Applegate W, Deyo R, Kramer A, Meehan S
Department of Medicine, University of Tennessee, Memphis.
J Am Geriatr Soc. 1991 Sep;39(9 Pt 2):2S-7S. doi: 10.1111/j.1532-5415.1991.tb05926.x.
In the last decade the concept of geriatric evaluation and management (GEM) has been widely discussed in the literature. Studies of GEM have occurred primarily in three settings: inpatient units, outpatient clinics, and specialized types of home care. We have reviewed the literature, focusing on randomized trials, to determine the strength of the evidence for the efficacy of these interventions. Two single-site randomized controlled trials of inpatient GEM units have been conducted and indicate that such units that provide care to targeted disabled older patients probably have a favorable impact on subsequent physical function, rates of institutionalization, and mortality. Two randomized trials of inpatient GEM consultation teams have been conducted. The trial that did not target high-risk individuals showed no benefit while the trial that did target an at-risk group showed that those receiving the service had improvements in mental status and short-term mortality. The results of randomized trials of outpatient GEM clinics to date have been unimpressive. Two trials of in-home GEM by a trained observer tended to show that the service resulted in a reduction in mortality. To date randomized trials of GEM have been very heterogeneous in terms of the type of assessment and subsequent care, the site in which services are delivered, and the manner in which patients are selected for the studies. This limits the ability to compare and extrapolate across studies. In the future there is a need to better clarify the selection of study participants, the exact structure of the assessment intervention provided, and the elements of successful interventions that may be most critical to insuring a good outcome.
在过去十年中，老年评估与管理（GEM）的概念在文献中得到了广泛讨论。GEM的研究主要在三种环境中进行：住院病房、门诊诊所和特定类型的家庭护理。我们回顾了文献，重点关注随机试验，以确定这些干预措施有效性的证据强度。已经进行了两项关于住院GEM病房的单中心随机对照试验，结果表明，为有针对性的残疾老年患者提供护理的此类病房可能会对后续身体功能、机构化率和死亡率产生有利影响。已经进行了两项关于住院GEM咨询团队的随机试验。未针对高危个体的试验未显示出益处，而针对高危群体的试验表明，接受该服务的患者在精神状态和短期死亡率方面有所改善。迄今为止，门诊GEM诊所的随机试验结果并不理想。两项由经过培训的观察员进行的家庭GEM试验倾向于表明，该服务可降低死亡率。迄今为止，GEM的随机试验在评估类型和后续护理、提供服务的地点以及选择患者进行研究的方式方面差异很大。这限制了跨研究进行比较和推断的能力。未来需要更好地明确研究参与者的选择、所提供评估干预的确切结构以及成功干预的要素，这些要素可能对确保良好结果最为关键。
