MMSE Score [MMSE= 2.4 (Clock Score) + 12.7] (26). The Time and Change test has two parts. First, the patient must correctly interpret the time of a clock face set at 11:10. Two attempts are allowed for a correct response within a 60-second period. Second, three quarters, seven dimes, and seven nickels are placed in front of the patient, who is prompted to give one dollar in change. Two attempts are allowed for a correct response within a 120-second period (23). Results on a mental status exam alone is not sufficient to make the diagnosis of dementia. Additional components of the assessment include a focused history, a physical exam, and a functional status evaluation. Because making the diagnosis of dementia can be difficult in the setting of depression or medication-related complications, a depression evaluation and a comprehensive medication review (with particular attention to medications with sedative or anticholinergic properties) are also recommended. Family and close friends are invaluable sources of information on whether the members functional needs are being met in the current environment. Obtaining a brain imaging study, such as a CAT scan or MRI, as a routine component of the evaluation is not supported by current scientific evidence (27). Kaiser Permanente, Colorado Region, refers members with dementia to a Senior Care Coordinator who conducts a comprehensive assessment that consists of an evaluation of the members medical needs, mental status, informal caregiving resources, vision, and hearing. With the members consent, the Senior Care Coordinator makes a referral to the local chapter of the Alzheimers Association. Following an assessment and care planning session, the Alzheimers Association staff person then discusses the care plan with the Senior Care Coordinator to ensure coordinated care.
33
Interventions
The expected positive outcomes for the care of patients with dementia differ from traditional outcomes of care (28;29). For example, expected positive outcomes may include improved management of other comorbid conditions, improved referral rates to community organizations such as the Alzheimers Association, improved caregiver physical and mental health status, fewer injuries attributed to home safety, and lower rates of institutionalization. Dementia can be treated through both non-pharmacologic and pharmacologic means, which can be employed either separately or concurrently. Treatment often entails the participation of both the member and informal caregiver(s). As with all of the geriatric conditions discussed in this report, MCOs need to do more than encourage PCPs to detect problems such as dementia. Rather, they need to provide them with brief and efficient screening and assessment instruments, facilitate linkages to community resources, provide access to care managers and social workers skilled in the dementia care, and encourage adherence to post-diagnosis treatment guidelines. Although some aspects of dementia management may take place outside of the clinic, the ongoing role of the primary care team in managing medications (i.e., avoiding medications that may negatively affect cognitive function), encouraging advanced care planning, and careful monitoring to avoid health crises remains critical to the success of any intervention. Nonpharmacologic approaches are primarily aimed at training caregivers to handle disruptive behavior, facilitating referral to available resources for persons with dementia and their caregivers, and ensuring the members safety. Resources which may help patients and caregivers include caregiver education programs, adults day care programs, and respite programs. Local chapters of the Alzheimers Association offer support groups for caregivers with dementia that specifically address managing disruptive behavior. Mittelman and colleagues have shown that providing family caregivers with a comprehensive support and counseling program is effective in delaying time to nursing home placement by more than 30 percent (30). This program consisted of six sessions offered over four months and was followed by a support group that met on an ongoing basis. Hepburn and colleagues demonstrated that a family training intervention aimed at improving knowledge and skills significantly improved outcomes for both persons with dementia and their caregivers (31). Local Area Agencies on Aging (AAAs) are another important resource to support family members and friends in their role as caregivers. For example, the Lahey Clinic partners with its local AAA for in-home assessment and caregiver support for older members with dementia. The Lahey Clinic also partners with local AAAs that provide adult day health programs for persons with dementia. These programs provide the opportunity for appropriate activities and socialization for persons with dementia and regular short-term respite for their caregivers. To facilitate care coordination, AAA representatives provide regular feedback to Lahey practitioners. Sierra Health Services has partnered with local adult day health programs to provide respite to caregivers who need to access community resource programs such as support groups offered by the Alzheimers Association. Completion of advanced directives early in the course of the illness while the member has insight and can participate in the discussion is another reason for MCOs to initiate programs aimed at early detection
34
Section 5 Dementia
of dementia. The objective of these discussions is to encourage the member to make informed decisions regarding which types of treatment are acceptable and to designate the most appropriate person to assist with health care decisions should the member be incapacitated (i.e., a durable power of attorney for health care). These discussions are important because many older adults with dementia receive treatment that is either inconsistent with their preferences or is of questionable therapeutic efficacy. For example, tube feeding (placing a tube through the nose and into the intestine or placing a tube through the skin into the persons intestine to directly provide liquid nutritional supplement) has received much attention in the media and the scientific literature. In most circumstances, this intervention does little to prolong life or improve quality of life and can often result in medical complications (32;33). A recent study found that 90 percent of persons with end-stage dementia received treatments believed to be burdensome yet had no documentation in their records that any discussion took place regarding goals of care (34). Pharmacologic management seeks to slow the rate of decline in cognitive function and facilitate the management of disruptive behavior. The medications do not provide a cure, and pharmacologic management may not be as widely applicable to persons with dementia as the non-pharmacologic strategies discussed above. Three memory-enhancing prescribed medications currently available to reduce disease progression include Donapezil (Aricept), Rivastigmine (Exelon) and Galantamine (Reminyl). Non-prescribed medications include vitamin E and Ginko Biloba. Treatment benefits of these medications have been modest. However, because there is no reliable way of predicting which patients will benefit, a one-to-two month trial may be appropriate.16 MCOs can serve as an educational resource to clinicians unfamiliar with these medications and those designed to control associated behavioral disturbances. Several excellent sources are available on the effective management of behavioral symptoms of dementia (3;35-37). Three MCOs in Southern California, Kaiser Permanente, Scripps Health, and University of California San Diego, have developed a partnership to improve the care of their members with dementia. The MCOs are collaborating with Meals on Wheels, the Caregiver Resource Center, and the local chapter of the Alzheimers Association in order to develop a web-based standardized intake for persons diagnosed with dementia. After giving permission, older members and their caregivers are asked to provide information only once, thereby reducing the burden of multiple intake questionnaires. This intake facilitates sharing of information among the three relevant community providers on a need to know basis. The three MCOs have defined a minimum level of quality dementia care that all members should receive including care management, ensuring that members obtain necessary services (i.e., Medicaid, adult day services, respite care) and support for informal caregivers. Similarly, at the Centura Senior Life Center in Colorado, the MCO case manager communicates electronically (with appropriate safeguards for confidentiality) with the Alzheimers Association chapter case manager about the management of common older patients with dementia. These approaches reduce the burden on members to complete multiple surveys and facilitate communication between relevant practitioners and community agencies.
16
In general, persons with mild to moderate dementia are more likely to respond than those with advanced dementia.
35
Finally, MCOs can go beyond the purview of direct patient care to support the care of members with dementia. They can work collaboratively with local community agencies to ensure that appropriate services are available to serve members and their informal caregivers. Table 3 provides representative examples of the types of community resources available to assist persons with dementia and their caregivers. In addition to ensuring that practitioners are aware of these community resources, MCO collaboration may also entail developing strategic relationships with individual agencies (e.g., serving on the community board) or developing strategic relationships with the leadership of community-wide providers of dementia care.
Table 3. Community Resources of Potential Benefit to Persons with Dementia
Case Management Services Adult Day Care Housing Assistance (Assisted Living, Board and Care) Respite Care Home Health Services Meals on Wheels Long Term Placement
Educational Programs Support Groups Low Cost Counseling Crisis Counseling and Hotlines Bereavement Advance Directives Legal Services Financial Planning
It has taken many years for dementia to be accepted as medical condition rather than being considered a normal manifestation of growing older. Clinicians may mistakenly believe that persons with dementia are unable to experience improvements in function or quality of life and, therefore, not invest time or resources in their care. The absence of tools, incentives, and resources to support PCPs in the identification and management of members with dementia is yet another barrier. Persons with dementia comprise a relatively small portion of a primary care practice. PCPs often do not have adequate time or training to administer and interpret comprehensive mental status assessments (22). Finally, PCPs may not feel that providing linkages to community agencies or supporting informal caregivers is within their scope of responsibility. Denial on the part of the member and their caregivers is another barrier to implementing dementia programs. Given the historical stigma of the diagnosis and the absence of a cure, encouraging members to participate in self-administered screening programs can be difficult. Also, family members may not disclose symptoms of cognitive impairment to a practitioner, believing that they are protecting the loved one from being exposed or institutionalized. Family members may help older patients compensate for their cognitive decline at the expense of their own health. Not having a caregiver that can both assist the member and serve as an advocate for obtaining care is another barrier to diagnosis and management.
36
Section 5 Dementia
Economic Impact
Current evidence suggests significant potential for reducing hospital use for persons with dementia, such as by targeting these patients at the time of admission and initiating strategies to prevent delirium or improve its management (39;40). Careful attention to prevention of pressure ulcers and urinary tract infections is also important. Collaborative management arrangements with psychiatric facilities may also reduce hospitalization of persons with dementia who experience behavioral disruption that cannot be managed in the ambulatory setting. Evidence is growing that early identification of dementia reduces use of ambulatory services. McCormick and colleagues demonstrated that ambulatory visits decreased following diagnosis of dementia (41). Making the diagnosis appears to help members and family members better understand the change in health status and allay feelings of distress. Programs that facilitate early detection and support members potentially lead to more appropriate outpatient utilization. Fostering more effective management of behavioral symptoms through family and practitioner educational programs may reduce hospital and nursing home use (30). Shelton and colleagues found that providing persons with dementia and their caregivers with additional supportive services led to a 40 percent reduction in hospitalization utilization among caregivers. These services included an initial in-home assessment conducted by a nurse case manager, identification of medical and psychosocial problems and service needs for both the patient and the caregiver, and the development of a detailed care plan. Care plans were developed in conjunction with the patient and caregiver and were shared with the primary care physician. Case managers provided authorization and monitoring of all services for a monthly capitation rate for each patient (5). Favorable economic impact for persons with dementia may also be achieved by improving management of concurrent comorbid conditions. Advancing age is a risk factor for chronic conditions besides dementia, including congestive heart failure, chronic obstructive pulmonary disease, diabetes, and arthritis. Dementia can confound treatment of these conditions through poor adherence to diet and medications. Further, patients with these conditions and concurrent dementia may be less likely to receive early intervention for an exacerbation of a chronic condition due to underreporting of sentinel symptoms. Suboptimal management of these conditions can precipitate higher utilization of ambulatory, emergency, and hospital services. For example, older persons with dementia who fracture their hip may not be able to fully comprehend post-surgical rehabilitation instructions. If this lack of comprehension is not taken into account, their recovery can be prolonged and their risk of re-fracture heightened. This is not to say that persons with dementia do not benefit from interventions such as surgery to repair a fractured hip. Persons with dementia, in an appropriately tailored surgical and rehabilitative care program, can achieve similar levels of functional improvement and rates of return to community living as persons without dementia (42-44).
37
Reference List
(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) (17) (18) (19) (20) (21) (22) (23) (24) (25) (26) (27) McCormick W, Kukull W, Van Belle G, Bowen J, Teri L, Larson E. Symptom patterns and comorbidity in the early stages of Alzheimers Disease. Journal of the American Geriatrics Society 1994; 42(5):517-521. Larson E. Management of Alzheimers Disease in a primary care setting. American Journal of Geriatric Psychiatry 1998; 6(2):S34-S40. Costa PT, Williams TF, Somerfield M, et al. Recognition and initial assessment of Alzheimers Disease and related dementias. Clinical practice guideline no. 19. 97-0702. 1996. Rockville MD, US Department of Health and Human Services, Agency for Health Care Policy and Research. Eloniemi-Sulkava U, Notkola I, Hentinen M, Kivela S, Sivenius J, Sulkava R. Effects of supporting community-living demented patients and their caregivers: a randomized controlled trial. Journal of the American Geriatrics Society 2001; 49:1282-1287. Shelton P, Schraeder C, Dworak D, Fraser C, Sager MA. Caregivers utilization of health services: results from the Medicare Alzheimers Disease Demonstration, Illinois site. Journal of the American Geriatrics Society 2001; 49:1600-1605. Baumgarten M, Battista R, Infante-Rivard C, Hanley J, Becker R, et al. Use of physician services among family caregivers of elderly persons with dementia. Journal of Clinical Epidemiology 1997; 50(11):1265-1272. Taylor D, Sloan F. How much do persons with Alzheimers Disease cost Medicare? Journal of the American Geriatrics Society 2000; 48(6):639646. Gutterman EM, Markowitz JS, Lewis B, Fillit H. Cost of Alzheimers Disease and related dementia in managed-Medicare. Journal of the American Geriatrics Society 1999; 47:1065-1071. Weiner M, Powe NR, Weller WE, Shaffer TJ, Anderson GF. Alzheimers Disease under managed care: implicatons from Medicare utilization and expenditure patterns. Journal of the American Geriatrics Society 1998; 46:762-770. Weiler P, Lubben J, Chi I. Cognitive impairment and hospital use. American Journal of Public Health 1991; 81(9):1153-1157. Lyketsos C, Sheppard J, Rabins P. Dementia in elderly persons in a general hospital. American Journal of Psychiatry 2000; 157(5):704-707. Albert S, Costa R, Merchant C, Small S, Jenders R, Stern Y. Hospitalization and Alzheimers Disease: results from a community-based study. Journal of Gerontology A Biological and Medical Sciences 1999; 54A(5):M267-M271. McCormick W, Hardy J, Kukull W, Bowen J, Teri L, et al. Healthcare utilization and costs in managed care patients with Alzheimers Disease during the last few years of life. Journal of the American Geriatrics Society 2001; 49:1156-1170. Doraiswamy M, Leon J, Cummings J, Marin D, Neumann P, Gardner E. Prevalence and impact of medical comorbidity in Alzheimers Disease. Neurology 1999; 52 (supplement 2):A127-A127. Newcomer R, Clay T, Luxenberg J, Miller R. Misclassification and selection bias when identifying Alzheimers Disease solely from medicare claims records. Journal of the American Geriatrics Society 1999; 47(2):215-219. Kales H, Blow F, Copeland L, Bingham R, Kammerer E, Mellow A. Health care utilization by older patients with coexisting dementia and depression. American Journal of Psychiatry 1999; 156(4):550-556. Boise L, Powers M. Dementia often undiagnosed in clinical settings. Progress in Alzheimers Disease Research 2000;1-2. Mundt JC, Freed DM, Griest JH. Lay person-based screening for early detection of Alzheimers Disease: development and validation of an instrument. Journal of Gerontology 2000; 55B:163-170. Folstein M, Folstein S, McHugh P. Mini-mental state: a practical method for grading the cognitive state of patients for the clinician. Journal of Psychiatric Research 1975; 12(3):189-198. Pfeiffer E. A short portable mental status questionnaire for the assessment of organic brain deficit in elderly patients. Journal of the American Geriatrics Society 1975; 23:433-441. Blessed G, Tomlinson BE, Roth M. Blessed-Roth Dementia Scale. Psychopharmacology Bulletin 1988; 24:705-708. Tangalos E, Smith G, Ivnik R, Petersen R, Kokmen E, Kurland L et al. The mini-mental state examination in general medical practice: clinical utility and acceptance. Mayo Clinical Proceedings 1996; 71(9):829-837. Froehlich T, Robison J, Inouye S. Screening for dementia in the outpatient setting: the time and change test. Journal of the American Geriatrics Society 1998; 46(12):1506-1511. Mendez MF, Ala T, Underwood KL. Development and scoring criteria for the clock drawing task in Alzheimers Disease. Journal of the American Geriatrics Society 1992; 40(11):1095-1099. Ferrucci L, Cecchi F, Guralnik JM, Giampaoli S, Lo Noce C, et al. Does the clock drawing test predict cognitive decline in older persons independent of the Mini-Mental Status Examination? Journal of the American Geriatrics Society 1996; 44(11):1326-1331. Shua-Haim J, Koppuzha G, Gross J. A simple scoring system for clock drawing in patients with Alzheimers Disease. Journal of the American Geriatrics Society 1996; 44(3):335. Siu AL. Screening for dementia and investigating its causes. Annals of Internal Medicine 1991; 115:122-132.
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Section 5 Dementia
(28) Whitehouse P, Maslow K. Defining and measuring outcomes in Alzheimer Disease research: introduction and overview. Alzheimers Disease and Associated Disorders 1997; 11(6):1-6. (29) Maslow K, Whitehouse P. Defining and measuring outcomes in Alzheimers Disease research: conference findings. Alzheimers Disease and Associated Disorders 1997; 11(6):186-195. (30) Mittelman MS, Ferris SH, Shulman E, Steinberg G, Levin B. A family intervention to delay nursing home placement of patients with Alzheimers Disease: a randomized controlled trial. JAMA 1996; 276(21):1725-1731. (31) Hepburn KW, Tornatore J, Center B, Ostwald SW. De mentia family caregiver training: affecting beliefs about caregiving and caregiving outcomes. Journal of the American Geriatrics Society 2001; 49(4):450-457. (32) Finucane TE, Christmas C, Travis K. Tube feeding in patients with advanced dementia: a review of the evidence. JAMA 1999; 282(14):13651370. (33) Gillick MR. Rethinking the role of tube feeding in patients with advanced dementia. New England Journal of Medicine 2000; 342(3):206210. (34) Morrison RS, Siu AL. Survival in end-stage dementia following acute illness. JAMA 2000; 284(1):47-52. (35) California Geriatric Education Center, Los Angeles Alzheimers Association. Guidelines for Alzheimers Disease management. 126-148. 1998. (36) California Workgroup on Guidelines for Alzheimers Disease Management. Guidelines for Alzheimers Disease Management. www.alzla.org/ medical/SuppDoc.html, 1-15. 2001. Los Angeles.
(37) University Health System Consortium/Department of Veterans Affairs. Dementia identification and assessment: guidelines for primary care practitioners. www.guideline.gov, 1-112. 1997. Oak Brook IL, UHC. (38) Duncan BA, Siegal AP. Early diagnosis and management of Alzheimers Disease. Journal of Clinical Psychiatry 1998; 59(suppl 9):15-21. (39) Inouye SK, Bogardus S, Charpentier P, Leo-Summers L, Acampora D, Holford T et al. A multicomponent intervention to prevent delirium in hospitalized older patients. New England Journal of Medicine 1999; 340(9):669-676. (40) Inouye SK. Prevention of delirium in hospitalized older patients: risk factors and targeted intervention strategies. Annals of Internal Medicine 2000; 32(4):257-263. (41) McCormick W, Kukull W, Van Belle G, Bowen J, Teri L, Larson EB. The effect of diagnosing Alzheimers Disease on frequency of physician visits: a case-control study. Journal of General Internal Medicine 1995; 10(4):187-193. (42) Alexander JCT, Brenneman SK, Yurkow JR, Evans LK, Manzano-Rivera S. Differences in functional status and balance outcomes among cognitively intact and cognitively impaired older adults. Physical Therapy 1999; 79(5):S59-S69. (43) Goldstein FC, Strausser DC, Woodard JL, Roberts VJ. Functional outcome of cognitively impaired hip fracture patients on a geriatric rehabilitation unit. Journal of the American Geriatrics Society 1997; 45:32-42. (44) Hamman RJ. Rehabilitation following hip fracture in patients with Alzheimers Disease and related disorders. American Journal of Alzheimers Disease 1997; Sept/Oct:209-211.
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Section 6
Depression
Clinical Vignette
Mr. B. is a 75-year-old member of Independence Blue Cross who experienced recurrent hospital admissions for congestive heart failure. Traditional attempts at improving the management of his disease were attempted, but without success. An astute care manager wondered whether additional factors complicated his care. She screened for depression and found Mr. B. to be depressed. She also learned that, following the death of his wife, he failed to comply with his medication regimen and began drinking excessively. Mr. B. stated that the attention he received from the staff in the hospital was his only source of counseling for his depressed mood. The case manager brought the depression to the attention of his primary care physician and facilitated referral to the plans behavioral health program. Mr. B.s mood, energy, and participation in the self-care of his congestive heart failure gradually improved. His only subsequent contact with the hospital was on the anniversary of his wifes death, when he visited to deliver flowers and chocolates to the nursing staff as an expression of his appreciation.

MCOs should:
Heighten awareness among both members and practitioners of the impact of depression on quality of life and on the management of other acute and chronic conditions. Regard older members with chronic illnesses and those receiving rehabilitation for conditions such as stroke and myocardial infarction as candidates for targeted screening. Support the development of evidence-based treatment programs that include primary care teams (formal or informal) with expertise in diagnosing and treating depression in older adults, active monitoring of patients started on treatment, and consultation from mental health specialists for patients who do not improve with treatments offered by the primary care team. Ensure that primary care practitioners have the tools, incentives, and resources to facilitate identification and appropriate monitoring of older members with depression.
41
Facilitate effective communication between primary care and mental health services. Whether mental health services are internal or external (i.e., carve-outs), MCOs should ensure that they communicate with the primary care practitioner, offer expertise in geriatric psychiatry, prescribe medications that are accessible to members via the medication formulary, and manage members across the care continuum.

Depression has a significant impact on both function and quality of life in older adults and is associated with greater use of health care services (1-11). Depression can be more disabling than diabetes, angina, lung problems, or back ailments (11;12). The reciprocal relationship between disability and depression has been clearly established, and effective treatment for depression can significantly improve quality of life in older adults (13). Older patients who suffer from both depression and other chronic medical conditions have worse outcomes than those without depression (3;10;14;15). Depressed older persons with cardiovascular disease and stroke have significantly higher rates of mortality and morbidity compared to those without depression (16;17). Further, older patients with depression achieve less benefit from rehabilitation for conditions such as stroke, Parkinsons disease, heart disease, pulmonary disease, and hip fracture (6;18). In the outpatient setting, untreated depression can complicate the management of common and costly chronic illnesses, including diabetes, asthma, and congestive heart failure (19). Depressed older patients incur significantly higher inpatient and outpatient costs than do those patients who do not suffer from depression. After controlling for co-morbidity, depressed patients have been found to have about 50 percent higher mean total costs than persons without depression, attributed to higher utilization in every category of care (i.e., emergency department, primary care, medical specialty, medical inpatient, pharmacy, laboratory) (5;7;20-22). These patients have been found to have 38 percent more visits and 61 percent higher total charges in the outpatient setting compared with non-depressed older patients (22). In the time period immediately following a heart attack, older patients with depression have 41 percent higher total costs compared with those without depression (23). Estimates for the prevalence of major depression by treatment setting are as follows: 5-10 percent of community-residing outpatients, 30-40 percent of persons recently hospitalized, and 15-30 percent of older persons residing in long-term care facilities (6;24). The prevalence of minor depression is believed to be greater, although the epidemiology is less well developed. Depression in late life differs from its manifestation in younger populations. The predominant symptoms in older adults may be a lack of interest in activities or a loss of energy in contrast with depressed mood, which is more common in younger adults. Suicide is more common in late life, with older male adults comprising the highest risk of all age groups (25). Depression is often accompanied by other conditions discussed in this report, including dementia, undernutrition, and urinary incontinence (26-28).
42
Section 6 Depression
Many depressed older individuals are not appropriately diagnosed and do not receive treatments of established efficacy, whether in managed care or fee-for-service delivery systems (14;29-32). Garrard found that only half of patients with self-reported depression were detected by their health care practitioners (33). Even when primary care physicians do diagnose depression, they infrequently provide treatment that is in accordance with evidence-based practice (22;34;35).

Certain situational or social risk factors are associated with an elevated risk for depression. Older persons who are socially isolated with little informal support are at greater risk for depression, as are older persons who have experienced either a change in their ability to function in prior roles or a decline in physical independence. Similarly older adults making transitions between sites of care (e.g., transition from hospital to a skilled nursing facility) are another high-risk group. Loss of a spouse, family member, close friend, or a pet can also increase risk. Chronic pain, alcohol and substance abuse, and terminal illness approaching the end of life represent additional important factors. Members with chronic medical conditions are also at risk, particularly those who have Parkinsons disease or who recently experienced a heart attack or stroke (24;36). By virtue of this association, significant numbers of older members enrolled in disease management or case management programs are likely to be depressed. Because of a high likelihood for relapse (nearly 40 percent), a prior history of depression is a significant risk factor for developing depression in the future (6). Finally, older white men are the highest risk group for suicide (37). An astounding 75 percent of these men visited their primary care physician within the preceding month of their deaths; however, their symptoms were largely unrecognized and untreated (6).

Brief screens for depression can be administered as part of mailed screening to members or during scheduled outpatient visits and annual examinations. Screening can also be targeted to older members who exhibit the risk factors described in the previous section (e.g., post-myocardial infarction or stroke) or those receiving care in certain settings (e.g., admission to subacute care). Receptionists at selected VA general medicine clinics have been trained to administer brief screening tools for depression to patients while they are waiting for their appointment. PacifiCare members have the opportunity to download education materials and self-screen for depression using an instrument available on its web site as part of a program entitled, Taking Charge of Your Depression. Members who score above a predetermined threshold are advised to discuss their results with their primary care physician. The most widely used screening question for depression inquires whether an individual often feels sad or blue (sometimes sad or depressed is substituted). The principal advantage of this question is its ease of use and acceptability by older patients. It has been directly compared with more formal depression screening instruments such as the 30-item Geriatric Depression Scale (GDS) and found to have
43
comparable predictive accuracy (one questionsensitivity = 0.69, specificity = 0.90; GDSsensitivity = 0.54, specificity = 0.93) (38;39). MCOs that ask this question find a high incidence of undiagnosed depression among their enrolled older population. For example, Group Health Cooperative has found that, on average, 23 percent of screened older members answer yes to the single sad or blue question, as do 11 percent of older Kaiser Permanente, Colorado Region, newly enrolled members, 16% of Oxford members, and 17 percent of Sierra members. Similarly, Whooley found that a screen comprised of two simple questions was comparable to screening using more comprehensive instruments (40). These questions were: During the past month have you often been bothered by feeling down, depressed or hopeless? and During the past month, have you often been bothered by little interest or pleasure in doing things? Mulrow compared nine different screening instruments and found no significant difference in predictive accuracy (41). Administrative data have not traditionally been employed as a means for screening for depression, but a number of studies have used such data to identify patients for quality improvement efforts for depression in primary care (42-46). They can serve to identify members with such risk factors such as previous diagnosis or treatment of depression; high use of medical services; and high-risk medical conditions such as heart disease, stroke, Parkinsons disease or dementia. In collaboration with their pharmacy benefit managers, MCOs can also use administrative data to identify members who are on antidepressants or who have recently received escalating dosing of pain medications. Kaiser Permanente, Colorado Region, uses administrative data to identify members who have experienced the death of a spouse in the past three months. After obtaining consent, a Widowed Person Services volunteer invites the recently widowed member to one of four support groups held in the Denver metropolitan area. Members who respond affirmatively to a simple depression screen require further assessment. This may involve such tools as the Geriatric Depression Scale (GDS), the Hamilton Depression Scale, the Beck Depression Inventory, or the revised Diagnosis and Statistical Manual (DSM IVR) (38;47;48). These validated tools have been used extensively in older populations. Other important components of a depression assessment in addition to use of formal depression appraisal tools include evaluation for social isolation, cognitive decline (dementia and depression often present concurrently), substance abuse (alcohol in particular), and suicidal ideation. In addition, medications that may contribute to depressive symptoms, such as Digoxin, beta-blockers, steroids, and sedative/ hypnotic medications, need to be considered. Assessing the adequacy of pain control in the setting of chronic pain is another component in the evaluation of depression.
Interventions
Older adults respond to treatment for depression and are as likely to improve with early intervention as are younger adults (49;50;51). Most studies have focused on treatment of major depression, although interest in minor depression is increasing (6;51;52). The hallmarks of successful treatment programs entail collaboration between mental health specialists and PCPs (i.e., depression care teams), active follow-up of patients started on treatment, and additional
44
monitoring visits in primary care. The collaboration between PCPs and mental health specialists can be face-to-face, telephonic, or via written communication. These teams can either be structured formally (i.e., having the same mental health specialists attend primary care clinics on certain days) or informal (ad hoc communication about a given patient or patients). In addition, decision support is another effective tool in depression management. For example, practitioners who initiate pharmacologic therapy may receive a reminder to re-evaluate symptom response and consider adjusting the dose of medication after six weeks. Although most of these strategies have been developed and tested in group and staff model MCOs, creative adaptations of these models in other settings appears feasible (19;53;54). Depression is a chronic illness with high rates of recidivism that can be reduced most effectively with pharmacologic treatment, brief cognitive behavioral therapy, or the two in combination (50;51). Overall, controlled trials have demonstrated that these approaches are safe and effective for both major and minor depression (50;55). One of the more promising approaches for treating depression in older adults is to provide the primary care team with greater support and mental health expertise. Many older members prefer to be treated in the primary care setting rather than being referred to a mental health practitioner, in part due to a perceived stigma of the latter. Katon and colleagues have conducted studies to demonstrate the value of bringing a collaborative mental health treatment team into Seattle-based primary care clinics at Group Health Cooperative in Seattle. This multifaceted intervention was designed to provide greater support for the role of primary care practitioners to meet the needs of depressed patients and emphasized the importance of active monitoring of symptoms and relapse prevention. Patients received frequent monitoring visits, which alternated between the mental health team and the primary care practitioner. Close attention was paid to patient education, compliance with treatment guidelines, tolerance of therapy, and medication adjustment. This approach was shown to both improve outcomes of depression and satisfaction among both patients and providers (42;56). Group Health Cooperative, Kaiser Permanente, Northern California Region, the Lahey Clinic, and Health Care Partners have all developed programs that integrate mental health specialists into primary care settings. Building on the lessons of Katons collaborative model, the John A. Hartford Foundation and the California Health Care Foundation have recently funded a randomized trial in seven health care systems with 18 participating primary care clinics that specifically targets older adults.17 Following identification through screening and referral, a depression specialist (either a registered nurse, social worker, or a clinical psychologist) works collaboratively with the primary care practitioner to initiate treatment with medications or problem-solving behavioral therapy (six to eight sessions). The depression specialist also obtains additional expertise through consultation with a geriatric psychiatrist. Symptom monitoring and adherence to the care plan are monitored through regular clinic visits as well as telephone followup. The latter has been shown to be an effective adjunct in depression care (57). Preliminary analyses suggest that this approach is feasible, acceptable to practitioners, and effective as about 70 percent of persons receiving the intervention experienced improvement in depression scores.
17
Not all sites are MCOs and only three of the seven health care systems are group or staff model MCOs.
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Physical activity is becoming recognized as an important intervention strategy for reducing depressive symptoms (58-63). Blumenthal and colleagues studied older adults with major depression and found that aerobic physical activity may be as effective as antidepressant therapy (64). Additional studies have shown that regular physical activity offers a protective effect on depressive symptoms (65;66). Recent intervention trials have demonstrated that progressive resistance training improved scores for depression (52;60). Sierra Health Services makes a special effort to provide depressed members access to structured exercise programs. Because depression may rob many older adults of the motivation and energy needed to participate in such programs, antidepressants or psychotherapy are initially provided to members in order to overcome potential inertia that may impede participation in a physical activity program. MCOs can be instrumental in ensuring that PCPs have the necessary tools and access to collaborative mental health expertise. They also need population-based systems of care to facilitate identification and appropriate follow-up (67). Physicians affiliated with MCOs that provide greater infrastructure for geriatric care reported that they were much more likely to address geriatric issues, including depression (68). Rollham and colleagues recently demonstrated improved quality of depression care by using a computerized mood module to identify patients at risk, notifying the PCP via an interactive email alert generated through the electronic medical record system, and presenting the PCP with patient-specific treatment recommendations (69). Many plans offer programs designed to prevent or reduce depression. Sierra Health Services administers the 15-item GDS following a positive response to the sad or blue screening question. Members with a score that is consistent with major depression are referred to a behavioral health program. Members whose score is consistent with minor depression are referred to situational counseling or a support group. Follow-up scores on the 15-item GDS have revealed significant improvement with over 70 percent of members no longer meeting criteria for depression. Group Health Cooperative has developed a clinical roadmap for depression that incorporates screening and management of both major and minor depression. Older members are initially identified at health maintenance visits using the sad or blue screening question. Members who respond affirmatively are assessed for major or minor depression. Those members that meet criteria for either major or minor depression are entered into a depression registry to facilitate treatment and ongoing management. Members with major depression receive pharmacologic and behavioral therapy. Group Health Cooperative is actively developing strategies for improving the management of members with minor depression. A second clinical roadmap for senior care is exploring the role of physical activity programs and optimizing management of comorbid conditions that may contribute to depressive symptoms (i.e., urinary incontinence and functional deficits) to improve outcomes.
Many PCPs do not feel confident in their diagnosis and management skills for depression and are often frustrated by their practice environment (19;70-72). However, simply providing greater PCP education alone is unlikely to be sufficient (73). Lack of time and tools to support treatment and monitoring, and a lack of coordination between primary care, mental health, and social services all represent additional barriers to
46
improved care. These barriers are supported by a study conducted by Meredith and colleagues. Their surveys of physicians in staff model and network model MCOs revealed that staff model physicians were more likely to report time limitation as a major barrier, while network physicians were more likely to report poor access to mental health specialists as a major barrier (74). Older patients themselves may inadvertently create barriers to diagnosis and treatment. They may perceive a stigma to acknowledging impaired mental health in general, and to depression in particular (75). They may deny and consequently underreport symptoms, or they may implore their PCP to evaluate their multiple somatic complaints in an effort to attribute their symptoms to a diagnosis that is more acceptable to them than depression (4;57). MCOs can provide older members with education regarding the adverse effects of depression on quality of life and management of their other conditions, while assuring them that depression can be effectively treated. Older members and their significant others need to be encouraged to report depressive symptoms and discuss treatment with their PCP. For example, Oxford Health Plan enlists the services of a geriatric psychiatrist to work collaboratively with care managers to identify members with depressive symptoms and encourage them to discuss their concerns with their PCP. Finally, external contracting (i.e., carve-outs) for behavioral health services can create additional barriers to comprehensive care. Many of the managed behavioral health contractors lack expertise in geriatric mental health (i.e., geropsychiatrists and geropsychologists). Medications prescribed by the contract program may not be on the formulary for the pharmacy benefits manager (PBM). Furthermore, because older members making transitions between sites of care are at particularly high risk for depression, contract programs cannot simply attend to only those members in the ambulatory setting. Often, the primary care team does not have access to contract mental health records and interprovider communication is particularly challenging in the setting of depression due to concerns over patient confidentiality. Such concerns preceded recent Federal legislation (i.e., Health Insurance Portability and Accountability Act or HIPAA) and can be overcome by patient consent. Thus, these carve out arrangements have the potential to further fragment geriatric care.
Economic Impact
Although treatment for depression may reduce both inpatient18 and general medical costs, whether this reduction offsets the initial investment in providing better care for depression remains unclear (8;76;77). Untreated depression can further increase costs to the delivery system by complicating the management of other chronic medical illnesses (7;23;78). Campbell and colleagues found that physicians who diagnosed depression and anxiety at higher rates than their peers had lower per capita costs, ordered fewer unnecessary tests, had lower rates of patient referral to specialists, and were less likely to admit their patients to the hospital for potentially avoidable reasons (79). Revicki and colleagues compared patients receiving recommended versus less-than-recommended antidepressant therapy over a 6-month time period. Those patients who received recommended therapy had lower mean total costs ($1,872 versus $2,622), with differences primarily attributable to significantly lower non-mental healthrelated inpatient costs (8).
18
These inpatient costs were not mental health-related.
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Treatment of depression requires an investment in resources, including medications and mental health expertise. Sturm and Wells suggest that practice guidelines for depression can improve overall cost effectiveness of care (29). However, delivery systems may need to initially increase their depression care-related costs. For example, although attempts to shift away from the use of mental health specialists can decrease immediate costs, functional outcomes for depression are often worse (29). Kaiser Permanente, Colorado and Southern California Regions, have confronted this cost trade-off in their selection of formulary medications. The use of a particular class of antidepressants, Selected Serotonin Receptor Inhibitors (SSRIs) represents one of their single highest drug expenses. Although less expensive options are available, these Regions decided to provide SSRIs based on evidence suggesting that the lower cost medications lead to higher non-medication costs, attributed to intolerance, side effects, and non-compliance (80).
Reference List
(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) Cronin-Stubbs D, Mendes de Leon CF, Beckett LA, Field TS, Glynn EJ, Evans DA. Six-year effect of depressive symptoms on the course of physical disability in community-living older adults. Archives of Internal Medicine 2000; 160:3074-3080. Kivela SL, Pahkala K. Depressive disorder as a predictor of physical disability in old age. Journal of the American Geriatrics Society 2001; 49(290):296. Koenig HG, George L. Depression and physical disability outcomes in depressed medically ill hospitalized older adults. American Journal of Geriatric Psychiatry 1998; 6(3):230-247. Lyness J, King D, Cox C, Yoediono Z, Caine E. The importance of subsyndromal depression in older primary care patients: prevalence and associated functional disability. Journal of the American Geriatrics Society 1999; 47(6):647-652. Unutzer J, Patrick DL, Simon G, Grembowski D, Walker E, et al. Depressive symptoms and the cost of health services in HMO patients aged 65 years and older: a 4-year prospective study. JAMA 1997; 277(20):1618-1623. Lebowitz B, Pearson J, Schneider L, Reynolds C, Alexopoulos G, et al. Diagnosis and treatment of depression in late life: consensus statement update. JAMA 1997; 278(14):1186-1190. Henk HJ, Katzelnick DJ, Kobak KA, Greist JH, Jefferson JW. Medical costs attributed to depression among patients with a history of high medical expenses in a health maintenance organization. Archives of Internal Medicine 1996; 53(10):899-904. Revicki D, Simon G, Chan K, Katon W, Heiligenstein JH. Depression, health-related quality of life, and medical cost outcomes of receiving recommended levels of antidepressant treatment. Journal of Family Practice 1998; 47(6):446-452. Koenig HG, Blazer DG. Minor depression in late life. American Journal of Geriatric Psychiatry 1996; 4(4):S14-S21. Dunham NC, Sager MA. Functional status, symptoms of depression, and the outcomes of hospitalization in community-dwelling elderly patients. Archives of Family Medicine 1994; 3:676-681. Santiago JM. The costs of treating depression. Journal of Clinical Psychiatry 1993; 54(11):425-426. Unutzer J, Patrick DL, Diehr P, Simon G, Grembowski D, Katon W. Quality adjusted life years in older adults with depressive symptoms and chronic medical disorders. International Psychogeriatrics 1997; 12(1):15-33. Graney MJ. The reciprocal relationship between disability and depression. Journal of the American Geriatrics Society 2000; 48:452-453. Wells KB, Stewart A, Hays RD, Burnam MA, Rogers W, et al. The functioning and well-being of depressed patients. Results from the Medical Outcomes Study. JAMA 1989; 262(7):914-919. Covinsky KE, Fortinsky RH, Palmer RM, Kresevic DM, Landefeld CS. Relation between symptoms of depression and health status outcomes in acutely ill hospitalized older persons. Annals of Internal Medicine 1997; 126(6):417-425. Panzarino J. The costs of depression: direct and indirect; treatment versus nontreatment. Journal of Clinical Psychiatry 1998; 59(suppl 20):11-14.
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(17) Penninx BWJH, Guralnik JM, Bandeen-Roche K, Kasper JD, Simonsick EM, et al. The protective effect of emotional vitality on adverse health outcomes in disabled older women. Journal of the American Geriatrics Society 2000; 48:1359-1366. (18) Katz IR, Alexopoulos GS. The diagnosis and treatment of late-life depression. American Journal of Geriatric Psychiatry 1996; 4(4):S1-S2. (19) Ford D. Managing patients with depression: is primary care up to the challenge? Journal of General Internal Medicine 2000; 15:344-345.
(20) Simon GE, Von Korff M, Barlow W. Health care costs of primary care patients with recognized depression. Archives of General Psychiatry 1995; 52(10):850-856. (21) Pearson Sd, Katzelnick DJ, Simon GE, Manning WG, Helstad CP, Henk HJ. Depression among high utilizers of medical care. Journal of General Internal Medicine 1999; 14:461-468. (22) Callahan C, Hui S, Nienaber N, Musick B, Terney W. Longitudinal study of depression and health services use among elderly primary care patients. Journal of the American Geriatrics Society 1994; 42(8):833-838. (23) Frasure-Smith N, Lesperance F, Gravel G, Masson A, Juneau M, et al. Depression and health-care costs during the first year following myocardial infarction. Journal of Psychosomatic Research 2000; 48:471-478. (24) Lebowitz BD. Diagnosis and treatment of depression in late life: an overview of the NIH consensus statement. American Journal of Geriatric Psychiatry 1996; 4(4):S3-S6. (25) Blazer D, Bachar J, Manton K. Suicide in late life. Journal of the American Geriatrics Society 1986; 34(7):519-525. (26) Dugan E, Cohen S, Bland D, Preisser J, Davis C, et al. The association of depressive symptoms and urinary incontinence among older adults. Journal of the American Geriatrics Society 2000; 48(4):413-416. (27) Kales H, Blow F, Copeland L, Bingham R, Kammerer E, Mellow A. Health care utilization by older patients with coexisting dementia and depression. American Journal of Psychiatry 1999; 156(4):550-556. (28) Silverman M, McDowell B, Musa D, Rodriguez E, Martin D. To treat or not to treat: issues in decisions not to treat older persons with cognitive impairment, depression and incontinence. Journal of the American Geriatrics Society 1997; 45(9):1094-1101. (29) Sturm R, Wells KB. How can care for depression become more cost-effective? JAMA 1995; 273(1):51-58. 30) Katon W, Von Korff M, Lin E, Bush T, Ormel J. Adequacy and duration of antidepressant treatment in primary care. Medical Care 1992; 30(1):67-76.
(31) Wells KB, Katon W, Rogers B, Camp P. Use of minor tranquilizers and antidepressant medications by depressed outpatients: results from the medical outcomes study. American Journal of Psychiatry 1994; 151(5):694-700. (32) Unutzer J, Simon G, Belin TR, Datt M, Katon W, Patrick D. Care for depression in HMO patients aged 65 and older. Journal of the American Geriatrics Society 2000; 48(8):871-878. (33) Garrard J, Rolnick SJ, Nitz NM, Luepke L, Jackson J, Fischer LR et al. Clinical detection of depression among community-based elderly people with self-reported symptoms of depression. Journal of Gerontology A Biological and Medical Sciences 1998; 53A(2):M92-M101. (34) Callahan CM, Hendrie HC, Tierney WM. The recognition and treatment of late-life depression: a view from primary care. International Journal of Psychiatry and Medicine 1996; 26(2):155-171. (35) Unutzer J, Katon W, Sullivan M, Miranda J. Treating depressed older adults in primary care: narrowing the gap between efficacy and effectiveness. The Milbank Quarterly 1999; 77(2):225-256. (36) Frasure-Smith N, Lesperance F, Talajic M. Depression following myocardial infarction: impact on 6-month survival. JAMA 1993; 270(15):1819-1825. (37) Kaplan MS, Adamek ME, Geling O. Sociodemographic predictors of firearm suicide among older white males. Gerontologist 1996; 36(4):530-533. (38) Yesavage JA, Brink TL, Rose TL, Lum O, Huang V, et al. Development and validation of a geriatric depression screening scale: a preliminary report. Journal of Psychiatric Research 1983; 17:37-49. (39) Mahoney J, Drinka T, Abler R, Gunter-Hunt G, Matthews C, Gravenstein S et al. Screening for depression: single question versus GDS. Journal of the American Geriatrics Society 1994; 42(9):1006-1008. (40) Whooley MA, Avins AL, Miranda J, Browner WS. Case-finding instruments for depression: two questions are as good as many. Journal of General Internal Medicine 1997; 12:439-445. (41) Mulrow C, Williams Jr J, Gerety M, Ramirez G, Montiel O, Kerber C. Case-finding instruments for depression in primary care settings. Annals of Internal Medicine 1995; 122(12):913-921. (42) Katon W, Von Korff M, Lin E, Walker E, Simon G, et al. Collaborative management to achieve treatment guidelines: impact on depression in primary care. JAMA 1995; 273(13):1026-1031. (43) Katon W, Von Korff M, Lin E, Simon G, Walker E, et al. Collaborative management to achieve depression treatment guidelines. Journal of Clinical Psychiatry 1997; 58(Suppl 1):20-23. (44) Katon W, Rutter CM, Lin E, Simon G, Von Korff M, et al. Are there detectable differences in quality of care or outcome of depression across primary care providers? Medical Care 2000; 38(6):552-561.
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(45) (46) (47) (48) (49) (50) (51) (52) (53) (54) (55) (56) (57) (58) (59) (60) (61) (62) (63) (64) (65) (66) (67) (68) (69) (70) (71) (72) (73)
Simon GE, Unutzer J, Young BE, Pincus HA. Large medical databases, population-based research, and patient confidentiality. American Journal of Psychiatry 2000; 157(11):1731-1737. Simon GE, Von Korff M, Rutter CM, Wagner E.H. Randomised trial of monitoring, feedback, and management of care by telephone to improve treatment of depression in primary care. BMJ 2000; 320(7234):550-554. Hamilton M. Development of a rating scale for primary depressive illness. British Journal of Social and Clinical Psychology 1967; 6:278-296. Beck AT, Steer RA, Garbin MG. Psychometric properties of the Beck Depression Inventory: twenty-five years of evaluation. Clinical Psychology Reviews 1988; 8:77-100. Conwell Y. Outcomes of depression. American Journal of Geriatric Psychiatry 1996; 4(4):S34-S44. Reynolds C, Frank E, Perel J, Imber S, Cornes C, et al. Notriptyline and interpersonal psychotherapy as maintenance therapies for recurrent major depression: a randomized controlled trial in patients older than 59 years. JAMA 1999; 281(1):39-45. Williams JWJ, Barrett J, Oxman T, Frank E, Katon W, et al. Treatment of dysthymia and minor depression in primary care: a randomized controlled trial in older adults. JAMA 2000; 284(12):1519-1526. Singh N, Clements K, Fiatrone M. A randomized controlled trial of progressive resistance training in depressed elders. Journal of Gerontology A Biological and Medical Sciences 1997; 52A(1):M27-M35. Dwight-Johnson M, Unutzer J, Sherbourne CD, Tang L, Wells KB. Can quality improvement programs for depression in primary care address patient preferences for treatment? Medical Care 2001; 39(9):934-944. Wells KB, Sherbourne CD, Schoenbaum M, Duan N, Meredith LS, et al. Impact of disseminating quality improvement programs for depression in managed primary care: a randomized controlled trial. JAMA 2000; 283(2):212-220. King M, Tinetti M. Falls in community-dwelling older persons. Journal of the American Geriatrics Society 1995; 43(10):1146-1154. Katon W, Robinson P, Von Korff M, Lin E, Bush T, et al. A multifaceted intervention to improve treatment of depression in primary care. Archives of General Psychiatry 1996; 53(10):924-932. Dietrich AJ. The telephone as a new weapon in the battle against depression. Effective Clinical Practice 2000; 3(4):191-193. Lavie CJ, Milani RV, Cassidy MM, Gilliland YE. Effects of cardiac rehabilitation and exercise training programs in women with depression. American Journal of Cardiology 1999; 83(10):1480-1483. Miser WF Exercise as an effective treatment option for major depression in older adults. Journal of Family Practice 2000; 49(2):109-110. Martinsen EW. Physical activity and depression: clinical experience. Acta Psychiatry Scandinavia 1994; Suppl 377:23-27. Byrne A, Byrne DG. The effect of exercise on depression, anxiety and other mood states: a review. Journal of Psychosomatic Research 1993; 37(6):565-574. Martinsen EW. Benefits of exercise for the treatment of depression. Sports Medicine 1990; 9(6):380-389. North TC, McCullagh P, Vu Tran Z. Effect of exercise on depression. Exercise and Sport Science Reviews 1990; 18:379-415. Blumenthal J, Babyak M, Moore K, Craighead E, Herman S, Khatri P et al. Effects of exercise training on older patients with major depression. Archives of Internal Medicine 1999; 159:2349-2356. Farmer ME, Locke B, Moscicki E, Dannenberg A, Larson D, Radloff LS. Physical activity and depressive symptoms: the NHANES I epidemiologic follow-up study. American Journal of Epidemiology 2001; 128(6):1340-1351. Camacho T, Roberts R, Lazarus N, Kaplan G, Cohen R. Physical activity and depression: evidence from the Alameda County Study. American Journal of Epidemiology 1991; 134(2):220-231. Katon W, Von Korff M, Lin E, Unutzer J, Simon G, et al. Population-based care of depression: effective disease management strategies to decrease prevalence. General Hospital Psychiatry 1997; 19(3):169-178. Dixon MK, Kirschner PB, Edelberg HK, Ayanian JZ, Wei JY. Physician perceptions of HMO care for older persons. Journal of the American Geriatrics Society 2000; 48:607-612. Rollman BL, Hanusa BH, Gilber T, Lowe HJ, Kapoor WN, Schulberg HC. The electronic medical record: a randomized trial of its impact on primary care physicians. Archives of Internal Medicine 2001; 161(2):189-197. Callahan CM, Nienaber NA, Hendrie HC, Tierney WM. Depression of elderly outpatients: primary care physicians attitudes and practice patterns. Journal of General Internal Medicine 1992; 7:26-31. Wagner EH, Von Korff M, Simon GE. Anxious and depressed patients in primary care: the need for more clinical epidemiology. Journal of General Internal Medicine 1994; 9:534-535. Covinsky KE, Landefeld CS. Using the biopsycosocial model in practice: improving the care of patients with late-life depression. Journal General Internal Medicine 1996; 11(4):249-250. Lin E, Katon W, Simon GE, Von Korff M, Bush TM, et al. Achieving guidelines for the treatment of depression in primary care: is physician education enough? Medical Care 1997; 35:831-842.
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(74) Meredith LS, Rubenstein LV, Rost K, Ford DE, Gordon N, et al. Treating depression in staff-model versus network-model managed care organizations. Journal of General Internal Medicine 1999; 14:39-48. (75) Rabins PV. Barriers to diagnosis and treatment of depression in elderly patients. American Journal of Geriatric Psychiatry 1996; 4(4):S79S83. (76) Sambamoorthi U, Walkup J, Olfson M, Crystal S. Antidepressant treatment and health services utilization among HIV-infected Medicaid patients diagnosed with depression. Journal of General Internal Medicine 2000; 15:311-320. (77) Wei F, Mark D, Hartz A, Campbell C. Are PRO discharge screens associated with postdischarge adverse outcomes? Health Services Research 1995; 30(3):489-506. (78) Nesse RE, Finlayson RE. Management of depression in patients with coexisting medical illness. American Family Physician 1996; 76:391396. (79) Campbell TL, Franks P, Fiscella K, McDaniel SH, Zwanziger J, Mooney C, et al. Do physicians who diagnose more mental health disorders generate lower health care costs? Journal of Family Practice 2000; 49(4):305-310. (80) Simon G, Von Korff M, Heiligenstein J, Revicki D, Grothaus L, et al. Initial antidepressant choice in primary care: effectiveness and cost of fluoxetine vs trycyclic antidepressants. JAMA 1996; 275(24):1897-1901.
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Section 7
Undernutrition
Clinical Vignette
Mrs. S.C. is an 84-year-old Kaiser member with asthma who was recently widowed after 51 years of marriage. She lives alone and her children live out of state. During an acute visit to her primary care physician, she complained of worsening shortness of breath and fatigue. Her physician believed that this exacerbation was due to the fact that Mrs. S.C. had stopped taking her breathing medications. However, the physician also noticed that her weight had decreased 11 pounds since her last visit 6 months before. After a metabolic work-up did not reveal any contributing factors, the physician referred her for further evaluation to the Senior Care Coordination program. Using a functional screen, a nutrition screen, a depression screen, and a cognitive screen, the Senior Care Coordinator learned that the weight loss was an important clue to a more complex decline in her ability to care for herself and manage her chronic lung disease. Depression, social isolation, alcohol use, and mild cognitive impairment combined to interfere with her consuming regular meals and taking her medications. The Senior Care Coordinator arranged for her to attend a local senior center five times a week and to receive visits from a companion on weekends. At the senior center, she benefited not only from the daily nutritious meals but also from greater social interaction. The staff at the senior center reminded her during the week to use her breathing medications, and her companion did the same over the weekend. She regained her weight, and her asthma remained in excellent control.

MCOs should:
Educate practitioners regarding the central role of undernutrition in chronic disease management and functional rehabilitation. Promote the evaluation of body weight as a routine vital sign taken at each medical encounter. Members who experience a weight loss of 10 pounds or greater over the past six months should receive further assessment. Ensure that nutritional status is a focus of care management and disease management programs.
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Encourage practitioners to evaluate older members for undernutrition upon admission to hospital, subacute, and home health care since patients undergoing care transitions represent an underrecognized high-risk group. Establish linkages with community nutrition programs and work with practitioners to facilitate referrals.

The management of many chronic diseases can be improved with proper attention to nutrition, enhancing both health and quality of life outcomes for older members (1). There is significant evidence for the role of nutrition therapy in the management of cardiovascular disease, heart failure, high blood pressure, diabetes, osteoporosis, and pre-dialysis kidney failure (1). Inadequate nutritional status also contributes to the development of pressure ulcers, anemia, infection, dehydration, and hip fractures (2). Poor nutritional status contributes to longer hospital length of stays, higher rates of re-hospitalization, higher total health care costs, higher complication rates, and higher mortality rates (3-7). This longer hospital length of stay is attributable, in part, to longer recovery time from surgery, prolonged ICU stays, and adverse effects on rehabilitation (8-14). In one study, older patients at-risk for undernutrition19 were found to have longer average length of stay (six versus four days), have higher average hospital cost ($6,196 versus $4,563), use more home health care services, and require more post-hospital subacute care (15). As many as 15 percent of community dwelling and 35-65 percent of hospitalized older adults suffer from inadequate nutritional status (16). Although undernutrition offers an excellent opportunity for upstream intervention, it often goes unrecognized and unaddressed (17). Manson and Shea found primary care physicians did not record a diagnosis of malnutrition or weight loss in approximately 50 percent of cases and did not prescribe specific therapy (e.g., nutritional supplements) in more than 75 percent of such cases (18). Similar studies have documented lack of awareness among practitioners caring for hospitalized older adults (5;19;20). Undernutrition has traditionally been underaddressed, whether by MCOs or PCPs, for multiple reasons. MCOs may not cover certain nutritional therapies (e.g., nutritional supplements) and, consequently, may be reluctant to identify members at risk. PCPs have commonly viewed nutritional problems as being in the domain of social services rather than medicine. However, because undernutrition adversely impacts the management of many chronic diseases and functional rehabilitation, it is incumbent on MCOs and PCPs to address this problem.
19 Defined as weight for height less than 75 percent of ideal body weight, serum albumin level less than 3 grams per deciliter, or 10 percent or greater unintentional weight loss during the past month.
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Section 7 Undernutrition

Risk for poor nutritional status increases with age, mostly attributable to a higher prevalence of diseases that affect nutritional status, the associated need for multiple medications, changes in internal organ function, and socioeconomic factors such as isolation and inadequate income. Relevant chronic illnesses include congestive heart failure, chronic lung disease, cancer, hyperthyroidism, hip fracture, dementia, and intestinal malabsorption syndromes. Older members receiving hospital or post-hospital care are at particularly high risk for undernutrition and accompanying poor outcomes of care. Disease and agerelated changes in both kidney and liver function also increase risk. Sensory loss, including loss of taste and smell, are additional risk factors, as are neurologic deficits that interfere with swallowing, such as stroke and dementia. Medication use may lead to undernutrition due to adverse effects on nutrient absorption or effects on appetite and swallowing. Social isolation, depression, widowhood, inadequate financial resources, alcoholism, and poor dentition are also associated with poor nutrition (1;21).

Screening can be conducted through questionnaires mailed to new members and through clinician referral or administrative data for existing members. Admissions to the hospital, skilled nursing facility, case management or disease management, or home nursing visits are all opportunities to assess nutritional status. The most widely used screening tools include an assessment of weight loss, serum albumin, the Nutrition Screening Initiative (NSI) DETERMINE Checklist, and Body Mass Index (BMI). Examination of weight loss is among the simplest tools for identifying undernutrition in older members. Weight loss of more than 10 pounds in the previous six months is considered to be a positive screen.20 The distinction regarding whether weight loss was intentional or not does not appear to influence the association with adverse outcomes (22). Older adults reporting a weight loss of 10 pounds or greater are at significant risk for experiencing functional decline over the next three years (23). MCOs have considerable experience with this screening approach, as this question comprises one of the items on the PraPlus (24). At Group Health Cooperative, primary care practitioners routinely ask members who have scheduled annual evaluations whether they have experienced a 10-pound weight loss during their scheduled annual evaluation. Some MCOs enter patients weight into an electronic medical record that can serve as an additional resource for identifying existing members at risk. The potential use of administrative data for risk identification has prompted interest in the role of laboratory biomarkers. Serum albumin appears to have the greatest utility and is the most studied. Albumin levels below 3.5 grams/deciliter have been associated with prolonged hospitalization and rehospitalization, higher cost of care, infectious complications, functional limitation, and mortality (3;5;25-29). In the setting of significant acute illness, injury, or inflammatory conditions, however, albumin levels may not be reliable (30).
20 With the caveat that this weight loss is not simply due to a reduction in fluid in the lower extremities or lungs in the setting of conditions such as congestive heart failure.
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Friedmann and colleagues examined the relationship between nutritional status and hospital readmission. They demonstrated that a combined measure of change in weight and serum albumin was the best predictor of 90-day re-admission rates following hospitalization (sensitivity of 50 percent, a specificity of 100 percent, and a positive predictive value of 90 percent) (4). Although MCOs have traditionally not employed lab data for risk screening, information on nutritional parameters such as albumin could be requested from their laboratory vendors. The NSI DETERMINE Checklist is the result of a multidisciplinary effort that was supported by over 30 national medical, nutrition, and aging organizations (31). The Checklist is used by Area Agencies on Aging to identify older adults who might benefit from programs such as Meals on Wheels. The 10item checklist can be administered by self-report or over the phone. A Spanish version is available. High scores on the NSI DETERMINE Checklist are associated with depression and functional disability (32). The NSI DETERMINE Level II Screen is a comprehensive assessment tool with 34 check box items that include questions regarding weight change, living and eating habits, alcohol and medication use, depression, dentition, and limitations in functional status. Jensen and colleagues found that a subset of items on this screen identified older persons at risk for hospital admission (33). Select items from the Pra (Probability of repeat hospital admissions) (34) and the NSI Level II Screen were comparable in identifying patients at risk for hospitalization. These items included eating problems (difficulty chewing or swallowing, pain in mouth, teeth or gums), weight loss, consumption of special diets, and taking three or more medications daily.21 The Geisinger Clinic in Pennsylvania identified newly enrolled Medicare risk members who reported a weight loss of 10 or more pounds in the previous six months based on their responses to the NSI DETERMINE Level II Screen. The prevalence of weight loss in this population was found to be more than eight percent. In addition, those members who had lost weight were more likely to have functional impairment (26). Independence Blue Cross incorporates the 11-item NSI Checklist into its screening and assessment form for Medicare members (35). Preliminary analysis has supported the role of this screening tool for identifying older members who might benefit from proactive case management and intervention. Although the NSI DETERMINE Checklist is the most widely used screening tool for undernutrition, its utility for identifying older adults at risk has not been adequately quantified (36). In particular, it has been criticized for having poor test characteristics (sensitivity 46 percent, specificity 46 percent, positive predictive value 38 percent), retaining items that are not significantly associated with the outcomes of interest, and including items that are not amenable to intervention by either the PCP or the MCO (1;37). These concerns have prompted questions as to whether all 11 items need to be administered and whether the NSI DETERMINE Checklist has greater utility as a tool to promote awareness among providers rather than as a screening tool.
21
All four of these items appear on the NSI DETERMINE Checklist.
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BMI (defined as weight in kilograms divided by height in square meters) has been principally used in large national studies of nutritional disorders. Research evidence suggests that persons with low BMI have greater mortality, health care expenditures, and functional impairment compared with persons with normal BMI (38-41). Older patients with a BMI of 17 or less appear to be at high risk for mortality, while persons with a BMI between 17 and 21 appear to be at moderate risk. The National Institutes on Health recommends using a less restrictive BMI threshold of 18.5 for identifying the presence of undernutrition. However, the utility of the BMI as a clinical screening tool remains to be determined. For members who have a positive screen for nutritional risk, further assessment is warranted. Key elements of an evaluation for reversible contributing factors include a diet history, determining whether dental or swallowing problems affect dietary intake, and evaluating whether physical or cognitive functional impairment are interfering with the ability to acquire and prepare nutritious meals on a daily basis (30). Persons experiencing swallowing difficulties may benefit from an evaluation by a speech therapist. Cultural factors that may affect food choices should also be examined. In addition, members who suffer from undernutrition should be evaluated for the presence of depression and social isolation. Given the prevalence of thyroid disease in the older population and its association with weight change, laboratory evaluation of thyroid status is often indicated. Finally, a complete medication review should be conducted with particular attention to medications that adversely effect appetite such as Selective Serotonin Re-uptake Inhibitors (SSRIs) and Digoxin.
Interventions
In general, nutritional interventions designed to reduce the risk of poor nutritional status in older managed care populations have been achieved using both MCO and community resources (42). Such interventions need to account for members cultural preferences, financial resources, access to community programs, and literacy. Oxford Health Plan has implemented a nutrition screening and intervention program for its Medicare members. The nutrition survey, adapted from the Nutrition Screening Initiative (31), is administered telephonically to all new members residing in specific New York counties. High-risk members receive a telephone call from an Education & Outreach Associate, who designs an intervention tailored to the individuals functional status and nutritional practices. Examples of interventions include arranging a visit to a registered dietitian, referral to a congregate meal site, and providing the member with simple tools that facilitate meal preparation (e.g., a tool that helps persons with arthritis open a jar or can). High-risk members primary care practitioners receive detailed reports regarding the specific areas of nutritional concern and recommended interventions. In one borough, 24 percent of the 4,380 screened Oxford Medicare members were identified as highrisk. Education and Outreach workers telephoned these patients to discuss responses to the survey, answer questions, and recommend interventions. A follow-up letter summarizing the call and recommendations was sent to both the member and his or her primary care practitioner. High-risk
57
members received an additional phone call within two weeks to reinforce recommendations and help overcome any barriers. Fifty-seven percent of high-risk members were receptive to the recommended interventions and met established goals. Examples of these goals included obtaining formal assistance to get food into the home on a regular basis (e.g., Meals on Wheels) and working with an occupational therapist to overcome functional barriers to meal preparation. Six months later, members were mailed the same nutrition survey, and 38 percent of responding members originally classified as high-risk no longer met these criteria. As discussed earlier, Independence Blue Cross employs the NSI DETERMINE Checklist as part of its initial health risk screen for new Medicare members. The interventions for those identified as nutritionally underserved include nutritional counseling, access to discounted meals on wheels, and case management. Independence Blue Cross also provides practitioners with incentives to refer patients and collaborate with health plan care managers. Frequently, members needing high-intensity care management have nutritional needs. Practitioners working with care managers receive $50 for the first month and $25 for each subsequent month of the patients enrollment in the program. Reuben and colleagues have developed interventions for patients identified using laboratory data. Older attendees of an ambulatory clinic were screened for low albumin (less than 3.8 g/dl). Those who screened positive underwent a comprehensive in-home assessment by a registered nurse. Specific problems affecting nutrition included lack of economic resources, functional impairment, dental disorders, and medication side effects. Referrals to a social worker, dentist, physical therapist, and greater vigilance in monitoring of medication levels in the blood were examples of tailored protocols for high-risk patients. On average, this assessment generated a mean of 4.2 recommendations per participant. Three months after the intervention, patients were found to have a significant increase in serum albumin (43). Finally, the Geisinger Health Care System in Pennsylvania has implemented a nutrition risk-screening program among its rural members (26;44). In one pilot study, among 417 health plan members screened, 16 percent met criteria for high-risk and were provided with case management. Twenty-six of these 67 high-risk members received a targeted intervention and completed a follow-up survey at six months. Ten of the 67 high-risk members were subsequently determined to no longer meet risk criteria.
Lack of awareness of the central role nutrition plays in chronic disease management and rehabilitation remains one of the greatest barriers to implementation of effective interventions. Of the seven conditions discussed in this report, undernutrition appears to receive the least attention from health care practitioners. Most physicians received little training on the nutritional needs of older adults from their medical school and residency curriculum. Oxford Health Plan surveyed participating practitioners and found that nutrition was among the top three areas for which they lacked confidence in formulating a care plan or knowing when and where to refer.22 A pervasive attitudinal barrier is the misconception that nutritional problems belong in the realm of social programs rather than medical care. MCOs can
22
The other two areas were alternative medicines and physical activity counseling.
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promote continuing medical education on the role nutrition plays in chronic illness management, functional status, and quality of life. Further, MCOs can work with PCPs to help facilitate referrals to relevant community agencies. Sierra Health Services has found that members are more likely to attend classes on nutrition when advised to do so by a physician. Older members may perceive a stigma to accepting assistance from financial programs such as food stamps or congregate meals. MCOs can be instrumental in educating members regarding the importance of nutrition in maintaining health and encouraging the PCP to further reinforce this message. Community programs may inadvertently create barriers to meeting the needs of older members. For example, they may require the completion of application materials that are long or that do not account for low literacy levels. The services they offer may not reflect cultural preferences in the planning and preparation of meals. Lastly, in many communities, programs such as Meals on Wheels have long waiting lists.
Economic Impact
A recent Institute of Medicine report maintains that expanded coverage for nutrition therapy will generate economically significant benefits to Medicare beneficiaries and to the Medicare program itself, through reduced healthcare expenditures (1). Oxford Health Plan has found the costs for Medicare members in its high-risk nutrition intervention to be $30 per member per month (PMPM) lower over the subsequent 24-month period compared to a matched control group. In an attempt to determine whether specific targeting might further improve the cost-effectiveness of the nutrition intervention, Oxford examined outcomes among particular subgroups. Members with selected diagnoses achieved even greater savings. For example, those with diabetes and neurological diseases experienced savings of $73 PMPM and $79 PMPM, respectively. Sheils and colleagues estimated the cost savings that resulted from providing medical nutrition therapy to Group Health Cooperative members with diabetes and cardiovascular disease, age 55 and over (45). Medical nutrition therapy was defined as the assessment of the nutrition status of a client followed by nutrition therapy ranging from diet modification to the administration of enteral and parenteral nutrition. Provision of medical nutrition therapy to persons with diabetes was associated with a 9.5 percent reduction in utilization of hospital services and a 24 percent reduction in physician services. Similarly, provision of medical nutrition therapy to persons with cardiovascular disease was associated with an 8.6 percent reduction in utilization of hospital services and a 17 percent reduction in physician services (45). Nutritional supplementation has been shown to favorably influence clinical and utilization outcomes for other conditions as well. Tepaske and colleagues provided patients aged 70 years and older undergoing cardiac surgery with nutritional supplementation and they demonstrated a reduction in complications such as infection (46). Nutritional interventions for persons with chronic obstructive
59
pulmonary disease have led to improved lung function, exercise capacity, and sense of well being (47). Nutritional supplementation has also been shown to reduce hospital length of stay in burn patients (8). Nutritional interventions in subacute settings offer the potential for improved outcomes at lower cost. Hip fracture is a common problem encountered in the subacute setting. Oral nutritional supplementation to older adults with hip fracture has been associated with a reduction in time to recovery, a reduction in the rate of complications and a reduction in length of stay by approximately 50 percent (47-50).
Reference List
(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) (17) (18) Institute of Medicine. The role of nutrition in maintaining health in the nations elderly: evaluating coverage of nutrition services for the Medicare population. Institute of Medicine, 2000. Morley JE, Silver AJ Nutritional issues in nursing home care. Annals of Internal Medicine 1995; 123:850-859. Reilly J, Hull S, Albert N, Waller A, Bringardener S. Economic impact of malnutrition: a model system for hospitalized patients. Journal of Parenteral and Enteral Nutrition 1988; 12(4):371-376. Friedmann JM. Predicting early nonelective hospital readmission in nutritionally compromised older adults. American Journal of Clinical Nutrition 1997; 65:1714-1720. Sullivan DH. Risk factors for early hospital readmission in a select population of geriatric rehabilitation patients: the significance of nutritional status. Journal of the American Geriatrics Society 1992; 40(8):792-798. Van Nes MC, Herrmann FR, Gold G, Michel JP, Rizzoli R. Does the Mini-Nutritional Assessment predict hospitalization outcomes in older people? Age and Ageing 2001; 30:221-226. Covinsky KE, Martin GE, Beyth RJ, Justice AC, Sehgal AR, Landefeld CS. The relationship between clinical assessments of nutritional status and adverse outcomes in older hospitalized medical patients. Journal of the American Geriatrics Society 1999; 47:532-538. Barents Group KPM. The clinical and cost-effectiveness of medical nutrition therapy: evidence and estimates of potential Medicare savings from the use of selected nutrition interventions. 1996. Washington, DC.., The Nutrition Screening Initiative. 6-20-1996. Robinson G, Goldstein M, Levine G. Impact of nutritional status on DRG length of stay. Journal of Parenteral and Enteral Nutrition 1987; 11:49-51. Weinsier RL, Heimburger DC, Samples CM, Dimick AR, Birch R. Cost-containment: a contribution of aggressive nutritional support in burn patients. JBCR 1985; 6(5):436-441. Weinsier RL, Hunker EM, Krumdieck CL, Butterworth CE. Hospital malnutrition: a prospective evaluation of general medical patients during the course of hospitalization. American Journal of Clinical Nutrition 1979; 32:418-426. Dardaine V, Dequin P, Ripault H, Constans T, Ginies G. Outcome of older patients requiring ventilator support in the intensive care unit: Impact of nutritional status. Journal of the American Geriatrics Society 2001; 49:564-570. Haydock D, Hill G. Impaired wound healing in surgical patients with varying degrees of malnutrition. Journal of Parenteral and Enteral Nutrition 1986; 10(6):550-554. Epstein AM, Read JL, Hoefer M. The relation of body weight to length of stay and charges for hospital services for patients undergoing elective surgery: a study of two procedures. American Journal of Public Health 1987; 77:993-997. Chima CS, Barco K, Dewitt MLA, Maeda M, Teran JC, Mullen KD. Relationship of nutritional status to length of stay, hospital costs, and discharge status of patients hospitalized in the medicine service. Journal of the American Dietetic Association 1997; 97:975-978. Johnson L. Malnutrition. In: Reuben D, Yoshikawa T, Besdine R, editors. Geriatrics Review Syllabus. Dubuque: Kendall Hunt, 1996: 145-152. Wasson JH, Ahles T, Bazos D, Bracken A, Patterson JA, Johnson DJ. Streamlining nutritional care for the physicians office. European Journal of Clinical Nutrition 1999; 53(Supplement 2):S97-S100. Manson A, Shea S. Malnutrition in elderly ambulatory medical patients. American Journal of Public Health 1991; 81(9):1195-1197.
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(19) Roubenoff R, Roubenoff RA, Preto J, Balke CW. Malnutrition among hospitalized patients: a problem of physician awareness. Archives of Internal Medicine 1987; 147(8):1462-1465. (20) Sullivan DH, Moriarty MS, Chernoff R, Lipschitz DA. Patterns of care and analysis of the quality of nutritional care routinely provided to elderly hospitalized veterans. Journal of Parenteral and Enteral Nutrition 1989; 13(3):249-254. (21) Ryan AS, Craig LD, Finn SC. Nutrient intakes and dietary patterns of older Americans: a national study. Journal of Gerontology A Biological and Medical Sciences 1992; 47(5):M145-M150. (22) Wallace JI, Schwartz R S, LaCroix A, Uhlmann RF, Pearlman RA. Involuntary weight loss in older outpatients: incidence and clinical significance. Journal of the American Geriatrics Society 1995; 43(4):329-337. (23) Jensen GL, et al. Weight loss and functional decline (in press). Journal of the American Geriatrics Society 2001;000-000. (24) The HMO Workgroup on Care Management. Risk Screening Medicare Members Revisited. 2000. (25) Corti MC, Guralnik JM, Salive ME, Sorkin JD. Serum albumin level and physical disability as predictors of mortality in older persons. JAMA 1994; 272(13):1036-1042. (26) Jensen GL, Kita K, Fish J, Heydt D, Frey C. Nutrition risk screening characteristics of rural older persons: relation to functional limitations and health care charges. American Journal of Clinical Nutrition 1997; 66:819-828. (27) Anderson CF, Moxness K, Meister J, Burritt MF. The sensitivity and specificity of nutrition-related variables in relationship to the duration of hospital stay and complications. Mayo Clinical Proceedings 2001; 59:477-483. (28) Herrmann FR, Safran C, Levkoff SE, Minaker KL. Serum albumin level on admission as a predictor of death, length of stay, and readmission. Archives of Internal Medicine 1992; 152:125-130. (29) Ferguson RP, OConner P, Crabtree B, Batchelor A, Mitchell J, Coppola T. Serum albumin and prealbumin as predictors of clinical outcomes of hospitalized elderly nursing home residents. Journal of the American Geriatrics Society 1993; 41:545-549. (30) Reuben DB, Greendale GA, Harrison GG. Nutrition screening in older persons. Journal of the American Geriatrics Society 1995; 43:415425. (31) Posner B, Jette A, Smith K, Miller D. Nutrition and health risks in the elderly: the nutrition screening initiative. American Journal of Public Health 1993; 83(7):972-978. (32) Boult C, Krinke U, Urdangarin C, Skarin V. The validity of nutritional status as a marker for future disability and depressive symptoms among high-risk older adults. Journal of the American Geriatrics Society 1999; 47(8):995-999. (33) Jensen GL, Friedmann JM, Coleman CD, Smickilas-Wright H. Screening for hospitalization and nutritional risks among community-dwelling older persons. American Journal of Clinical Nutrition 2001; 74(2):201-205. (34) Pacala J, Boult C, Reed R, Aliberti E. Predictive validity of the PRA instrument among older recipients of managed care. Journal of the American Geriatrics Society 1997; 45(5):614-617. (35) Kerekes J, Thornton O. Incorporating nutritional risk screening with case management initiatives. Nutrition in Clinical Practice 1996; 11(3):95-97. (36) Sahyoun N, Jacques P, Dallal G, Russell R. Nutrition screening initiative checklist may be a better awareness/educational tool than a screening one. Journal of the American Dietetic Association 1997; 97(7):760-764. (37) Rush D. Evaluating the nutrition screening initiative (editorial). Am J Public Health 1993; 83(7):944-945. (38) Tayback M, Kumanyika S, Chee E. Body weight as a risk factor in the elderly. Archives of Internal Medicine 1989; 150:1065-1072. (39) Harris T, Cook E, Garrison R, Higgins M, Kannel W, Goldman L. Body mass index and mortality among nonsmoking older persons. JAMA 1988; 259(10):1520-1524. (40) Galanos A, Pieper C, Cornoni-Huntley J, Bales C, Fillenbaum G. Nutrition and function: is there a relationship between body mass index and the functional capabilities of community-dwelling elderly? Journal of the American Geriatrics Society 1994; 42(4):369-373. (41) Black D, Sciacca J, Coster D. Extremes in body mass index: probability of healthcare expenditures. Preventive Medicine 1994; 23(3):385393. (42) Coombs J, Welman N. Nutrition as prevention: beyond an apple a day. HMO Magazine 1994; Sept/Oct. (43) Reuben DB, Effros RB, Hirsch SH, Zhu X, Greendale GA. An in-home nurse-administered geriatric assessment for hypoalbuminemic older persons: development and preliminary experience. Journal of the American Geriatrics Society 1999; 47:1244-1248. (44) Klein G, Kita K, Fish J, Sinkus B, Jensen G. Nutrition and health for older persons in rural America: a managed care model. Journal of the American Dietetic Association 1997; 97(8):885-888. (45) Sheils JF, Rubin R, Stapleton DC. The estimated costs and savings of medical nutrition therapy: the Medicare populaton. Journal of the American Dietetic Association 1999; 99(4):428-435.
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(46)
Tepaske R, te Velthuis H, Oudemans-van Straaten HM, Heisterkamp SH, Van Deventer SJH, et al. Effect of preoperative oral immuneenhancing nutritional supplement on patients at high risk of infection after cardiac surgery: a randomised placebo-controlled trial. Lancet 2001; 358:696-701. Akner G, Cederholm T. Treatment of protein-energy malnutrition in chronic nonmalignant disorders. American Journal of Clinical Nutrition 2001; 74(1):6-24. Delmi M, Rapin CH, Bengoa JM DPVH, Bonjour JP. Dietary supplementation in elderly patients with fractured neck of the femur. Lancet 1990; 335(8696):1013-1016. Bastow MD, Rawlings J, Allison SP. Benefits of supplementary tube feeding after fractured neck of femur: a randomised controlled trial. BMJ 1983; 287:1589-1592. Avenell A. Nutritional supplementation for hip fracture aftercare in the elderly. Cochrane Database of Systematic Reviews 2001;(1):1-45.
(47) (48) (49) (50)
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Section 8
Urinary Incontinence
Clinical Vignette
Mrs. S. is a 74-year-old retired school teacher who had gradually reduced her regular social activities and walking program because of her embarrassing urinary incontinence. She became progressively more deconditioned, her osteoarthritis worsened, and she experienced two urinary tract infections that required a total of three ambulatory visits to address. During screening and assessment conducted by her MCO, Group Health Cooperative, a registered nurse learned of her problem and taught her Kegel exercises designed to strengthen the muscles that control urination. Her physician evaluated symptoms and determined that she had features of both stress and urge incontinence. The physician asked her to keep a bladder diary, reinforced the 90-day trial of Kegel exercises, and referred her to a physical therapist-led incontinence program that taught specific behavioral techniques and general patient education to help her manage this condition. Three months later, her incontinence had improved to the point that she had resumed her previously active lifestyle, including regular exercise. She was very satisfied with her care and required no further visits over the subsequent year for either her osteoarthritis or her incontinence.

MCOs should:

Seek to identify older members with urinary incontinence and initiate effective treatment. Offer an incontinence self-management program, led by an appropriately trained practitioner, for motivated and cognitively intact members suffering from urge or stress incontinence. Support primary care management of incontinence either by offering guided incontinence selfmanagement programs or by establishing a partnership with a community-based agency that provides this service. Empower members to discuss their incontinence symptoms with their primary care practitioners.
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Urinary incontinence is treatable, and improvement or even cure can be achieved for the majority of older individuals (1-5). Yet despite the high prevalence, negative effect on quality of life, and availability of effective treatment, health care practitioners remain unaware of more than half of their patients with urinary incontinence (5). This underrecognition, combined with lack of knowledge about effective interventions, creates significant barriers to improving incontinence management. Untreated urinary incontinence heightens the risk of infection, social isolation and depression, loss of sleep with daytime somnolence, deconditioning, falls and associated fractures, and nursing home admission (1;6-12). Urinary incontinence has financial implications for MCOs. Conservative estimates of the annual direct cost of caring for community-residing persons with incontinence exceed $11 billion (13;14). One study determined that urinary incontinence was the most costly diagnosis among Medicare beneficiaries receiving home health care (15). Through implementation of evidence-based programs for urinary incontinence, MCOs can significantly improve care of this condition, thereby reducing both morbidity and associated costs (11). Urinary incontinence affects 15-30 percent of persons 65 and older living in the community (11). The significant burden of urinary incontinence on health-related quality of life in older adults is striking (7). Older persons with incontinence who are otherwise in good health (i.e., are not frail) frequently rate their health status as poor (6;16). The stigma, embarrassment, and inconvenience of this condition often lead to a cascade of adverse interrelated events, culminating in functional dependence and reduced quality of life (12;17;18). For the purpose of this discussion, the etiology of incontinence is categorized with respect to the bladders main functions of storage and emptying. This categorization is useful for understanding the underlying etiology of an older persons condition and guiding further evaluation and treatment. The five main types of urinary incontinence include:
Bladder storage disorders
Urge incontinence: the bladder size is normal, but the bladder contracts before the older person can get to a toilet. Stress incontinence: the bladder size is normal, but the muscles that oppose loss of urine are weak.
Bladder emptying disorders

Detrusor underactivity: the bladder is distended due to an inability to contract and empty urine. Outlet obstruction: the bladder is distended due to obstruction of the urine outflow track.
Intact bladder
Functional incontinence: the bladder size is normal, but the person does not get to the toilet in time due to mobility limitations or cognitive decline that interferes with interpretation of the bodys signal for the need to urinate.
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Section 8 Urinary Incontinence

Urinary incontinence becomes more common with age but is not an inevitable consequence of aging. It occurs more frequently in women than in men. In women contributing factors include childbirth, loss of estrogen associated with menopause, and obesity. In men they include an enlarged prostate or having had prostate surgery. Medications can complicate incontinence, especially diuretics, sedatives, decongestants (e.g., pseudoephedrine), and anticholinergic agents (e.g., antihistamines, some types of antidepressants). Neurologic disruption of the bladder from stroke and other conditions occur in both men and women.

Given that incontinence affects 15-30 percent of members, nearly every older member should be screened (11). Screening can be conducted in several ways, including through new member questionnaires and as part of a routine primary care visit (19). A commonly used screening question for urinary incontinence in women inquires, During the last 12 months, have you ever lost urine and gotten wet? For those who respond affirmatively, a follow-up question asks, Have you lost your urine on at least 6 separate days? Previously validated questions in men include, How often do you have difficulty holding your urine until you can get to a toilet? Potential responses include daily or nightly, several times per week, once per week, less than weekly, or never (16). The PCP, a nurse, or a health educator working from a specific protocol can conduct the assessment for members who respond affirmatively to the screening question. The most important goal of the assessment is to determine the impact of incontinence on the members function and quality of life by asking questions such as have you restricted activities or lifestyle because of this problem? The assessment should also inquire as to the duration of the problem and the frequency of episodes. Associated precipitants may provide insight into the underlying etiology. For example, if the symptoms are loss of urine with sneezing or laughing, the etiology is likely stress incontinence. A history of childbirth or surgery in the abdomen or pelvis is an important component of the assessment, as is a history of neurologic problems (e.g., stroke). Additional essential components of the assessment include performing a urinalysis to determine whether infection is present, performing a post-void residual (using either a catheter or ultrasound device to measure the amount of urine left after urination is complete) to evaluate for an obstructed bladder, and a thorough review of both prescribed and over-the-counter medications. If neither infection nor obstruction is present (the two areas where oversight could lead to serious complications and require immediate attention), the member can be treated conservatively as described below. The impact of urinary incontinence on quality of life and function is highly variable (12;20). Thus, to effectively manage urinary incontinence practitioners need to first determine whether the condition is present and then assess the individual members preferences and motivation for behavioral change and pursuit of treatment. To make an informed decision, the member needs information that helps them to distinguish aging from disease and provides them with a realistic estimate of what can be expected from treatment. Experience has demonstrated that not all members desire to have further evaluation of their incontinence. Member preferences for forgoing treatment should be respected.
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Interventions
The three main treatment approaches for urinary incontinence are guided self-management therapy, pharmacologic therapy, and surgery. The conservative approaches that follow will be effective for the vast majority of members. A small minority of patients, however, may need additional evaluation and treatment. The underlying etiologies of incontinence can be grouped for the purpose of tailoring treatment. Members with urge and stress incontinence respond to different therapeutic approaches than those with obstructive symptoms. For members suffering from urge or stress incontinence who are motivated and cognitively intact, first line treatment should include brief (e.g., eight weeks) guided incontinence self-management therapy that teaches skills and strategies for preventing incontinence. Patients are taught biofeedback techniques to help them identify the pelvic muscles that control urination and teach them how to contract and relax these muscles selectively. In subsequent visits, patients are given specific exercise techniques designed to strengthen the muscles that control urination and are taught how to respond adaptively to the sensation of urinary urgency. Interventions may also include instruction for urinating at specific time intervals that are progressively widened (i.e., scheduled voiding). Outside of classes, patients are encouraged to follow specific regimens at home to reinforce class teaching. These interventions require monitoring and follow-up by an appropriately trained practitioner23 to ensure that they are being performed correctly and that the member is achieving symptomatic improvement. Many older adults respond to guided incontinence self-management therapy alone and do not require medications or surgery. In a randomized trial, this therapy was found to be effective in reducing incontinence in 81 percent of older women within eight weeks (2). This compares with 69 percent of women receiving pharmacologic therapy. Perhaps even more compelling, compared with women receiving pharmacologic therapy, those undergoing guided self-management therapy were more likely to perceive themselves as improved (74 percent vs. 51 percent), and far fewer were interested in changing to another form of therapy (14 percent vs. 76 percent). MCOs can also facilitate access to effective treatment programs. Despite the strong evidence for guided self-management therapy in improving incontinence and its potential for averting costs associated with pharmacologic or surgical treatment approaches, these programs are not uniformly available. MCOs can help members and their PCPs identify programs that offer this service at convenient locations in the community. Alternatively, the MCO may need to create a mechanism to refer members to established programs in the community. Both Group Health Cooperative and Kaiser Permanente, Colorado Division, offer group incontinence self-management therapy classes. Group Health Cooperative has evaluated over 100 graduates of their program. After 3 months, 73 percent of members reported that they were confident or much more confident in their ability to manage their incontinence. The Lahey Clinic offers incontinence selfmanagement training led by a trained registered nurse based in a urology clinic. Oxford Health Plan provides a similar service led by a physical therapist in the members home. Thus, because of its superior
23
Examples of practitioners include a urologist, gynecologist, trained registered nurse, or physical therapist.
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effectiveness, low side effect profile, and favorable effect on cost, the Workgroup views guided incontinence self-management as first-line therapy. In contrast to members with urge or stress incontinence, those with obstructive symptoms usually require urology referral for further evaluation. Members with detrusor underactivity may respond to scheduled voiding or may need instruction in how to catheterize themselves. Members with functional incontinence (e.g., due to severe arthritis or cognitive impairment) are best managed with scheduled voiding, possibly combined with the use of a urinal or commode. MCOs can play an essential role in improving the treatment of incontinence. One critical role is in screening and assessment. For example, Oxford Health Plan provides members who respond affirmatively to the initial incontinence screen with follow-up telephone assessment conducted by trained registered nurses who use defined protocols. Because members with incontinence are often reluctant to raise the topic of incontinence with their PCP, those identified with this condition are given a structured list of key questions for their PCP, thereby empowering them to initiate the discussion. Member-initiated evaluation has been shown to be one of the most effective strategies for improved management of incontinence and other geriatric conditions (21).
Implementation barriers can occur at the level of the MCO, the PCP, or the member. MCO barriers include the absence of a screening and assessment program, lack of access to a guided incontinence self-management program, or lack of coverage for such a program. PCP barriers include a mistaken belief that incontinence is a normal part of aging and a lack of training in appropriate diagnosis and management. In addition, PCPs may not have adequate resources for performing an assessment (e.g., obtaining a post-void residual test). Member barriers include a belief that incontinence is part of normal aging, reluctance to bring the topic up for discussion with the PCP, or a lack of readiness for behavioral change with respect to the customized treatment plan.
Economic Impact
Treating urinary incontinence using these low-cost therapeutic interventions has the potential for generating costs savings for both the MCO and members. For example, treating incontinence can reduce the need for medications (if prescription medications are a covered benefit) along with ambulatory and emergency utilization attributed to the drug-related confusion and cognitive deficits associated with these medications (22). Further, treatment can obviate the need for referrals to urology and gynecology and thereby reduce associated procedures such as cystoscopy, cystometry, and surgery. The cost of incontinence supplies (e.g., undergarments and pads) are largely borne by older members. Improved incontinence can significantly reduce members out-of-pocket monthly expenditures for such supplies. Comorbid conditions associated with incontinence are common and treatable. These include skin irritation, pressure ulcers, falls and associated fractures, and urinary tract infections. Because these associated conditions contribute to higher utilization of hospital, subacute, and skilled home health care, the economic implications of effective incontinence management can be substantial (11;13;14;23). In light of the considerable effects incontinence has on quality of life, MCOs may
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also benefit from enhanced member retention as a result of mitigation of the adverse effects of incontinence on quality of life.
Reference List
(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) Fantl J, Wyman J, McClish D, Harkins S, Elswick R, et al. Efficacy of bladder training in older women with urinary incontinence. JAMA 1991; 265(5):609-613. Burgio K, Locher J, Goode P, Hardin M, McDowell B, et al. Behavioral vs. drug treatment for urge urinary incontinence in older women: a randomized controlled trial. JAMA 1998; 280(23):1995-2000. Wells TJ, Brink CA, Diokno AC, Wolfe R, Gillis GL. Pelvic muscle exercises for stress urinary incontinence in elderly women. Journal of the American Geriatrics Society 1991; 39(785):791. McDowell B, Engberg S, Sereika S, Donovan N, Jubeck M, et al. Effectiveness of behavioral therapy to treat incontinence in homebound older adults. Journal of the American Geriatrics Society 1999; 47(309):319. Urinary incontinence in adults. JAMA 1989; 261(18):2685-2690. Burgio K, Ouslander J. Effects of urge urinary incontinence on quality of life in older people. Journal of the American Geriatrics Society 1999; 47(8):1032-1033. Wyman JF. Quality of life for older adults with urinary incontinence. Journal of the American Geriatrics Society 1998; 46(778):779. Dugan E, Cohen S, Bland D, Preisser J, Davis C, et al. The association of depressive symptoms and urinary incontinence among older adults. Journal of the American Geriatrics Society 2000; 48(4):413-416. Brown J, Posner S, Stewart S. Urge incontinence: new health-related quality of life measures. Journal of the American Geriatrics Society 1999; 47(8):980-988. DuBeau C, Kiely D, Resnick N. Quality of life impact of urge incontinence in older persons: a new measure and conceptual structure. Journal of the American Geriatrics Society 1999; 47(8):989-994. Urinary Incontinence Guideline Panel. Urinary incontinence in adults: clinical practice guideline. AHCPR Pub No. 92-0038. 1992. Rockville MD, Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services. Fultz NH, Herzog AR. Self-reported social and emotional impact of urinary incontinence. Journal of the American Geriatrics Society 2001; 49:892-899. Hu T. Impact of urinary incontinence on health-care costs. Journal of the American Geriatrics Society 1990; 38:292-295.
(14) Wilson L, Brown JS, Shin GP, Luc KO, Subak LL. Annual direct cost of urinary incontinence. Obstetrics and Gynecology 2001; 98(3):398406. (15) (16) (17) (18) (19) (20) (21) (22) (23) Ruther M, Helbing C. Health care financing trends: use and cost of home health care services under Medicare. Health Care Financing Review 1988; 10:105-108. Johnson II T, Kincade J, Bernard S, Busby-Whitehead J, Hertz-Picciotto, DeFriese G. The association of urinary incontinence with poor selfrated health. Journal of the American Geriatrics Society 1998; 46:693-699. Wyman JF, Harkins SW, Fantl JA. Psychosocial impact of urinary incontinence in the community-dwelling elderly population. Journal of the American Geriatrics Society 1990; 38:282-288. Tinetti ME, Inouye S, Gill TM, Doucette JT. Shared risk factors for falls, incontinence, and functional dependence: unifying the approach to geriatric syndromes. JAMA 1995; 273(17):1348-1353. The HMO Workgroup on Care Management. Risk Screening Medicare Members Revisited. 2000. Johnson II T, Ouslander JG. The shifting impact of UI. Journal of the American Geriatrics Society 2001; 49:998-999. Reuben D, Maly R, Hirsch S, Frank J, Oakes A, et al. Physician implementation of and patient adherence to recommendations from comprehensive geriatric assessment. American Journal of Medicine 1996; 100:444-451. Katz I, Sands L, DiFilippo S, Boyce A, DAngelo K. Identification of medications that cause cognitive impairment in older people: the case of oxybutin chloride. Journal of the American Geriatrics Society 1998; 46(1):8-13. Brown JS, Vittinghoff EF, Wyman JF, Stone KL, Nevitt MC, et al. Urinary incontinence: does it increase risk for falls and fractures? Journal of the American Geriatrics Society 2000; 48(7):847-848.
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Appendix
Illustrative Process and Outcome Measures

Programs that address geriatric conditions can be evaluated using both process and outcome measures. This appendix provides a brief overview of potential measures. In general, process measures assess specific changes in the delivery of care, while outcome measures assess the result or effectiveness of such care. These measures can be derived from multiple sources, including patient or caregiver selfreport, chart abstraction, administrative data, or pharmacy records. Although an in-depth discussion of this topic is beyond the scope of this report, several excellent resources are available (1-3). There is no single optimal measure for any given situation. Rather, the measure should reflect the objective of the intervention. In some cases, the measure, particularly if it reflects process rather than outcome, may be an interim only. For example, an evaluation of financial return resulting from a new program may require one to two years to complete. The ability to demonstrate that an interim improvement has occurred in specific care processes can be critical to sustaining the new program until the financial evaluation is available. Both process and outcome measures can, in some circumstances, help MCOs fulfill regulatory requirement. For example, the Center for Medicare and Medicaid Services (CMS) requires that MCOs, as part of their quality improvement efforts, implement programs that enhance the health status and function of older members. The illustrative process and outcome measures provided in Table 1 offer MCOs concrete examples to facilitate the implementation of new programs designed to improve geriatric care. The Workgroup hopes that the individual sections of this report and this appendix will inspire medical directors and operations leaders to champion new programs that better meet the needs of older members in their respective organizations.
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Reference List
(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) Kane RL. Understanding health care outcomes research. Gaithersburg, MD: Aspen Publishers, 1997. McDowell I, Newell C, editors. Measuring health. New York: Oxford University Press, 1996. Kane RL, Kane RA (editors). Assessing older persons: measures, meaning, and practical applications. New York : Oxford University Press, 2000. U.S.Department of Health and Human Services, Centers for Disease Control and Prevention. Physical activity and health: a report of the surgeon general executive summary. 9-14. 1996. Cardiovascular Health Branch, ed. Project PACE. Physician Manual. Atlanta, GA: Centers for Disease Control; 1992. Buchner D, Cress M, Wagner E, DeLateur B, Price R, et al. The Seattle FICSIT/MoveIt study: the effect of exercise on gait and balance in older adults. Journal of the American Geriatrics Society. 1993;41:321-25. Arfken CL, Lach HW, Birge SL, Miller JP. The prevalence and correlates of fear of falling in elderly persons living in the community. American Journal of Public Health 1994;84(4):565-570. Monane M, Matthias D, Nagle B, Kelly M. Improving prescribing patterns for the elderly through an online drug utilization review intervention: a system linking the physician, pharmacist and computer. JAMA. 1998;280:1249-52. Hanlon J, Weinberger M, Samsa G, Schmader K, Uttech K, et al. A randomized, controlled trial of a clinical pharmacist intervention to improve inappropriate prescribing in elderly outpatients with polypharmacy. American Journal of Medicine. 1996;100:428-37. Hepburn KW, Tornatore J, Center B, Ostwald SW. Dementia family caregiver training: affecting beliefs about caregiving and caregiving outcomes. Journal of the American Geriatrics Society. 2001;49:450-457. Yesavage JA, Brink TL, Rose TL, Lum O, Huang V, et al. Development and validation of a geriatric depression screening scale: a preliminary report. Journal of Psychiatric Research. 1983;17:37-49. Wells KB, Sherbourne CD, Schoenbaum M, Duan N, Meredith LS, et al. Impact of disseminating quality improvement programs for depression in managed primary care: a randomized controlled trial. JAMA. 2000;283:212-20. Jensen GL, Friedmann JM, Coleman CD, Smickilas-Wright H. Screening for hospitalization and nutritional risks among community-dwelling older persons. American Journal of Clinical Nutrition. 2001;74:201-5. Reuben DB, Effros RB, Hirsch SH, Zhu X, Greendale GA. An in-home nurse-administered geriatric assessment for hypoalbuminemic older persons: development and preliminary experience. Journal of the American Geriatrics Society. 1999;47:1244-48. Fantl J, Wyman J, McClish D, Harkins S, Elswick R, Taylor J et al. Efficacy of bladder training in older women with urinary incontinence. JAMA. 1991;265:609-13. Brown J, Posner S, Stewart S. Urge incontinence: new health-related quality of life measures. Journal of the American Geriatrics Society. 1999;47:980-988.
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Appendix
Geriatric Condition
Measure
Type of Measure
What It Measures/Representative Items
Reference
Physical Inactivity
Activity Recall or Diaries Physician-based Assessment and Counseling for Exercise (PACE) Falls Diaries
Frequency
In the past week, how many days have you accumulated 30 minutes or more of moderate exercise? Choose the ONE statement that best describes your CURRENT level of physical activity: (11 statements ranging from I do not exercise regularly to I do vigorous exercise 6 or more times per week). Monthly return-addressed postcards documenting number of falls, whether or not an injury was sustained, and whether treatment was obtained. Asks whether fear of falling interferes with performing daily activities. Proportion of older patients who are no longer prescribed long-acting benzodiazepines (e.g., Valium and related medications). Proportion of older patients who experience an adverse drug events. Proportion of informal caregivers to a patient with dementia who have received knowledge and skills training. Proportion of older patients and caregivers who are referred to the Alzheimers Association for supportive services. Proportion of older patients previously identified as meeting criteria for depression who experience a significant reduction in symptom score. Proportion of older patients identified with depression who are receiving medication and/or behavioral therapy . Proportion of at-risk older patients who meet desired weight gain target. Proportion of at-risk older patients who have a tailored plan of care to meet their nutritional needs. Two week bladder diaries that detail the time of every void and incontinent episode, volume loss (large or small) and any associated circumstances. In the past 4 weeks, how often has your urinary leakage interfered with going places, exercise activities, your self image, or your relationships?
Self-rated Activity
Frequency
Falls Fear of Falling Self-efficacy
Reduction of Long-acting Benzodiazepines Reduction of Adverse drug events Caregiver Support
Process of Care
Process of Care
Process of Care
10
Dementia Alzheimers Association Referral Geriatric Depression Scale Depression Treatment for Depression Weight Change Undernutrition Nutrition Care Plan Process of Care Process of Care Process of Care
Quality of Life
11
12
Risk Reduction
13
14
Bladder Diaries Urinary Incontinence UrgeUrinary Incontinence Impact Scale
Frequency
15
Quality of Life
16
71

Improving The Care of Older Adults Full Report

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Improving the Care of Older Adults with Common Geriatric Conditions

A Report from the HMO Workgroup on Care Management

Improving the Care of Older Adults with Common Geriatric Conditions

Peter D. Fox Chair

Improving the Care of Older Adults with Common Geriatric Conditions

Bonnie Hillegass, RN, MHA

Danielle Butin, MPH, OTR

Jan Clarke, MD, MPH

Joy Luque, RN, BSN, CCM

*Eric A. Coleman, MD, MPH

Richard D. Della Penna, MD

Ingrid Venohr, RN, PhD

Nancy A. Whitelaw, PhD

Peter D. Fox, PhD

Brian Hayes, MD, CMCE

* Served as scientific consultant Served as Convener and Chair

Improving the Care of Older Adults with Common Geriatric Conditions

Illustrative Process and Outcome Measures

Improving the Care of Older Adults with Common Geriatric Conditions

Improving the Care of Older Adults with Common Geriatric Conditions

Physical Inactivity Falls Medication-related Complications Dementia

Depression Undernutrition Urinary Incontinence

Improving the Care of Older Adults with Common Geriatric Conditions

Recommendations for Managed Care Organizations

Improving the Care of Older Adults with Common Geriatric Conditions

Nature of the Problem

Target Population and Risk Factors

Section 2 Physical Inactivity

Screening and Assessment

The activity or activities do not necessarily need to be performed continuously.

Improving the Care of Older Adults with Common Geriatric Conditions

The video can be obtained by calling 1-800-222-2225 or online at http://www.nih.gov/nia.

Section 2 Physical Inactivity

Improving the Care of Older Adults with Common Geriatric Conditions

Section 2 Physical Inactivity

Improving the Care of Older Adults with Common Geriatric Conditions

Section 2 Physical Inactivity

Recommendations for Managed Care Organizations

Improving the Care of Older Adults with Common Geriatric Conditions

Nature of the Problem

Target Population and Risk Factors

This category includes anti-psychotics, tricyclic antidepressants, and benzodiazepines.

Screening and Assessment

Longer time intervals are associated with reduced reporting accuracy.

Improving the Care of Older Adults with Common Geriatric Conditions

Improving the Care of Older Adults with Common Geriatric Conditions

Improving the Care of Older Adults with Common Geriatric Conditions

Recommendations for Managed Care Organizations

Improving the Care of Older Adults with Common Geriatric Conditions

Nature of the Problem

Target Population and Risk Factors

Section 4 Medication-Related Complications

Screening and Assessment

Improving the Care of Older Adults with Common Geriatric Conditions

Section 4 Medication-Related Complications

Improving the Care of Older Adults with Common Geriatric Conditions

Section 4 Medication-Related Complications

Improving the Care of Older Adults with Common Geriatric Conditions

Section 4 Medication-Related Complications

Recommendations for Managed Care Organizations

Improving the Care of Older Adults with Common Geriatric Conditions

Nature of the Problem