Falls in the elderly are an important independent marker of frailty. Up to half of elderly people over 65 experience a fall every year. They are associated with high morbidity and mortality and are responsible for greater than 20 billion dollars a year in healthcare costs in the United States. This article presents a review and guide for the primary care provider of the predisposing and situational risk factors for falls; comprehensive assessment for screening and tailored intervention; and discussion of single and multicomponent measures for fall prevention and management in the older person living in the community. Interventions for the cognitively impaired and demented elderly will also be addressed.

Objectives Older adults with serious illness are increasingly becoming homebound. By nature of their homebound status they lack access to basic services including dental care. We conducted a study to assess the oral health status, dental utilization and dental needs of the homebound elderly and to determine whether medical diagnoses or demographic factors influenced perceived oral health. Design Cross-sectional analysis Methods A total of 125 homebound patients received a comprehensive clinical examination in their home by a trained dental research team and completed a dental utilization and needs survey as well as the Geriatric Oral Health Assessment Index (GOHAI). Results Patients who reported a high level of unmet oral health needs were more likely to be non-white, although this effect was not significant in multivariate analysis. Individual medical diagnoses and the presence of multiple comorbidities were not associated with unmet oral health needs. Conclusions The oral health status of the homebound elderly regardless of their medical diagnoses was poor. High unmet oral health needs combined with strong desire to receive dental care suggests there is an imperative need to improve access to dental care for this growing population. In addition to improving awareness among geriatricians and primary care providers who care for the homebound, the medical community must partner with the dental community to develop home-based programs for older adults.

Homebound older adults may receive suboptimal care during hospitalizations and transitions home or to postacute settings. This 2-year study describes a nurse practitioner (NP)-led transitional care program embedded within an existing home-based primary care (HBPC) program. The transitional care pilot program was designed to improve coordination and continuity of care, reduce readmissions, garner positive provider feedback, and demonstrate financial benefits through shorter length of stay, lower cost of inpatient stay, and better documentation of patient complexity. A detailed mixed-methods evaluation was conducted to characterize the hospitalized homebound population and investigate provider feedback and program feasibility, effectiveness, and costs. Length of stay (LOS), case-mix index, and admission-related financial costs were compared before and after the intervention using a pre-post design. Structured focus groups were conducted with inpatient and primary care providers to collect feedback on the usefulness of and satisfaction with the program. The program improved communication between home-based primary care providers and inpatient providers of all disciplines and facilitated the timely and accurate transfer of critical patient information. The intervention failed to decrease hospital LOS and readmission rate significantly for people who were hospitalized. The financial implications were reassuring, although future studies are necessary. This model of a NP-led program may be feasible for enhancing inpatient management and transitional care for older adults in HBPC programs and should be considered to augment the HBPC care model.

Objectives To document the degree of symptom burden in an urban homebound population. Design Cross-sectional survey. Setting The Mount Sinai Visiting Doctors Program (MSVD). Participants All individuals newly enrolled in the MSVD. Measurements Edmonton Symptom Assessment Scale (ESAS), which consists of 10 visual analogue scales scored from 0 to 10; symptoms include pain, tiredness, nausea, depression, anxiety, drowsiness, appetite, well-being, shortness of breath, and other. Results ESAS scores were completed for 318 participants. Most participants were aged 80 and older (68%) and female (75%); 36% were white, 22% black, and 32% Hispanic. Forty-three percent had Medicaid, and 32% lived alone. Ninety-one percent required assistance with one or more activities of daily living, 45% had a Karnofsky Performance Scale score between 0 and 40 (unable to care for self), and 43% reported severe burden on one or more symptoms. The most commonly reported symptoms were loss of appetite, lack of well-being, tiredness, and pain; the symptoms with the highest scores were depression, pain, appetite, and shortness of breath. Participants were more likely to have severe symptom burden if they self-reported their ESAS, had chronic obstructive pulmonary disease or diabetes mellitus with end organ damage, or had a Charlson Comorbidity Index greater than 3 and less likely to have severe burden if they had dementia. Conclusion In chronically ill homebound adults, symptom burden is a serious problem that needs to be addressed alongside primary and specialty care needs.