A pilot study to identify factors associated with frailty within the World Trade Center general responder cohort.

BACKGROUND: Given the significant exposures experienced by the World Trade Center (WTC) general responders, there is increasing interest in understanding the effect of these exposures on aging in this population. We aim to identify factors that may be associated with frailty, a clinical syndrome characterized by a decrease in one's reserve that has been linked to poor health outcomes. METHODS: WTC general responders enrolled in the WTC Health Program aged 50 and older provided informed consent. Validated frailty assessments, the Frailty Phenotype (with the Johns Hopkins Frailty Assessment Calculator) along with the FRAIL scale, categorized nonfrail from prefrail/frail. Fall risk, functional status, and cognition were also assessed. WTC variables, including an identified WTC-certified condition, were utilized. The risk of frailty was estimated using log binomial regression analysis. A 95% confidence interval (CI) was used to estimate the prevalence ratio (PR). RESULTS: One hundred and six participants were included; 38 (35.8%) were classified as pre-frail or frail. More of the pre-frail/frail group were obese (57.9% vs. 25%; p = 0.004) and had a WTC-certified condition (78.9% vs. 58.8%; p = 0.036). Obesity (PR = 2.43, 95% CI = 1.31, 4.53), a WTC-certified condition (PR = 1.77, 95% CI = 1.09, 2.89), and risk of falling (PR = 1.97, 95% CI = 1.01, 3.84) were independently associated with frailty. CONCLUSIONS: Obesity and having a WTC-certified condition were found to be risk factors for frailty in our pilot study. Future work may focus on further identifying risk factors for frailty in the larger WTC general responder population.

Needs for Successful Engagement in Telemedicine Among Rural Older US Veterans and Their Caregivers: Qualitative Study.

BACKGROUND: Telemedicine is an important option for rural older adults who often must travel far distances to clinics or forgo essential care. In 2014, the Geriatric Research, Education, and Clinical Centers (GRECC) of the US Veterans Health Administration (VA) established a national telemedicine network called GRECC Connect. This network increased access to geriatric specialty care for the 1.4 million rural VA-enrolled veterans aged 65 years or older. The use of telemedicine skyrocketed during the COVID-19 pandemic, which disproportionately impacted older adults, exacerbating disparities in specialty care access as overburdened systems shut down in-person services. This surge presented a unique opportunity to study the supports necessary for those who would forgo telemedicine if in-person care were available. OBJECTIVE: In spring 2021, we interviewed veterans and their informal caregivers to (1) elicit their experiences attempting to prepare for a video visit with a GRECC Connect geriatric specialist and (2) explore facilitators and barriers to successful engagement in a telemedicine visit. METHODS: We conducted a cross-sectional qualitative evaluation with patients and their caregivers who agreed to participate in at least 1 GRECC Connect telemedicine visit in the previous 3 months. A total of 30 participants from 6 geographically diverse GRECC Connect hub sites agreed to participate. Semistructured interviews were conducted through telephone or the VA's videoconference platform for home telemedicine visits (VA Video Connect) per participant preference. We observed challenges and, when needed, provided real-time technical support to facilitate VA Video Connect use for interviews. All interviews were recorded with permission and professionally transcribed. A team of 5 researchers experienced in qualitative research analyzed interview transcripts using rapid qualitative analysis. RESULTS: From 30 participant interviews, we identified the following 4 categories of supports participants described regarding successful engagement in telemedicine, as defined by visit completion, satisfaction, and willingness to engage in telemedicine in the future: (1) caregiver presence to facilitate technology setup and communication; (2) flexibility in visit modality (eg, video from home or a clinic or telephone); (3) technology support (eg, determining device compatibility or providing instruction and on-demand assistance); and (4) assurance of comfort with web-based communication, including orientation to features like closed captioning. Supports were needed at multiple points before the visit, and participants stressed the importance of eliciting the varying needs and preferences of each patient-caregiver dyad. Though many initially agreed to a telemedicine visit because of pandemic-related clinic closures, participants were satisfied with telemedicine and willing to use it for other types of health care visits. CONCLUSIONS: To close gaps in telemedicine use among rural older adults, supports must be tailored to individuals, accounting for technology availability and comfort, as well as availability of and need for caregiver involvement. Comprehensive scaffolding of support starts well before the first telemedicine visit.

The Development and Use of a New Visual Tool (REVISIT) to Support Participant Recall: Web-Based Interview Study Among Older Adults.

BACKGROUND: Qualitative health services research often relies on semistructured or in-depth interviews to develop a deeper understanding of patient experiences, motivations, and perspectives. The quality of data gathered is contingent upon a patient's recall capacity; yet, studies have shown that recall of medical information is low. Threats to generating rich and detailed interview data may be more prevalent when interviewing older adults. OBJECTIVE: We developed and studied the feasibility of using a tool, Remembering Healthcare Encounters Visually and Interactively (REVISIT), which has been created to aid the recall of a specific telemedicine encounter to provide health services research teams with a visual tool, to improve qualitative interviews with older adults. METHODS: The REVISIT visual appointment summary was developed to facilitate web-based interviews with our participants as part of an evaluation of a geriatric telemedicine program. Our primary aims were to aid participant recall, maintain focus on the index visit, and establish a shared understanding of the visit between participants and interviewers. The authors' experiences and observations developing REVISIT and using it during videoconference interviews (N=16) were systematically documented and synthesized. We discuss these experiences with REVISIT and suggest considerations for broader implementation and future research to expand upon this preliminary work. RESULTS: REVISIT enhanced the interview process by providing a focus and catalyst for discussion and supporting rapport-building with participants. REVISIT appeared to support older patients' and caregivers' recollection of a clinical visit, helping them to share additional details about their experience. REVISIT was difficult to read for some participants, however, and could not be used for phone interviews. CONCLUSIONS: REVISIT is a promising tool to enhance the quality of data collected during interviews with older, rural adults and caregivers about a health care encounter. This novel tool may aid recall of health care experiences for those groups for whom it may be more challenging to collect accurate, rich qualitative data (eg, those with cognitive impairment or complex medical care), allowing health services research to include more diverse patient experiences.

The role of Department of Veterans Affairs community-based outpatient clinics in enhancing rural access to geriatrics telemedicine specialty care.

BACKGROUND: Half of the 4.7 M veterans who reside in rural communities and rely on U.S. Department of Veterans Affairs (VA) health care are older (≥65). Their rurality presents unique challenges, including a shortage of clinicians skilled in geriatric medicine. Community-based outpatient clinics (CBOCs) help extend VA's geographic reach but are typically located in under-resourced settings. Telemedicine may increase access to care, but little is known about CBOCs' capacity to leverage telemedicine to meet older patients' needs. We identified organizational barriers and facilitators to the use of geriatric telemedicine specialty care from the perspective of rural clinicians and staff. METHODS: From February-April 2020, we interviewed CBOC clinicians and staff (N = 50) from 13 rural CBOCs affiliated with four VA Geriatric Research Education and Clinical Centers. Semi-structured interviews addressed patient population characteristics; CBOC location, staffing, and in-house resources; use of VA specialty care services; and telemedicine use. We developed a codebook using an iterative process and Gale's Framework Method thematically organize and analyze data. RESULTS: Respondents perceived that their CBOCs serve a predominantly older patient population. Four characteristics enabled CBOCs to offer geriatric telemedicine specialty care: partnerships with larger VA Medical Center teams; social worker/telehealth clinical technician knowledge of geriatrics and telehealth resources; periodic outreach/education from geriatric specialists; and routine use of other telehealth services. Barriers included: constraints on clinic space and unstable internet for telemedicine visits; staffing challenges leading to limited familiarity with telemedicine resources; and clinician and staff perceptions of older veterans' preference for in-person visits. CONCLUSIONS: Telemedicine is an important modality to enhance access to care for an increasingly older and medically complex patient population. Although rural CBOCs provide a large portion of care to VA's growing geriatric population, staff are insufficiently trained in geriatrics, work in resource-poor settings, and are largely unaware of VA telemedicine programs designed to support them.

Connecting the disconnected: Leveraging an in-home team member for video visits for older adults.

BACKGROUND: Older adults are interested and able to complete video visits, but often require coaching and practice to succeed. Data show a widening digital divide between older and younger adults using video visits. We conducted a qualitative feasibility study to investigate these gaps via ethnographic methods, including a team member in older participants' homes. METHODS: This ethnographic feasibility study included a virtual medication reconciliation visit with a clinical pharmacist for Veterans aged 65 and older taking 5 or more medications. An in-home study team member joined the participant and recorded observations in structured fieldnotes derived from the Updated Consolidated Framework for Implementation Research and Age-Friendly Health Systems. Fieldnotes included behind-the-scenes facilitators, barriers, and solutions to challenges before and during the visits. We conducted a thematic analysis of these observations and matched themes to implementation solutions from the Expert Recommendations for Implementing Change. RESULTS: Twenty participants completed a video visit. Participants were 74 years old (range 68-80) taking 12 daily medications (range 7-24). Challenges occurred in half of the visits and took the in-home team member and/or pharmacist an average of 10 minutes to troubleshoot. Challenges included notable new findings, such as that half of the participants required technology assistance for challenges that would not have been able to be solved by the pharmacist virtually. Furthermore, although many participants had a device or had used video visits before, some did not have a single device with video, audio, Internet, and access to their email username and password. CONCLUSIONS: Clinicians may apply these evidence-based implementation solutions to their approach to video visits with older adults, including having a team member join the visit before the clinician, involving tech-savvy family members, ensuring the device works with the visit platform ahead of time, and creating a troubleshooting guide from our common challenges.

Perceived benefits of geriatric specialty telemedicine among rural patients and caregivers.

OBJECTIVE: Explore the perceived benefits of a Veterans Health Administration (VHA) geriatric specialty telemedicine service (GRECC Connect) among rural, older patients and caregivers to contribute to an assessment of its quality and value. DATA SOURCES: In Spring 2021, we interviewed a geographically diverse sample of rural, older patients and their caregivers who participated in GRECC Connect telemedicine visits. STUDY DESIGN: A cross-sectional qualitative study focused on patient and caregiver experiences with telemedicine, including perceived benefits and challenges. DATA COLLECTION: We conducted 30 semi-structured qualitative interviews with rural, older (≥65) patients enrolled in the VHA and their caregivers via videoconference or phone. Interviews were recorded, transcribed, and analyzed using a rapid qualitative analysis approach. PRINCIPAL FINDINGS: Participants described geriatric specialty telemedicine visits focused on cognitive assessments, tailored physical therapy, medication management, education on disease progression, support for managing multiple comorbidities, and suggestions to improve physical functioning. Participants reported that, in addition to prescribing medications and ordering tests, clinicians expedited referrals, coordinated care, and listened to and validated both patient and caregiver concerns. Perceived benefits included improved patient health; increased patient and caregiver understanding and confidence around symptom management; and greater feelings of empowerment, hopefulness, and support. Challenges included difficulty accessing some recommended programs and services, uncertainty related to instructions or follow-up, and not receiving as much information or treatment as desired. The content of visits was well aligned with the domains of the Age-Friendly Health Systems and Geriatric 5Ms frameworks (Medication, Mentation, Mobility, what Matters most, and Multi-complexity). CONCLUSIONS: Alignment of patient and caregiver experiences with widely-used models of comprehensive geriatric care indicates that high-quality geriatric care can be provided through virtual modalities. Additional work is needed to develop strategies to address challenges and optimize and expand access to geriatric specialty telemedicine.

Exploring the intersection of structural racism and ageism in healthcare.

The American Geriatrics Society (AGS) has consistently advocated for a healthcare system that meets the needs of older adults, including addressing impacts of ageism in healthcare. The intersection of structural racism and ageism compounds the disadvantage experienced by historically marginalized communities. Structural racism and ageism have long been ingrained in all aspects of US society, including healthcare. This intersection exacerbates disparities in social determinants of health, including poor access to healthcare and poor outcomes. These deeply rooted societal injustices have been brought to the forefront of the collective public consciousness at different points throughout history. The COVID-19 pandemic laid bare and exacerbated existing inequities inflicted on historically marginalized communities. Ageist rhetoric and policies during the COVID-19 pandemic further marginalized older adults. Although the detrimental impact of structural racism on health has been well-documented in the literature, generative research on the intersection of structural racism and ageism is limited. The AGS is working to identify and dismantle the healthcare structures that create and perpetuate these combined injustices and, in so doing, create a more just US healthcare system. This paper is intended to provide an overview of important frameworks and guide future efforts to both identify and eliminate bias within healthcare delivery systems and health professions training with a particular focus on the intersection of structural racism and ageism.

Implementation of an evidence-based medicine curriculum in a fellowship program: Can it influence clinical practice?

While evidence-based medicine (EBM) curricula improves knowledge scores, correlation with physician behavior, and patient outcomes are not clear. We established an EBM curriculum for Geriatrics and Palliative Medicine fellows that included didactic teaching, opportunity for deliberate practice and presentation, and coaching and feedback from faculty experts, to determine the impact on self-assessed confidence in teaching EBM, Practice-Based Learning and Improvement (PBLI) competency rating and patient care decisions. Seventeen fellows at a New York City academic medical center participated during 2014-2015 academic year. We analyzed pre-/posttest surveys for self-assessed confidence in teaching EBM concepts, EBM worksheets for content of clinical questions and impact on patient care, and PBLI competency ratings for overall impact. Posttest survey indicated that fellows' self-assessed confidence in teaching EBM increased significantly. While most found Journal Club discussions and EBM case conferences valuable, only 36% of fellows found EBM worksheets completion to be good use of time (average completion time 89 minutes). EBM worksheets helped reinforce or change plan of care in 32 out of 50 cases. There was no impact on end-of-the-year PBLI ratings. This curriculum, integrating didactic, self-directed and peer learning with objective feedback, increased self-assessed confidence in teaching EBM, and influenced patient care plans.

Moving the needle on fall prevention: A Geriatric Emergency Care Applied Research (GEAR) Network scoping review and consensus statement.

BACKGROUND: Although falls are common, costly, and often preventable, emergency department (ED)-initiated fall screening and prevention efforts are rare. The Geriatric Emergency Medicine Applied Research Falls core (GEAR-Falls) was created to identify existing research gaps and to prioritize future fall research foci. METHODS: GEAR's 49 transdisciplinary stakeholders included patients, geriatricians, ED physicians, epidemiologists, health services researchers, and nursing scientists. We derived relevant clinical fall ED questions and summarized the applicable research evidence, adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews. The highest-priority research foci were identified at the GEAR Consensus Conference. RESULTS: We identified two clinical questions for our review (1) fall prevention interventions (32 studies) and (2) risk stratification and falls care plan (19 studies). For (1) 21 of 32 (66%) of interventions were a falls risk screening assessment and 15 of 21 (71%) of these were combined with an exercise program or physical therapy. For (2) 11 fall screening tools were identified, but none were feasible and sufficiently accurate for ED patients. For both questions, the most frequently reported study outcome was recurrent falls, but various process and patient/clinician-centered outcomes were used. Outcome ascertainment relied on self-reported falls in 18 of 32 (56%) studies for (1) and nine of 19 (47%) studies for (2). CONCLUSION: Harmonizing definitions, research methods, and outcomes is needed for direct comparison of studies. The need to identify ED-appropriate fall risk assessment tools and role of emergency medical services (EMS) personnel persists. Multifactorial interventions, especially involving exercise, are more efficacious in reducing recurrent falls, but more studies are needed to compare appropriate bundle combinations. GEAR prioritizes five research priorities: (1) EMS role in improving fall-related outcomes, (2) identifying optimal ED fall assessment tools, (3) clarifying patient-prioritized fall interventions and outcomes, (4) standardizing uniform fall ascertainment and measured outcomes, and (5) exploring ideal intervention components.

Development and Validation of a Clinical Frailty Index for the World Trade Center General Responder Cohort.

Objectives: To develop and validate a clinical frailty index to characterize aging among responders to the 9/11 World Trade Center (WTC) attacks. Methods: This study was conducted on health monitoring data on a sample of 6197 responders. A clinical frailty index, WTC FI-Clinical, was developed according to the cumulative deficit model of frailty. The validity of the resulting index was assessed using all-cause mortality as an endpoint. Its association with various cohort characteristics was evaluated. Results: The sample's median age was 51 years. Thirty items were selected for inclusion in the index. It showed a strong correlation with age, as well as significant adjusted associations with mortality, 9/11 exposure severity, sex, race, pre-9/11 occupation, education, and smoking status. Discussion: The WTC FI-Clinical highlights effects of certain risk factors on aging within the 9/11 responder cohort. It will serve as a useful instrument for monitoring and tracking frailty within this cohort.

Delirium Prevention, Detection, and Treatment in Emergency Medicine Settings: A Geriatric Emergency Care Applied Research (GEAR) Network Scoping Review and Consensus Statement.

BACKGROUND: Older adult delirium is often unrecognized in the emergency department (ED), yet the most compelling research questions to overcome knowledge-to-practice deficits remain undefined. The Geriatric Emergency care Applied Research (GEAR) Network was organized to identify and prioritize delirium clinical questions. METHODS: GEAR identified and engaged 49 transdisciplinary stakeholders including emergency physicians, geriatricians, nurses, social workers, pharmacists, and patient advocates. Adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews, clinical questions were derived, medical librarian electronic searches were conducted, and applicable research evidence was synthesized for ED delirium detection, prevention, and management. The scoping review served as the foundation for a consensus conference to identify the highest priority research foci. RESULTS: In the scoping review, 27 delirium detection "instruments" were described in 48 ED studies and used variable criterion standards with the result of delirium prevalence ranging from 6% to 38%. Clinician gestalt was the most common "instrument" evaluated with sensitivity ranging from 0% to 81% and specificity from 65% to 100%. For delirium management, 15 relevant studies were identified, including one randomized controlled trial. Some intervention studies targeted clinicians via education and others used clinical pathways. Three medications were evaluated to reduce or prevent ED delirium. No intervention consistently prevented or treated delirium. After reviewing the scoping review results, the GEAR stakeholders identified ED delirium prevention interventions not reliant on additional nurse or physician effort as the highest priority research. CONCLUSIONS: Transdisciplinary stakeholders prioritize ED delirium prevention studies that are not reliant on health care worker tasks instead of alternative research directions such as defining etiologic delirium phenotypes to target prevention or intervention strategies.

GRECC Connect: Geriatrics Telehealth to Empower Health Care Providers and Improve Management of Older Veterans in Rural Communities.

A telehealth program supports meaningful partnerships between urban geriatric specialists and rural health care providers to facilitate increased access to specialty care.

Training Programs on Geriatrics in Rural Areas: A Review.

PURPOSE OF REVIEW: To understand the current scope of training in geriatrics in rural areas for rural providers and teams, we reviewed current literature to identify training programs which pertain to geriatric education and training of the rural workforce. RECENT FINDINGS: Older adults are one of the fastest growing demographics in the United States and represent a higher share of the population in rural areas than in other counties. Older adults in rural areas often have complex health challenges and may benefit from care from healthcare teams with geriatrics training. However, there is a paucity of geriatrics workforce in the country and particularly in rural areas. Geriatric training programs targeting rural practitioners may serve to bridge this gap through providing training and support to rural teams taking care of older adults in rural areas. SUMMARY: Ten unique programs were identified which described efforts to introduce geriatrics to rural practitioners. Each used different methods of training at a distance, leveraging the use of telecommunications and the internet, or face to face training methods alone or in combination with distance training. Improvements in clinician knowledge, skills and other impacts were described. Current evidence demonstrates that providing training in geriatrics is feasible and may yield positive impacts on rural clinical teams and potential downstream effects on patient care.

An Interdisciplinary Academic Detailing Approach to Decrease Inappropriate Medication Prescribing by Physician Residents for Older Veterans Treated in the Emergency Department.

OBJECTIVE: To evaluate the impact of an academic detailing intervention delivered as part of a quality improvement project by a physician-pharmacist pair on (1) self-reported confidence in prescribing for older adults and (2) rates of potentially inappropriate medications (PIMs) prescribed to older adults by physician residents in a Veteran Affairs emergency department (ED). METHODS: This quality improvement project at a single site utilized a questionnaire that assessed knowledge of Beers Criteria, self-perceived barriers to appropriate prescribing in older adults, and self-rated confidence in ability to prescribe in older adults which was administered to physician residents before and after academic detailing delivered during their emergency medicine rotation. PIM rates in the resident cohort who received the academic detailing were compared to residents who did not receive the intervention. RESULTS: Sixty-three residents received the intervention between February 2013 and December 2014. At baseline, approximately 50% of the residents surveyed reported never hearing about nor using the Beers Criteria. A significantly greater proportion of residents agreed or strongly agreed in their abilities to identify drug-disease interactions and to prescribe the appropriate medication for the older adult after receiving the intervention. The resident cohort who received the educational intervention was less likely to prescribe a PIM when compared to the untrained resident cohort with a rate ratio of 0.73 ( P < .0001). CONCLUSION: Academic detailing led by a physician-pharmacist pair resulted in improved confidence in physician residents' ability to prescribe safely in an older adult ED population and was associated with a statistically significant decrease in PIM rates.