Stuck A E, Aronow H U, Steiner A, Alessi C A, Büla C J, Gold M N, Yuhas K E, Nisenbaum R, Rubenstein L Z, Beck J C
Department of Medicine, University of California, Los Angeles, USA.
N Engl J Med. 1995 Nov 2;333(18):1184-9. doi: 10.1056/NEJM199511023331805.
The prevention of disability in elderly people poses a challenge for health care and social services. We conducted a three-year, randomized, controlled trial of the effect of annual in-home comprehensive geriatric assessment and follow-up for people living in the community who were 75 years of age or older. The 215 people in the intervention group were seen at home by gerontologic nurse practitioners who, in collaboration with geriatricians, evaluated problems and risk factors for disability, gave specific recommendations, and provided health education. The 199 people in the control group received their regular medical care. The main outcome measures were the prevention of disability, defined as the need for assistance in performing the basic activities of daily living (bathing, dressing, feeding, grooming, transferring from bed to chair, and moving around inside the house) or the instrumental activities of daily living (e.g., cooking, handling finances and medication, housekeeping, and shopping), and the prevention of nursing home admissions.
At three years, 20 people in the intervention group (12 percent of 170 surviving participants) and 32 in the control group (22 percent of 147 surviving participants) required assistance in performing the basic activities of daily living (adjusted odds ratio, 0.4; 95 percent confidence interval, 0.2 to 0.8; P = 0.02). The number of persons who were dependent on assistance in performing the instrumental activities of daily living but not the basic activities did not differ significantly between the two groups. Nine people in the intervention group (4 percent) and 20 in the control group (10 percent) were permanently admitted to nursing homes (P = 0.02). Acute care hospital admissions and short-term nursing home admissions did not differ significantly between the two groups. In the second and third years of the study, there were significantly more visits to physicians among the participants in the intervention group than among those in the control group (mean number of visits per month, 1.41 in year 2 and 1.27 in year 3 in the intervention group, as compared with 1.11 and 0.92 visits, respectively, in the control group; P = 0.007 and P = 0.001, respectively). The cost of the intervention for each year of disability-free life gained was about $46,000.
A program of in-home comprehensive geriatric assessments can delay the development of disability and reduce permanent nursing home stays among elderly people living at home.
预防老年人残疾对医疗保健和社会服务构成挑战。我们针对75岁及以上社区居民开展了一项为期三年的随机对照试验，以研究年度居家综合老年评估及随访的效果。干预组的215人由老年护理从业者上门访视，这些从业者与老年病专家协作，评估残疾问题及风险因素，给出具体建议并提供健康教育。对照组的199人接受常规医疗护理。主要结局指标包括预防残疾，即定义为在进行日常生活基本活动（洗澡、穿衣、进食、修饰、从床上转移到椅子上以及在屋内走动）或日常生活工具性活动（如做饭、处理财务和用药、家务管理及购物）时需要协助，以及预防入住养老院。
三年后，干预组有20人（170名存活参与者中的12%），对照组有32人（147名存活参与者中的22%）在进行日常生活基本活动时需要协助（校正比值比为0.4；95%置信区间为0.2至0.8；P = 0.02）。两组在依赖协助进行日常生活工具性活动但不依赖进行基本活动的人数方面无显著差异。干预组有9人（4%），对照组有20人（10%）被永久送入养老院（P = 0.02）。两组在急性护理医院住院次数和短期养老院入住次数方面无显著差异。在研究的第二年和第三年，干预组参与者看医生的次数显著多于对照组（干预组第二年每月平均就诊次数为1.41次，第三年为1.27次，而对照组分别为1.11次和0.92次；P分别为0.007和0.001）。每获得一年无残疾生活的干预成本约为46,000美元。
居家综合老年评估项目可延缓居家老年人残疾的发展并减少其在养老院的长期停留时间。
