Effecten van geriatrische screening en doelenbepaling op de gezondheid van kwetsbare ouderen

Advancing age often compasses chronic diseases and subsequent functional decline. The accumulation of impairments with age and the lack of ability to compensate for them is called frailty. Being frail implies impairment in mobility, social activities or well-being. The health care for frail elderly is exceeding its budget and moreover does not meet the elderly’s needs. It is expected that care for frail elderly can be improved by providing pro-active, multi-disciplinary and patient-centered care. All of this is framed within a comprehensive geriatric assessment (CGA). In our study we evaluate the results of a specialised centre conducting this assessment. Participants will be screened for their degree of frailty. The CGA will be provided by a nurse or elderly care physician, with emphasis on well-being en social and functional participation of the elderly. Advices in consequence of the assessment will be given to the elderly and their general practitioner. The elder will formulate his/her own personal goals through Goal Attainments Scaling. We will study the effect of this CGA on %goals attained, frailty, daily activity functioning, quality of life and health care consumption. The CGA can be considered a complex intervention. Therefore, we will also analyse this process of implementation and clarify barriers en facilitators for improved care for the (frail) elderly.