Book Review

New Ways to Care for Older People: Building systems based on evidence

N Engl J Med 1999; 341:1159-1160October 7, 1999

Article

New Ways to Care for Older People: Building systems based on evidence
Edited by Evan Calkins, Chad Boult, Edward H. Wagner, and James T. Pacala. 260 pp., illustrated. New York, Springer Publishing, 1999. $43.95. ISBN: 0-8261-1220-X

The care of older people has come a long way during the 20-year life span of geriatrics in this country. In the early 1980s, there were few centers of clinical research that studied effective methods of caring for older people. By now there has been enough activity to warrant a book highlighting only the best evidence for advances in care across the spectrum of older people's needs. This book is a tribute to the exciting growth of the field of geriatrics.

New Ways to Care for Older People is a coherent, succinct, multiauthored reference for anyone interested in improving the status quo of the frequently fragmented, reactive care of older people. It is readably organized according to the spectrum of older people's functional status or risk of impairment: from health and independence through chronic and acute illness (including care at the end of life) to disability. Within this functional organization, the editors and their coauthors — all acknowledged experts in their respective fields of research — detail the highest-quality evidence that supports interventions at each stage along the continuum of care. This organization offers the reader easy access to particular areas of interest. The clinician who is trying to improve office-based care of older patients, the administrator of a managed-care plan who is deciding on preventive care programs, the policy maker who is seeking evidence supporting community-based long-term care — all these readers will easily find an informative, concise appraisal of these topics in this book.

The authors begin with the healthy older adult and the prevention of frailty — the reduction of physiologic reserve that was once taken for granted as an inevitable consequence of aging. Physical activity is emerging as the key to reduction of the risk of numerous common geriatric syndromes such as falls, and innovative office-based and community-based programs are available for disease prevention.

To care better for home-dwelling older persons with chronic illnesses (e.g., diabetes or Parkinson's disease), the authors offer examples of improved outcomes that resulted from the reorganization of care at the levels of the patient, provider, and system. Although many health care systems now provide case management for patients at risk for hospitalization, few systems incorporate interdisciplinary care and comprehensive geriatric evaluation and management — care that is closely coordinated by many professional disciplines — despite proven benefits. The authors emphasize appropriately that the technology to reduce mortality, dysfunction, and discomfort exists; the challenge is to implement these approaches in practices and health plans. The many practice settings that currently lack detailed computerized data on demographic characteristics and health will need to invest in the information technology that is so central to these innovations.

Care that is reorganized around the particular needs of older adults who are hospitalized for acute care and that incorporates nurse-initiated interventions has also resulted in improved outcomes. The care of acute illness in the home is an attractive option for patients and care givers who see greater benefits than burdens in turning a part of their home into a hospital room, and it is currently being studied in a randomized trial. The authors briefly discuss the less robust results of such care in randomized trials, with the exception of care for stroke and hip fracture, for which outcomes of rehabilitation units are better than those of skilled-nursing facilities.

Community-based long-term care of disabled older adults is important in preventing hospitalization, providing respite for care givers, and delaying — but not replacing — nursing home care. The authors describe the contributions of special units for patients with dementia and cite the promising efforts to improve nursing homes through nationwide standardized assessment and care plans, focused guidelines, and increased primary care for nursing home residents.

The book concludes with an informative section on quality improvement across sites of geriatric care from the perspective of the Health Care Financing Administration; national demonstrations of integrated acute care and community long-term care; Medicare and managed care; the patient's role in the collaborative management of chronic illness; and integrated health care systems of the future. Combining funds from Medicare, personal and employer expenditures, and Medicaid will reward the health care team that has performed best across the spectrum of disease and care settings — for instance, in preventing heart attacks, lowering mortality from coronary-artery bypass surgery, and caring for patients with congestive heart failure.

The authors succeed in providing a compendium of programs to improve care and the evidence that supports them. Each section of the book contains a helpful preface to its chapters, and each chapter contains a summary of findings and recommendations. Tables summarizing the evidence for and relative strengths of the many interventions mentioned would have enhanced the book's value as a reference. The early chapter on the prevention of frailty concludes with a brief dialogue on frequently asked questions, a helpful technique that the editors might have required of their other authors. Curiously, that same chapter omits one of the principal recent interventions, modified tai chi, which has been shown to reduce falls among community-dwelling elders.

A broad audience will want to read this book for its compilation of useful approaches to improving the care of older people. The evidence presented throughout underscores the positive, proactive, and patient-centered approaches to many once seemingly intractable concomitants of aging, and it challenges us to reorganize our health care programs right now. Can we afford to do anything less?

Claus Hamann, M.D.
Massachusetts General Hospital, Boston, MA 02114