Infusing geriatrics in Indian Health Service general primary care clinics: Extending VA workforce development training.

As federal partners, the Veterans Health Administration (VA) and the Indian Health Service (IHS) agreed to share resources, such as education. The VA Geriatric Scholars Program, a workforce development program, provides one of its training programs on team-based primary care of elders to clinicians working in IHS and Tribal Health Programs. The practical impact of that training is described. A mixed methods approach was applied to the course's evaluation survey at five clinics in the Northwestern Plains, Southwest, Pacific Coast, and Alaska. Quantitative approaches assessed participants' self-reported intention to improve recognition and assessment of common geriatric syndromes. A qualitative approach applied to open-ended text responses revealed intensions to improve team-based care. Among the 51 respondents in our sample, we found significant improvements in self-reported ability to recognize previously unfamiliar potential risks to elders' health and safety, t(49) = 8.0233, p < .001, as well as increased comfort with conducting geriatric assessments and increased confidence in interprofessional team-based communication. Improvements to team-based care included enhanced clinical skills, organizational factors and the need to train additional employees. This evaluation demonstrates the value of sharing resources among federal partners and its value for participants in IHS and Tribal Health Programs.

Dementia and Falls Management in Underserved Populations: The Cognition and Mobility Care Management Program.

BACKGROUND/OBJECTIVES: Cognitive and mobility impairments are common and underdiagnosed chronic conditions that afflict community-dwelling older adults. This study describes the organization, implementation, and evaluation of an intervention for underserved and ethnically diverse older patients with dementia and/or falls risk. DESIGN: Observation, baseline and 1 year after intervention. SETTING: Community-based primary care county clinics in inland southern California. PARTICIPANTS: A total of 272 persons, aged 70 years and older, who screened positive for falls and/or dementia and enrolled in the Cognition and Mobility Care Management program during the study period. INTERVENTION: A nurse care manager performed a patient and caregiver evaluation and created and implemented a care plan with medical, behavioral, and psychosocial interventions in partnership with patients and their primary care providers. MEASUREMENTS: Process outcomes included rates of positive screening for dementia and fall risk, referral, enrollment, and visit completion. Patient outcomes included fall history, mobility and cognitive assessments, and depression scales. Patients and/or caregivers completed questionnaires rating perceived benefits of enrollment after 1 year in the program. RESULTS: Medical assistants screened 573 patients aged 70 years and older during the study period; 78% screened positive for dementia and/or fall risk. Of the patients who screened positive, 94% were referred; 91% of contacted patients elected to enroll, and 272 patients completed an intake visit (meanage = 77 years; 65% female; 75% Latino; 10% African American). The patients and caregivers who completed satisfaction questionnaires 1 year after enrollment rated the program highly, and 92% would recommend the program to others. CONCLUSION: A primary care-based screening and comanagement program to identify and manage dementia and falls risk in primarily Latino and African American older adult patients living in an underserved area was well received, with high satisfaction and perceived benefit from patients and caregivers.

Derivation and Validation of a Geriatric-Sensitive Perioperative Cardiac Risk Index.

BACKGROUND: Surgical patients aged 65 and over face a higher risk of cardiac complications from noncardiac surgery. The Revised Cardiac Risk Index (RCRI) and the Gupta Myocardial Infarction or Cardiac Arrest (MICA) calculator are widely used to predict this risk, but they are not specifically designed to predict MICA in geriatric patients. Our hypothesis is that a new geriatric-sensitive index, derived from geriatric data, will capture this population's unique response to risk factors. METHODS AND RESULTS: The model was developed using the NSQIP (National Surgical Quality Improvement Program) 2013 geriatric cohort (N=584,931) (210,914 age ≥65) and validated on the NSQIP 2012 geriatric cohort (N= 485,426) (172,905 age ≥65). Least Angle Shrinkage and Selection Operator regression was used for initial variable selection. The Geriatric-Sensitive Cardiac Risk Index (GSCRI) was then evaluated in the 2012 data set. The area under the curve (AUC) was compared among the GSCRI, RCRI, and Gupta MICA in the 2012 data set. The GSCRI had an AUC of 0.76 in the validation cohort among geriatric patients. When the Gupta MICA was tested on geriatric patients in the validation cohort, a significant deterioration (≈17%) was noted, as well as a significant underestimation of the risk. The GSCRI AUC of 0.76 in the geriatric subset was significantly greater (P<0.001) than those in the RCRI (AUC=0.63) or Gupta MICA (AUC=0.70) models, outperforming the RCRI and Gupta MICA models in geriatric patients by 13% and 6%, respectively, with a ΔAUC and P-value of 0.13 (P<0.001), and 0.06 (P<0.001). CONCLUSIONS: The GSCRI is a significantly better predictor of cardiac risk in geriatric patients undergoing noncardiac surgery.

Development and Validation of a Geriatrics Knowledge Test to Evaluate Geriatrics Fellowship Programs.

BACKGROUND/OBJECTIVES: Although the Accreditation Council for Graduate Medical Education requires that geriatrics fellowship programs be evaluated, evaluation is challenging because of lack of appropriate instruments. The purpose of this study was to develop and validate a geriatrics knowledge test appropriate for evaluation of geriatrics fellowship programs. DESIGN: Initial and replication cross-sectional validation studies. SETTING: Academic medical center. PARTICIPANTS: Initial study: 11 postgraduate year (PGY)-2 and five PGY-3 internal medicine residents, eight incoming and eight graduating geriatrics fellows, and 11 geriatrics faculty (N = 43). Replication study: nine graduating fellows and three mid-year fellow cohorts (n = 11, 8, and 9) (N = 37). MEASUREMENTS: A geriatrics knowledge test was developed consisting of 31 multiple-choice questions (MCQs) selected from a 54-item pool of MCQs that the authors created. Selection criteria included content appropriateness, item correlation with total score, item discriminatory power, and item difficulty. RESULTS: The instrument demonstrated high reliability (Cronbach alpha = 0.83) and known group validity. The mean percentage correct scores on the knowledge test were progressively higher with more geriatrics training (P < .001). The replication study continued to show patterns of progressive increases in score with additional training. There were no floor or ceiling effects. CONCLUSION: A 31-item geriatrics knowledge test demonstrates sound reliability and validity. The findings support that it is appropriate as a tool for evaluation of geriatrics fellowship programs.

Do SSRIs play a role in decreasing bone mineral density?

Osteoporosis is expected to increase as our population pyramid shifts toward old age. It is associated with increased risk of fractures, leading to complications of limitation of ambulation, loss of independence, and chronic pain. Depression is also a common occurrence in the elderly population. Currently, up to 35% of residents in long term care may experience either major depression or clinically significant depressive symptoms. Selective serotonin receptor inhibitors constitute 62% of all antidepressant drug prescribing. Recently, serotonin transporters have been described in bone, raising the question of whether medications that block serotonin reuptake could affect bone metabolism and ultimately affect osteoporosis-related fractures. Current evidence suggests that depression, particularly in the setting of selective serotonin receptor inhibitors use, should be considered as an addition to the list of risk factors prompting clinicians to evaluate bone health status.

A synopsis of phosphate disorders in the nursing home.

Elderly patients are at an increased risk of developing both hypophosphatemia and hyperphosphatemia. Renal insufficiency predisposes elderly patients to elevated serum concentrations of phosphate. On the other hand, poor dietary intake and loss of phosphorus in the urine can lead to deficiency states. It is well documented that hyperphosphatemia is correlated with an increase in morbidity and mortality as a result of vascular calcification. This article reviews the etiology, pathophysiology, symptoms, and treatment of hypophosphatemia and hyperphosphatemia.

Apathy: a common psychiatric syndrome in the elderly.

Apathy, or a lack of motivation, has been increasingly recognized as a distinct psychiatric syndrome. Apathy is primarily a dysfunction of the frontal-subcortical circuit and is associated with various neuropsychiatric disorders including Alzheimer's disease. Apathy is associated with a number of adverse outcomes, including apparent cognitive impairment, decreased daily function, poor insight into one's own functional and cognitive impairment, and poor outcome from rehabilitation treatment. Furthermore, the degree of caregiver's burden in these patients is significant. This article reviews the definition of apathy, prevalence and associated adverse outcomes, causation, the approach to patients with apathy, and available treatment options with particular attention to studies conducted in a nursing home setting. The purpose of this article is to increase the recognition of apathy by physicians working in the nursing home.

Nonsurgical treatment for rotator cuff injury in the elderly.

Shoulder pain is a common musculoskeletal complaint in the general population. The elderly population is often afflicted, and rotator cuff problems are among the most common causes of shoulder pain seen in primary care practices. The prevalence of shoulder pain in the elderly has been estimated to range from 21% to 27%, and the prevalence of rotator cuff tear increases with advanced age. The etiology of rotator cuff disease is likely multifactorial, including both extrinsic and intrinsic factors. Rotator cuff dysfunction encompasses a spectrum of pathological changes, ranging from impingement syndrome to rotator cuff tendonitis to rotator cuff tendon tear. In the elderly population, the clinical manifestations from rotator cuff dysfunction can translate into significant morbidity and disabilities, interfering with ability for self care and functional independence. The goals of managing rotator cuff disease are to regain normal shoulder function and biomechanics, and to improve functional abilities in elderly patients. Treatment can consist of various conservative therapies (including ice, simple exercises, medications), and progress to more intensive physical therapy and/or corticosteroid injections. Rotator cuff dysfunction is a common musculoskeletal disorder in elderly patients and is often underdiagnosed and undertreated. Physicians should be aware of the prevalence of rotator cuff disease in this population and provide early diagnosis and treatment to help preserve the functional ability and independence of older patients.

Encouraging geriatric medicine fellows to write review articles: a description of our experience.

Medical education in the United States develops many skills, but writing is not usually one of them. At the UCLA Multicampus Division of Geriatrics, we recently instituted a project that attempts to provide the opportunity for each of our Geriatric Medicine fellows to write and publish a review article. We report our experiences of the first 3 years of this program in an effort to share our successes, our shortcomings and our impressions.

The utility of PET brain imaging in the initial evaluation of dementia.

Given the challenges and benefits of timely and accurate diagnosis of neurodegenerative disorders and the importance of appropriate subsequent treatments, physicians and patients alike desire tools that aid in diagnosing dementia as early and as precisely as possible. One of these tools may be functional brain imaging, specifically positron emission tomography (PET). Recent technological advancements, ongoing research studies, and approval for reimbursement by various insurance companies and Medicare, under certain circumstances, have led to an increased interest in the use of this tool in the evaluation of dementia. This article will review PET brain imaging in the initial assessment and diagnosis of dementia, including its place in current guidelines and role in diagnostic algorithms, its applicability in differentiating among various dementia syndromes and major psychiatric disorders, and some of the controversies surrounding its utility in general clinical practice.

Orthostatic hypotension in the nursing home setting.

Orthostatic hypotension is a common condition among nursing home (NH) residents. NH residents tend to have multiple disease processes and tend to be on multiple medications associated with orthostatic hypotension and are predisposed to a myriad of negative clinical consequences, most notably falls. This article discusses a commonsense approach to diagnosis, evaluation, and treatment of patients with this disorder, with an emphasis on nonpharmacological interventions, such as patient and staff education.

Falls in the nursing home: are they preventable?

INTRODUCTION: Falls are prevalent in elderly patients residing in nursing homes, with approximately 1.5 falls occurring per nursing home bed-years. Although most are benign and injury-free, 10% to 25% result in hospital admission and/or fractures. Primary care providers for nursing home residents must therefore aim to reduce both the fall rate as well as the rate of fall-related morbidity in the long-term care setting. Interventions have been demonstrated to be successful in reducing falls in community-dwelling elderly patients. However, less evidence supports the efficacy of fall prevention in nursing home residents. METHODS: The authors conducted a Medline search using the key words Falls and Nursing Homes. RESULTS: Several studies examined the efficacy of multifaceted intervention programs on reducing falls in nursing homes with varied results. Components of these intervention programs include: environmental assessment, assistive device evaluation and modification, medication changes, gait assessment and training, staff education, exercise programs, hip protector use, and blood pressure evaluation. Current literature supports the use of environmental assessment and intervention in reducing falls in nursing homes, and demonstrates an association between certain medications and falls. However, there are no studies that examine the effect of medication adjustments on fall rates. Also, the literature does not strongly suggest that exercise programs are effective in fall reduction. Although not effective in reducing fall rates, the use of hip protectors appears to result in less fall-related morbidity. CONCLUSION: More studies must be done to clarify the effects of high-risk medication reduction, the optimal nature and intensity of exercise programs, and patient targeting criteria to maximize the effectiveness of nursing home fall prevention programs. Based on the current literature, an effective multifaceted fall prevention program for nursing home residents should include risk factor assessment and modification, staff education, gait assessment and intervention, assistive device assessment and optimization, as well as environmental assessment and modification. Although there is no association between the use of hip protectors and fall rates, their use should be encouraged because the ultimate goal of any fall prevention program is to prevent fall-related morbidity.

What is the proper use of hemoglobin A1c monitoring in the elderly?

Diabetes mellitus (DM) is a major health problem for the aging population. Glycemic control is fundamental to the management of diabetes, as glycemic levels are closely linked to development of diabetes-related complications. Measurement of the hemoglobin A1c (A1c) to assess chronic glycemic control is an integral component of diabetes care. Currently, there is no clear evidence that age alters the relationship between A1c and average blood glucose. The Diabetes Control and Complications trial and the United Kingdom Prospective Diabetes Study are the 2 main studies that have provided evidence leading to the widespread recommendation of A1c monitoring. The American Diabetes Association recommends achieving an A1c level of 7% or lower. However, older diabetics represent a heterogeneous population ranging from frail nursing home residents to active community-dwelling elderly with variable life expectancies. One needs to look at the individual in order to best balance risk versus benefit associated with tight glycemic control. Benefits of intensive therapy in an effort to lower A1c must always be weighed against the greater risk of disabling and unpredictable hypoglycemia, as the geriatric population is less likely to benefit from reducing the risk of microvascular complications and more likely to suffer serious adverse effects from hypoglycemia.

Falls in the nursing home: Are they preventable?

INTRODUCTION: Falls are prevalent in elderly patients residing in nursing homes, with approximately 1.5 falls occurring per nursing home bed-years. Although most are benign and injury-free, 10% to 25% result in hospital admission and/or fractures. Primary care providers for nursing home residents must therefore aim to reduce both the fall rate as well as the rate of fallrelated morbidity in the long-term care setting. Interventions have been demonstrated to be successful in reducing falls in community-dwelling elderly patients. However, less evidence supports the efficacy of fall prevention in nursing home residents. METHODS: The authors conducted a Medline search using the key words Falls and Nursing Homes. RESULTS: Several studies examined the efficacy of multifaceted intervention programs on reducing falls in nursing homes with varied results. Components of these intervention programs include: environmental assessment, assistive device evaluation and modification, medication changes, gait assessment and training, staff education, exercise programs, hip protector use, and blood pressure evaluation. Current literature supports the use of environmental assessment and intervention in reducing falls in nursing homes, and demonstrates an association between certain medications and falls. However, there are no studies that examine the effect of medication adjustments on fall rates. Also, the literature does not strongly suggest that exercise programs are effective in fall reduction. Although not effective in reducing fall rates, the use of hip protectors appears to result in less fall-related morbidity. CONCLUSION: More studies must be done to clarify the effects of high-risk medication reduction, the optimal nature and intensity of exercise programs, and patient targeting criteria to maximize the effectiveness of nursing home fall prevention programs. Based on the current literature, an effective multifaceted fall prevention program for nursing home residents should include risk factor assessment and modification, staff education, gait assessment and intervention, assistive device assessment and optimization, as well as environmental assessment and modification. Although there is no association between the use of hip protectors and fall rates, their use should be encouraged because the ultimate goal of any fall prevention program is to prevent fall-related morbidity.

Can we prevent aspiration pneumonia in the nursing home?

Aspiration pneumonia is a significant cause of morbidity, hospitalization, and mortality in the nursing home population. Patients who aspirate have three times higher mortality than patients who do not aspirate. We discuss the factors known to increase the risk of aspiration and its consequences, and recognize some of the preventive measures for aspiration pneumonia. We suggest approaches to decrease the risk of this very prevalent syndrome.