A man with urethral polyembolokoilamania successfully treated with electroconvulsive therapy.

Polyembolokoilamania is the act of inserting foreign objects into bodily orifices and can be classified as a paraphilia if done for sexual pleasure. Although problematic sexual behaviors are common in dementia, the majority of case reports of urethral polyembolokoilamania in the elderly have occurred in the absence of dementia or cognitive impairment. Little empirical evidence exists for managing problematic sexual behaviors in the elderly and in dementia. Most evidence in the form of case reports demonstrates that behavioral, environmental, and pharmacological interventions can be effective. In this case report, we describe the management of sexually disinhibited behavior in the form of polyembolokoilamania in a 67-year-old man suffering from treatment-resistant depression, obsessive compulsive disorder, and early signs of frontotemporal dementia. The successful treatment included a course of electroconvulsive therapy.

Aging is not an Illness: Exploring Geriatricians' Resistance to Serious Illness Conversations.

CONTEXT: Serious illness conversations help clinicians align medical decisions with patients' goals, values, and priorities and are considered an essential component of shared decision-making. Yet geriatricians at our institution have expressed reluctance about the serious illness care program. OBJECTIVES: We sought to explore geriatricians' perspectives on serious illness conversations. METHODS: We conducted focus groups with interprofessional stakeholders in geriatrics. RESULTS: Three key themes emerged that help explain the reluctance of clinicians caring for older patients to have or document serious illness conversations: 1) aging in itself is not a serious illness; 2) geriatricians often focus on positive adaptation and social determinants of health and in this context, the label of "serious illness conversations" is perceived as limiting; and 3) because aging is not synonymous with illness, important goals-of-care conversations are not necessarily documented as serious illness conversations until an acute illness presents itself. CONCLUSION: As institutions work to create system-wide processes for documenting conversations about patients' goals and values, the unique communication preferences of older patients and geriatricians should be specifically considered.

Building community and resilience in Massachusetts nursing homes during the COVID-19 pandemic.

During the COVID-19 pandemic, frontline nursing home staff faced extraordinary stressors including high infection and mortality rates and ever-changing and sometimes conflicting federal and state regulations. To support nursing homes in evidence-based infection control practices, the Massachusetts Senior Care Association and Hebrew SeniorLife partnered with the Agency for Healthcare Research and Quality AHRQ ECHO National Nursing Home COVID-19 Action Network (the network). This educational program provided 16 weeks of free weekly virtual sessions to 295 eligible nursing homes, grouped into nine cohorts of 30-33 nursing homes. Eighty-three percent of eligible nursing homes in Massachusetts participated in the Network, and Hebrew SeniorLife's Training Center served the vast majority. Each cohort was led by geriatrics clinicians and nursing home leaders, and coaches trained in quality improvement. The interactive sessions provided timely updates on COVID-19 infection control best practices to improve care and also created a peer-to-peer learning community to share ongoing challenges and potential solutions. The weekly Network meetings were a source of connection, emotional support, and validation and may be a valuable mechanism to support resilience and well-being for nursing home staff.

Toward a 21st-century health care system: recommendations for health care reform.

The coverage, cost, and quality problems of the U.S. health care system are evident. Sustainable health care reform must go beyond financing expanded access to care to substantially changing the organization and delivery of care. The FRESH-Thinking Project (www.fresh-thinking.org) held a series of workshops during which physicians, health policy experts, health insurance executives, business leaders, hospital administrators, economists, and others who represent diverse perspectives came together. This group agreed that the following 8 recommendations are fundamental to successful reform: 1. Replace the current fee-for-service payment system with a payment system that encourages and rewards innovation in the efficient delivery of quality care. The new payment system should invest in the development of outcome measures to guide payment. 2. Establish a securely funded, independent agency to sponsor and evaluate research on the comparative effectiveness of drugs, devices, and other medical interventions. 3. Simplify and rationalize federal and state laws and regulations to facilitate organizational innovation, support care coordination, and streamline financial and administrative functions. 4. Develop a health information technology infrastructure with national standards of interoperability to promote data exchange. 5. Create a national health database with the participation of all payers, delivery systems, and others who own health care data. Agree on methods to make de-identified information from this database on clinical interventions, patient outcomes, and costs available to researchers. 6. Identify revenue sources, including a cap on the tax exclusion of employer-based health insurance, to subsidize health care coverage with the goal of insuring all Americans. 7. Create state or regional insurance exchanges to pool risk, so that Americans without access to employer-based or other group insurance could obtain a standard benefits package through these exchanges. Employers should also be allowed to participate in these exchanges for their employees' coverage. 8. Create a health coverage board with broad stakeholder representation to determine and periodically update the affordable standard benefit package available through state or regional insurance exchanges.

Shared decision-making for older adults with cardiovascular disease.

Shared decision-making is appropriate for clinical decisions involving multiple reasonable options, which occur frequently in the cardiovascular care of older adults. The process includes the communication of relevant factual information between the patient and the clinician, elicitation of patient preferences, and a mutual agreement on the best course of action to meet the patient's personal goals. For older adults, there are common challenges and considerations with regard to shared decision-making, some of which (eg, cognitive impairment) may be biologically linked to cardiovascular disease. There are tools designed to facilitate the shared decision-making process, known as decision aids, which are broadly effective although have shortcomings when applied to older adults. Novel approaches in clinical research and health systems changes will go some way toward improving shared decision-making for older adults, but the greatest scope for improvement may be within the grass roots areas of communication skills, interdisciplinary teamwork, and simply asking our patients what matters most.

Boarding Duration in the Emergency Department and Inpatient Delirium and Severe Agitation.

This cohort study examines the risk factors for developing delirium and/or agitation in patients in the emergency department waiting for an inpatient bed.

Teaching geriatric assessment: use of a hybrid method in a family medicine clerkship.

BACKGROUND AND OBJECTIVES: We addressed a lack of geriatric content in our third-year family medicine clerkship. Adding this content posed a challenge in that students are dispersed to clinical sites across New England. Our goal was to promote student skill in functional assessment of elderly patients. METHODS: We used multiple formats: a workshop, a small-group case discussion, an online video, and an online discussion of a new geriatric case. Students were directed to use five assessment tools on actual patients in the office and on a home visit. RESULTS: A total of 155 students participated in the new curriculum. Students completed a required home visit on an older patient and evaluated geriatric patients in an office setting. They performed the Mini-Mental State Exam (MMSE), Activities of Daily Living Scale (ADL), Instrumental Activities of Daily Living Scale (IADL), Geriatric Depression Scale (GDS), and Get-Up-and-Go tests in patients in both settings. There was significant improvement from before to after the clerkship in identification of the appropriate geriatric assessment tool to use (MMSE 86% to 96%; ADL/IADL 32% to 94%; GDS 71% to 94%, and Get-Up-and-Go 4% to 58%). Students evaluated the curriculum positively. CONCLUSIONS: We were able to successfully increase the correct selection of and document high rates of use of geriatric functional assessment tools in our third-year family medicine clerkship using a mixture of teaching methods.

The Patient's Perspective of the Intensive Care Unit Diary in the Cardiac Intensive Care Unit.

BACKGROUND: Many patients who survive an intensive care unit admission develop post-intensive care syndrome and face significant long-term physical, cognitive, and mental health impairments. The intensive care unit diary is a reality-sorting tool that is effective in aiding patients to connect their flashbacks and delusional memories to actual events. OBJECTIVES: To describe implementation of an intensive care unit diary in the cardiac intensive care unit and to describe the patient's perspective of the diary. METHODS: Consent for participation in the study was given by the patient health care proxy or a family member. The study consisted of 3 phases: writing in the diary about the patient's events in the cardiac intensive care unit, a follow-up visit with the patient within 1 week of cardiac intensive care unit transfer, and a follow-up telephone call 2 months after hospital discharge. RESULTS: Of 26 patients, 13 completed all phases of the study. Four themes were identified from the transcripts of the patients' responses: (1) The diary allowed patients to correlate memories to actual events, (2) it enabled patients to read about their families' experiences during their critical illness, (3) recovery was an emotional process that affected the patient's readiness to read the diary, and (4) patients expressed a desire for more entries by caregivers. CONCLUSIONS: The intensive care unit diary can help patients gain clarity of their time in the cardiac intensive care unit. Additional research on the use of the diary and long-term patient follow-up is warranted.

Chief Resident Immersion Training in the Care of Older Adults: A Successful National Replication of an Interspecialty Educational Intervention.

PURPOSE: Nongeriatricians must acquire skills and knowledge in geriatric medicine to ensure coordinated care of older adults' complex conditions by interspecialty and interprofessional teams. Chief residents (CRs) are an ideal target for an educational intervention. This study examined whether the Boston Medical Center Chief Resident Immersion Training (CRIT) in the Care of Older Adults was replicable at diverse medical institutions. METHOD: Between 2008 and 2010, 12 institutions in 11 states received funding, technical support, and a common program model. Each implemented 2.5-day CRITs, consisting of a patient case, geriatrics-related lectures, CR leadership sessions, action project planning, and networking time. Site faculty conducted 21 CRITs for 295 CRs representing 28 specialties. CRs completed knowledge pre- and posttests, and self-report baseline and six-month follow-up surveys. Outcome measures were change in pre- and posttest score, and change from baseline to six months in self-reported surveys. RESULTS: Response rate for CRs was 99% (n = 293) for the pre-post tests and 78% (n = 231) for matchable baseline and follow-up surveys. Participants' knowledge increased from 6.32 to 8.39 (P < .001) averaged from 12 questions. CRs' self-reported ability to apply clinical problem-solving skills to older patients (P < .001), number of geriatrics topics taught (P < .001), frequency of geriatrician consultations (P = .017), confidence in leadership skills (P < .001), and confidence to conduct CR work (P < .001) increased from baseline to follow-up. CONCLUSIONS: CRIT is an innovative way to give nongeriatricians knowledge and skills to treat complex older patients.

Practicing physician education in geriatrics: lessons learned from a train-the-trainer model.

Evidence of poor performance in the evaluation and management of common geriatric conditions suggests the need for changing physician behavior in these areas. Traditional lecture-style continuing medical education (CME) has not been shown to be effective. Expert faculty initially trained 60 nonexpert peer educators to conduct small-group, learner-centered CME using tool kits on memory loss, incontinence, and depression. Peer educators presented 109 community-based sessions to 1,309 medical practitioners. Surveys were administered to community participants immediately and 6 months after a session. Evidence of effectiveness included statistically significant increases in self-reported knowledge, attitudes, and office-based practices on the target topics at the time of training and at the 6-month follow-up (P<.001) and two-thirds of respondents reporting continued use of three or more tools at 6 months. Participants reported that the interactive presentation aided their understanding of and ability to use the tool kits more than an off-the-shelf review (mean rating+/-standard deviation 4.1+/-0.71, with 1 = not at all and 5 = significantly). After the formal evaluation period, additional information about the project dynamics and tool kits was obtained through a small interview sample and an on-line survey, respectively. Receiving copies of the tool kits was an important factor in enabling educators to offer sessions. Barriers to offering sessions included finding time, an audience, and space. Findings suggest that modest positive changes in practice in relation to common geriatric problems can be achieved through peer-led, community-based sessions using principles of knowledge translation and evidence-based tool kits with materials for providers and patients.

Professionalism and evolving concepts of quality.

For much of the twentieth century, quality of care was defined specifically in terms of physician characteristics and behaviors. High-quality physicians were well trained, knowledgeable, skillful, and compassionate. More recently, quality of care has been defined in terms of systems of care. High-quality organizations develop and adopt practices to reduce adverse events and optimize outcomes. This essay discusses this transformation from physician-based to organization-based concepts of quality and the consequences for patient care and medical professionalism.

Blogging as an Innovative Method of Peer-to-Peer Educational Sharing.

BACKGROUND: Nurses in the cardiac intensive care unit often attend professional education opportunities. However, it is difficult to share this information among nursing staff. Varying schedules, different shifts, and patient acuity limit the amount of time available for peer-to-peer sharing of educational information. A review of the literature revealed scant research on blogging for peer-to-peer education in general and particularly in nursing. OBJECTIVES: To explore nurses' perception of the effectiveness of using a blog as a forum to provide peer-to-peer sharing of relevant professional education. METHODS: Using a simple, free blogging website, the unit's nursing practice council developed a private blog for educational information sharing among the nursing staff. An online survey was administered to the unit's staff 15 months after the blog was implemented. RESULTS: Most respondents indicated that they thought the blog is an effective way to share professional education (86%), keeps them abreast of evidence-based practice (81%), and has led to practice change (59%). Nearly 80% of respondents agreed that they are more likely to attend professional conferences, and 62% would consider contributing blog posts. CONCLUSION: The survey results suggest that blogging may be an effective method of peer-to-peer sharing of education, although more rigorous research is required in this area.

Co-creation by the ABIM Geriatric Medicine Board and the AGS - Helping Move Geriatrics Forward.

The American board of internal medicine (ABIM) establishes standards for physicians. The American geriatrics society (AGS) is a not-for-profit membership organization of nearly 6,000 health professionals devoted to improving the health, independence, and quality of life of all older people. Beginning in 2013, ABIM redesigned its governance structure, including the role of the specialty boards. Specialty boards are charged with responsibilities for oversight in four main areas: (1) the assessments used in initial certification and maintenance of certification (MOC); (2) medical knowledge self-assessment and practice assessment in the specialty; (3) building relationships with relevant professional societies and other organizational stakeholders; and (4) issues related to training requirements for initial certification eligibility within the specialty. The aim of this paper is to inform the geriatrics community regarding the function of geriatric medicine board (GMB) of the ABIM, and to invite the geriatrics community to fully engage with and leverage the GMB as a partner to: (1) develop better certification examinations and processes, identifying better knowledge and practice assessments, and in establishing appropriate training and MOC requirements for geriatric medicine; (2) leverage ABIM assets to conduct applied research to guide the field in the areas of training and certification and workforce development in geriatric medicine; (3) make MOC relevant for practicing geriatricians. Active engagement of the geriatrics community with ABIM and the GMB will ensure that certification in geriatric medicine provides the greatest possible value and meaning to physicians, patients, and the public.

Continuing medical education, continuing professional development, and knowledge translation: improving care of older patients by practicing physicians.

Many community-based internists and family physicians lack familiarity with geriatrics knowledge and best practices, but they face overwhelming fiscal and time barriers to expanding their skills and improving their behavior in the care of older people. Traditional lecture-and-slide-show continuing medical education (CME) programs have been shown to be relatively ineffective in changing this target group's practice. The challenge for geriatrics educators, then, is to devise CME programs that are highly accessible to practicing physicians, that will have an immediate and significant effect on practitioners' behavior, and that are financially viable. Studies of CME have shown that the most effective programs for knowledge translation in these circumstances involve what is known as active-mode learning, which relies on interactive, targeted, and multifaceted techniques. A systematic literature review, supplemented by structured interviews, was performed to inventory active-mode learning techniques for geriatrics knowledge and skills in the United States. Thirteen published articles met the criteria, and leaders of 28 active-mode CME programs were interviewed. This systematic review indicates that there is a substantial experience in geriatrics training for community-based physicians, much of which is unpublished and incompletely evaluated. It appears that the most effective methods to change behaviors involved multiple educational efforts such as written materials or toolkits combined with feedback and strong communication channels between instructors and learners.

Faculty development in geriatrics for clinician educators: a unique model for skills acquisition and academic achievement.

As the size of the aged American population increases, so too does the shortage of trained providers in geriatrics. Educational strategies to train physicians at all levels of experience within adult medical and surgical disciplines are needed to complement fellowship training, given the small size of most academic faculties in geriatrics. This article describes a unique faculty development program that creates geriatrically oriented faculty in multiple disciplines. The Boston University Center of Excellence in Geriatrics (COE), funded by the John A. Hartford Foundation, has trained 25 faculty members. Four to six scholars enter the program each year and participate in the COE 1 day per week. Nine months are spent in four content modules-Geriatrics Content, Clinical Teaching, Evidence-based Medicine, and Health Care Systems; 3 months are spent in supervised scholarly activities and clinical settings. A self-report questionnaire and a structured interview were used to evaluate the outcomes of participation in the COE. The results from the first 4 years of the program are reported. The response rate was 83% for the self-report questionnaire and 75% for the structured interview. The results indicate that the COE is effective in improving scholars' assessment and management of older patients. The structured interview revealed that the COE program promotes the integration of geriatrics into clinical teaching at the medical student and resident level. Participants also completed scholarly projects in geriatrics. This program effectively trains faculty scholars to better care for older adults and to teach others to do likewise.