Effect of hormone therapy on personality traits: preliminary evidence in older men and women.

OBJECTIVE: Findings concerning the effects of hormone therapy (HT) on cognition and dementia are mixed, with some trials suggesting increased harm at older ages. Personality, like cognition, changes with dementia, but no clinical trials to date have examined the effects of HT on personality traits. This study aimed to determine the effects of HT on personality traits in older men and women. METHOD: Secondary data analysis was performed from randomized, double-blind, placebo-controlled cross-over studies of menopausal HT in women and testosterone therapy (TT) in men. Participants were community-dwelling cognitively normal adults (mean age = 75.2 years), including 29 men and 22 women. Three months of hormone intervention (for women, 0.625 mg/day conjugated equine estrogen with or without 2.5 mg/day medroxyprogesterone acetate; for men, 200 mg intramuscular testosterone enanthate every 2 weeks) were crossed over with 3 months of identical placebo with a 3-month washout between intervention phases. The main outcome measure was neuroticism and conscientiousness personality domains and facets assessed with the Revised NEO Personality Inventory (NEO-PI-R) after the active and placebo intervention phases. RESULTS: In linear mixed-effect models, HT in women decreased conscientiousness (p < 0.01) and the conscientiousness facet of achievement striving (p < 0.01), and increased vulnerability, a facet of neuroticism (p < 0.05). Testosterone in men decreased conscientiousness (p < 0.05) and the conscientiousness facet of dutifulness (p < 0.05), and increased vulnerability (p < 0.05). CONCLUSION: In a preliminary study of healthy older adults, HT and TT formulations produced adverse changes in vulnerability and conscientiousness facets that parallel personality changes in dementia.

Prevalence of caregiving and high caregiving strain among late-career medical school faculty members: workforce, policy, and faculty development implications.

BACKGROUND: Nearly one-third of medical school faculty members are age 55 + . As our population ages, the prevalence of family caregiving is increasing, yet we know very little about the caregiving experiences of aging faculty members in academic medicine. Faculty caregiving responsibilities coupled with projected physician shortages will likely impact the future academic medical workforce. We examined the prevalence of caregiving, concomitant caregiving strain, general well-being, and thoughts about retirement for medical school faculty members age 55 and older. METHODS: We analyzed data from a survey of 2,126 full-time medical school faculty 55 + years of age conducted in 2017. Chi-square tests of independence and independent samples t-tests were used to examine statistical differences between subgroups. RESULTS: Of the 5,204 faculty members invited to complete the parent survey, 40.8% participated (N = 2126). Most were male (1425; 67.2%), White (1841; 88.3%), and married/partnered (1803; 85.5%). The mean age was 62.3 years. Of this sample, 19.0% (n = 396) reported providing care on an on-going basis to a family member, friend, or neighbor with a chronic illness or disability, including 22.4% (n = 154) of the female respondents and 17.3% (n = 242) of the male respondents. Among the caregiving faculty members, 90.2% reported experiencing some or a lot of mental or emotional strain from caregiving. Caregivers gave lower ratings of health, social and emotional support, and quality of life, but greater comfort in religion or spirituality than non-caregivers. Both caregiving and non-caregiving faculty members estimated retiring from full-time employment at age 67.8, on average. CONCLUSION: These data highlight caregiving responsibilities and significant concomitant mental or emotional strain of a significant proportion of U.S. medical schools' rapidly aging workforce. Human resource and faculty development leaders in academia should strategically invest in policies, programs, and resources to meet these growing workforce needs.

Green Peace.

In this narrative medicine essay, a geriatrician finds synchronicity with medicine and gardening, an activity that calms his mind, stretches his limbs, and gives him insight.

A novel bedside cardiopulmonary physical diagnosis curriculum for internal medicine postgraduate training.

BACKGROUND: Physicians spend less time at the bedside in the modern hospital setting which has contributed to a decline in physical diagnosis, and in particular, cardiopulmonary examination skills. This trend may be a source of diagnostic error and threatens to erode the patient-physician relationship. We created a new bedside cardiopulmonary physical diagnosis curriculum and assessed its effects on post-graduate year-1 (PGY-1; interns) attitudes, confidence and skill. METHODS: One hundred five internal medicine interns in a large U.S. internal medicine residency program participated in the Advancing Bedside Cardiopulmonary Examination Skills (ACE) curriculum while rotating on a general medicine inpatient service between 2015 and 2017. Teaching sessions included exam demonstrations using healthy volunteers and real patients, imaging didactics, computer learning/high-fidelity simulation, and bedside teaching with experienced clinicians. Primary outcomes were attitudes, confidence and skill in the cardiopulmonary physical exam as determined by a self-assessment survey, and a validated online cardiovascular examination (CE). RESULTS: Interns who participated in ACE (ACE interns) by mid-year more strongly agreed they had received adequate training in the cardiopulmonary exam compared with non-ACE interns. ACE interns were more confident than non-ACE interns in performing a cardiac exam, assessing the jugular venous pressure, distinguishing 'a' from 'v' waves, and classifying systolic murmurs as crescendo-decrescendo or holosystolic. Only ACE interns had a significant improvement in score on the mid-year CE. CONCLUSIONS: A comprehensive bedside cardiopulmonary physical diagnosis curriculum improved trainee attitudes, confidence and skill in the cardiopulmonary examination. These results provide an opportunity to re-examine the way physical examination is taught and assessed in residency training programs.

The short-term and long-term impact of a brief aging research training program for medical students.

Summer training in aging research for medical students is a strategy for improving the pipeline of medical students into research careers in aging and clinical care of older adults. Johns Hopkins University has been offering medical students a summer experience of mentored research, research training, and clinical shadowing since 1994. Long-term outcomes of this program have not been described. The authors surveyed all 191 participants who had been in the program from 1994-2010 (60% female and 27% underrepresented minorities) and received a 65.8% (N = 125) response rate. The authors also conducted Google and other online searches to supplement study findings. Thirty-seven percent of those who have completed training are now in academic medicine, and program participants have authored or coauthored 582 manuscripts. Among survey respondents, 95.1% reported that participation in the Medical Student Training in Aging Research program increased their sensitivity to the needs of older adults. This program may help to build commitment among medical students to choose careers in aging.

Implementing staff nurse geriatric education in the acute hospital setting.

The implementation and evaluation of staff nurse geriatric educational interventions on medical units in an urban teaching hospital are described.

Implications of academic medicine's failure to recognize clinical excellence.

OBJECTIVE: To better understand the implications of inadequately recognizing clinical excellence in academia by exploring the perspectives of clinically excellent faculty within prominent American departments of medicine. DESIGN: Qualitative study. SETTING: 8 academic institutions. PARTICIPANTS: 24 clinically excellent department of medicine physicians. METHODS: Between March 1 and May 31, 2007, investigators conducted in-depth semi-structured interviews with 24 clinically excellent physicians at leading academic institutions. Interview transcripts were independently coded by two investigators and compared for agreement. Content analysis identified themes related to clinical excellence in academia. RESULTS: Twenty informants (83%) were Associate Professors or Professors, 8 (33%) were females, and the physicians hailed from a wide range of internal medicine specialties. The mean percent effort spent in clinical care by the physicians was 48%. The five domains that emerged related to academic medicine's failure to recognize clinical excellence were: (1) low morale and prestige among clinicians, (2) less than excellent patient care, (3) loss of talented clinicians, (4) a lack of commitment to improve patient care systems, and (5) fewer excellent clinician role models to inspire trainees. CONCLUSIONS: If academic medical centers fail to recognize clinical excellence among its physicians, they may be doing a disservice to the patients that they pledge to serve. It is hoped that initiatives aiming to measure clinical performance in our academic medical centers will translate into meaningful recognition for those achieving excellence such that outstanding clinicians may feel valued and decide to stay in academia.

A model intensive course in geriatric teaching for non-geriatrician educators.

INTRODUCTION: Because of the aging demographics nearly all medical specialties require faculty who are competent to teach geriatric care principles to learners, yet many non-geriatrician physician faculty members report they are not prepared for this role. AIMS: To determine the impact of a new educational intervention designed to improve the self-efficacy and ability of non-geriatrician clinician-educators to teach geriatric medicine principles to medical students and residents. DESCRIPTION: Forty-two non-geriatrician clinician-educator faculty from 17 academic centers self-selected to participate in a 3-day on-site interactive intensive course designed to increase knowledge of specific geriatric medicine principles and to enhance teaching efficacy followed by up to a year of mentorship by geriatrics faculty after participants return to their home institutions. On average, 24% of their faculty time was spent teaching and 57% of their clinical practices involved patients aged over 65 years. Half of all participants were in General Internal Medicine, and the remaining were from diverse areas of medicine. EVALUATION: Tests of geriatrics medical knowledge and attitudes were high at baseline and did not significantly change after the intervention. Self-rated knowledge about specific geriatric syndromes, self-efficacy to teach geriatrics, and reported value for learning about geriatrics all improved significantly after the intervention. A quarter of the participants reported they had achieved at least one of their self-selected 6-month teaching goals. DISCUSSION: An intensive 3-day on-site course was effective in improving self-reported knowledge, value, and confidence for teaching geriatrics principles but not in changing standardized tests of geriatrics knowledge and attitudes in a diverse group of clinician-educator faculty. This intervention was somewhat associated with new teaching behaviors 6 months after the intervention. Longer-term investigations are underway to determine the sustainability of the effect and to determine which factors predict the faculty who most benefit from this innovative model.

Association of a Care Coordination Model With Health Care Costs and Utilization: The Johns Hopkins Community Health Partnership (J-CHiP).

Importance: The Johns Hopkins Community Health Partnership was created to improve care coordination across the continuum in East Baltimore, Maryland. Objective: To determine whether the Johns Hopkins Community Health Partnership (J-CHiP) was associated with improved outcomes and lower spending. Design, Setting, and Participants: Nonrandomized acute care intervention (ACI) and community intervention (CI) Medicare and Medicaid participants were analyzed in a quality improvement study using difference-in-differences designs with propensity score-weighted and matched comparison groups. The study spanned 2012 to 2016 and took place in acute care hospitals, primary care clinics, skilled nursing facilities, and community-based organizations. The ACI analysis compared outcomes of participants in Medicare and Medicaid during their 90-day postacute episode with those of a propensity score-weighted preintervention group at Johns Hopkins Community Health Partnership hospitals and a concurrent comparison group drawn from similar Maryland hospitals. The CI analysis compared changes in outcomes of Medicare and Medicaid participants with those of a propensity score-matched comparison group of local residents. Interventions: The ACI bundle aimed to improve transition planning following discharge. The CI included enhanced care coordination and integrated behavioral support from local primary care sites in collaboration with community-based organizations. Main Outcomes and Measures: Utilization measures of hospital admissions, 30-day readmissions, and emergency department visits; quality of care measures of potentially avoidable hospitalizations, practitioner follow-up visits; and total cost of care (TCOC) for Medicare and Medicaid participants. Results: The CI group had 2154 Medicare beneficiaries (1320 [61.3%] female; mean age, 69.3 years) and 2532 Medicaid beneficiaries (1483 [67.3%] female; mean age, 55.1 years). For the CI group's Medicaid participants, aggregate TCOC reduction was $24.4 million, and reductions of hospitalizations, emergency department visits, 30-day readmissions, and avoidable hospitalizations were 33, 51, 36, and 7 per 1000 beneficiaries, respectively. The ACI group had 26 144 beneficiary-episodes for Medicare (13 726 [52.5%] female patients; mean patient age, 68.4 years) and 13 921 beneficiary-episodes for Medicaid (7392 [53.1%] female patients; mean patient age, 52.2 years). For the ACI group's Medicare participants, there was a significant reduction in aggregate TCOC of $29.2 million with increases in 90-day hospitalizations and 30-day readmissions of 11 and 14 per 1000 beneficiary-episodes, respectively, and reduction in practitioner follow-up visits of 41 and 29 per 1000 beneficiary-episodes for 7-day and 30-day visits, respectively. For the ACI group's Medicaid participants, there was a significant reduction in aggregate TCOC of $59.8 million and the 90-day emergency department visit rate decreased by 133 per 1000 episodes, but hospitalizations increased by 49 per 1000 episodes and practitioner follow-up visits decreased by 70 and 182 per 1000 episodes for 7-day and 30-day visits, respectively. In total, the CI and ACI were associated with $113.3 million in cost savings. Conclusions and Relevance: A care coordination model consisting of complementary bundled interventions in an urban academic environment was associated with lower spending and improved health outcomes.

Intramuscular testosterone treatment in elderly men: evidence of memory decline and altered brain function.

CONTEXT: Recent clinical trials of im testosterone in eugonadal men suggest positive effects on verbal memory, but other studies find no effect. OBJECTIVE: Our objective was to determine whether supraphysiological testosterone influences verbal memory and brain function during a verbal memory task in healthy eugonadal older men. PATIENTS, DESIGN, AND SETTING: Fifteen cognitively normal men, aged 66-86 yr, participated in a randomized, double-blind, placebo-controlled crossover trial involving 9 months of participation per participant at a hospital-based research facility. INTERVENTION: We used testosterone enanthate (200 mg im every other week for 90 d) crossed over with placebo (sesame oil vehicle im) with a 90-d washout between treatments. MAIN OUTCOME MEASURES: Performance was assessed on a standardized verbal memory test, and brain activity (relative glucose metabolic rates) in medial temporal and frontal regions was measured with positron emission tomography during a verbal memory task. RESULTS: Treatment increased total testosterone by 241%. Behavioral results showed a significant decrease in short-delay verbal memory with treatment (P < 0.05, effect size = 0.59 sd) and a nonsignificant decrease on a composite verbal memory measure (P = 0.09, effect size = 0.48 sd). Positron emission tomography scans revealed decreased relative activity in ventromedial temporal cortex (i.e. right amygdala/entorhinal cortex) and increased relative activity in bilateral prefrontal cortex with treatment. CONCLUSIONS: Decreased verbal memory and altered relative activity in medial temporal and prefrontal regions suggest possible detrimental effects of supraphysiological testosterone supplementation in elderly men. The results do not rule out potential benefits with other regimens, cognitive tests, or populations.

Individualising therapy for older adults with diabetes mellitus.

The goal when treating patients with diabetes mellitus is to achieve the maximum longevity consistent with an optimal quality of life. To achieve this goal, treatment is typically focused on management of hyperglycaemic symptoms and prevention of microvascular and macrovascular complications. While appropriate for most individuals, including many older adults with robust health, this focus is often too limited for older adults facing diminished life expectancy and co-existing medical illness, frailty and disability. Creating a treatment plan that optimises health and function, and reduces the risk for morbidity and mortality, requires individualised therapy that judiciously manages symptoms and multiple competing health risks while remaining consistent with the patient's or his/her caregiver's healthcare preferences. Physicians caring for older adults with diabetes must be adept at recognising conditions commonly associated with diabetes, including the interplay with co-morbid illness, and be able to assess the patient's health status and use this information to recommend a treatment plan that is consistent with the patient's personal goals for care. The majority of older adults with diabetes will benefit from management of cardiovascular risk, including intensive management of hypertension, lipids, use of aspirin (acetylsalicylic acid) and smoking cessation, and screening for common geriatric syndromes. For a significant minority of older adults with life expectancy of >or=10 years, it is reasonable to consider intensive management of hyperglycaemia (glycosylated haemoglobin [HbA1c] target

Using clinical guidelines designed for older adults with diabetes mellitus and complex health status.

Increasingly, adults are living to an advanced age. While many enjoy good health, nearly 50% of adults older than 65 years have 3 or more chronic medical conditions. Furthermore, within any age-sex cohort, older adults exhibit widely heterogeneous health status--ranging from robust to frail. This heterogeneity and individual medical complexity makes care for older patients particularly challenging and requires both careful medical judgment and a clear understanding of the patient's personal values and goals. Most current health care guidelines are disease-specific and do not address this complexity and heterogeneity, thus limiting their utility for guiding physicians in the care of older adult patients. The "Guidelines for Improving the Care of Older Persons With Diabetes Mellitus" are the first guidelines to specifically address this complexity and provide guidance to physicians who must prioritize therapies and goals for older adults with diabetes, comorbid medical conditions, and geriatric syndromes. By providing a rationale for prioritizing recommendations and the inclusion of geriatric syndromes that impact the patient's overall health and diabetic care, these guidelines may serve as a model for the development of other guidelines targeting older adults with complex health status.

Case Study: Johns Hopkins Community Health Partnership: A model for transformation.

To address the challenging health care needs of the population served by an urban academic medical center, we developed the Johns Hopkins Community Health Partnership (J-CHiP), a novel care coordination program that provides services in homes, community clinics, acute care hospitals, emergency departments, and skilled nursing facilities. This case study describes a comprehensive program that includes: a community-based intervention using multidisciplinary care teams that work closely with the patient's primary care provider; an acute care intervention bundle with collaborative team-based care; and a skilled nursing facility intervention emphasizing standardized transitions and targeted use of care pathways. The program seeks to improve clinical care within and across settings, to address the non-clinical determinants of health, and to ultimately improve healthcare utilization and costs. The case study introduces: a) main program features including rationale, goals, intervention design, and partnership development; b) illness burden and social barriers of the population contributing to care challenges and opportunities; and c) lessons learned with steps that have been taken to engage both patients and providers more actively in the care model. Urban health systems, including academic medical centers, must continue to innovate in care delivery through programs like J-CHiP to meet the needs of their patients and communities.

The Johns Hopkins Geriatric Summer Scholars Program: a model to increase diversity in geriatric medicine.

The Division of Geriatric Medicine and Gerontology at the Johns Hopkins University strives to create a workforce that represents the racial, ethnic, and sex diversity of U.S. society. To that end, the division has developed a summer program for underrepresented minority first-year medical students to expose them to geriatric medicine and research. The ultimate aim of this initiative is to recruit students to academic medicine, specifically geriatric medicine, where they are drastically underrepresented. Nineteen students participated in the program from the summer of 2002 to the summer of 2004. The participants have continued on to win seven other research fellowships, participate in the National Institute on Aging Technical Assistance Workshop, and present at four national conferences, including the American Geriatrics Society conference and the Gerontological Society of America meeting. One of the students, who is completing medical school in May 2005, is returning to begin the internal medicine residency program at Johns Hopkins Bayview, where the majority of the geriatric faculty practice medicine. Another student who is also graduating is obtaining her Masters in Public Health with a concentration in epidemiology from the Johns Hopkins Bloomberg School of Public Health before starting residency. This article describes the outcomes of the first 3 years of the program, with an emphasis on curriculum development and the recruitment and retention of underrepresented minority medical students.

Interaction with other health team members in caring for elderly patients.

Comprehensive health care of the geriatric patient requires thoughtful communication and coordination of services. Unlike young adults, older patients are likely to be frail, have multiple chronic conditions, and experience disability. Hence they are more likely to depend on others for help and to see a variety of health professionals at different sites. This complexity demands that health care professionals consider their care not in isolation, but as part of a team. They must ensure that other members of the team are kept informed and are consulted as appropriate to ensure safe and effective care. Accomplishing this goal requires being acquainted with the usual care providers, the necessary information for sharing, and the most effective communication methods within the team.

Demographic and health characteristics of residents choosing to use on-site medical care in a newly opened continuing care retirement community (CCRC).

OBJECTIVE: To determine demographic and health characteristics of older adults choosing to use on-site medical care in a continuing care retirement community (CCRC). DESIGN: A descriptive study of residents moving into a newly opened CCRC. Residents responded to a self-report mail survey composed of questions related to reasons for moving to a CCRC, health and functional status,health care use during the previous 5 years. RESULTS: Of 942 residents, 642 (68%) completed the survey. Medical center users and nonusers were similar demographically and reported similar reasons for moving to the CCRC including desire for a low maintenance apartment (49% vs. 48%; P = 0.806), concern about health or spouse's health (67% vs. 63%; P = 0.345), and desire for social activities (63% vs. 58%; P = 0.151). However, on-site medical center users versus nonusers reported increased rates of fair/poor health (31% vs. 18%; P = 0.0001), fair/poor vision (27% vs. 15%; P = 0.0003),difficulty walking in the home (13% vs. 8%; P = 0.53), using the toilet (6% vs. 2%; P = 0.044), shopping (29% vs. 20%; P = 0.007), using transportation (19% vs. 10%; P = 0.005), doing laundry (13% vs. 7%; P = 0.016), using the telephone (8% vs. 3%; P = 0.002), and taking medication (5% vs. 1%; P = 0.022). CONCLUSION: For both users and nonusers of the medical center, the most frequently cited reason for moving to the CCRC was concern about health. On-site medical center users had lower perceived health, were functionally more disabled, and had health characteristics that made them at higher risk for high health care utilization. The challenges to provide high quality medical care and enhance quality of life for CCRC residents will continue to increase. Physicians should play an active role not only in providing medical care to CCRC residents, but also in providing medical leadership for these institutions.