Our interim analysis suggested that the STEP instrument was useful to detect relevant health problems in old age and identify previously overlooked treatment needs. It also provided insight into the prevalence and management of multimorbidity among elderly patients in a primary care setting in Germany. As STEP was developed within a European concerted action, it has been already applied in other countries. The findings of our current project illustrate that its use in Germany is feasible and beneficial, and we have no reason to doubt that it would also work in the health care settings of other countries.
The most prevalent health problems uncovered by STEP were hypertension, missing or unknown immunization status, high blood cholesterol/known hypercholesterolemia, pain (in the last 4 weeks), and problems with medication. Lack of immunization is often reported among the elderly: although a representative telephone survey in Germany indicated that influenza immunization increased with age; only 44% of the persons above 59 years were vaccinated (14
). Regional data from Lower Saxony showed similar results (15
), while investigations in two European countries indicated that relatively few elderly were immunized against certain diseases. Piccoliori et al found that 35.7% of people aged 70 years and older in South Tyrol, Italy, had not received influenza vaccination (16
). In 2004, Mann et al found that 82.3% of patients in Austria aged 75 and older had received their last pneumococcal immunization more than 3 years ago (17
). However, the high proportion of patients with a missing or unknown immunization status in our interim analysis may also be due to the fact that the four types of immunization (influenza, pneumococcal, tetanus, diphtheria) were considered in aggregate; thus, if only one immunization status was negative or unknown, the overall status was assigned the same result.
The prevalence of hypertension (86%) and elevated blood cholesterol/known hypercholesterolemia (77%) in our study was higher than that described by a German health insurance company (18
). In that report, hypertension was diagnosed in more than 60% and high blood lipids in 45% of patients aged 65-80 years. A reason for this might be the high median age of patients recruited in our study. The number of chronic conditions increases with patient age (1
In addition to hypertension and hypercholesterolemia, many of the health problems most frequently identified in the STEP instrument occur commonly among the elderly, namely problems with medication, foot abnormalities, cognitive impairment (based on the clock drawing test), problems with hearing, and urinary incontinence. Our results indicate that the STEP instrument draws needed attention to problems typical of old age.
Five of the 44 health problems covered by STEP were new to the GPs in more than 50% of the patients reporting them: alcohol misuse, recent repeated falls, cognitive impairment (based on the clock drawing test), missing or unknown immunization status, and recent chest pain. Alcohol misuse and cognitive impairment (ranked first and third of 44 in frequency of occurrence), as well as fecal incontinence/constipation and financial problems (ranked ninth and tenth of 44), are topics that patients may hesitate to bring up themselves due to feelings of shame (19
). Therefore, they are rarely addressed during the consultation. Since physicians also tend to neglect these topics, the assessment seems to be a useful tool to initiate communication about these subjects.
Surprisingly, physicians were often unaware of recent chest pain. As we did not scrutinize the nature of the pain or the underlying problem, we could not differentiate between pain due to coronary heart disease or pain due to some other problem. In any case, chest pain can imply serious underlying disease and is certainly worth examining in further investigations. Two problems typically associated with aging were found among the 10 health problems most frequently new to the GPs: problems with mouth/chewing and problems with housing. Obviously, these problems, though relevant for patients and associated with their general health, are often not in a focus for physicians (20
), possibly because they think that housing is a matter for family or social services and mouth problems a matter for dentists. Nevertheless, many health problems were well-known to GPs. In more than 90% of cases, they were aware of problems that involved clinical measurements (pulse abnormality, hypertension) or laboratory values (blood cholesterol level, blood glucose level, thyroid hormone levels).
GPs planned further management most often for immunization, anxiety, or chest pain. The high proportion of interventions for immunization reflects the usefulness of STEP as a reminder instrument; it may also reflect the fact that immunizations are relatively inexpensive, simple, and widely recognized as beneficial. GPs apparently also considered psychological health problems and cognitive impairment to require diagnostic or therapeutic procedures. The high frequency of planned interventions for these health problems indicates that the GPs in our study were prepared to deal with psychological problems of their elderly patients.
A study conducted in Italy also examined whether GPs planned further interventions after using a geriatric assessment (16
). However, the authors of that study explored intervention planning and accomplishment solely for newly identified health problems. Our approach was broader because it assumed that well-known problems would benefit from a “reminder” within a health system often dominated by the “tyranny of the urgent” (23
), and that new interventions for old problems could still be initiated after an assessment.
Due to the interim nature of our analysis, we can only describe the data of a partial sample, and the results must be interpreted with caution. Analyses were flawed by the relatively high number of missing ratings due to inconsistent data and one physician’s misunderstanding of procedure. Most missing values occurred for the problem of cognitive impairment. Here, quality checks revealed that study nurses often misinterpreted the clock drawing test. In these cases, cognitive impairment was only diagnosed later and could not be included in GPs rating. Moreover, selection bias is possible in our study, since participating GPs may be more interested than the average GP in the health of the elderly, and thus cooperated more readily. Patient recruitment may also show selection bias, as only patients willing to be interviewed during the follow-up period consented. Moreover, we are aware that in some fields of the assessment, taboo subjects, or socially acceptable answers may have influenced patients’ responses.
Our results show that a geriatric assessment uncovered important health problems in elderly patients. The data also indicate how well-informed the physicians were about various domains of health problems in their patients, and for which domains they perceived a need for action. The final analysis of the complete data should lead to a deeper knowledge of patients’ and physicians’ perspectives of health problems. We expect it to reveal which factors influence physicians’ management, and whether a geriatric assessment improves patients’ (subjective) health. In this way, we hope to gain insights into the handling of multimorbidity among the elderly.