Beliefs regarding geriatrics primary care topics among medical students and internal medicine residents.

This study evaluated beliefs regarding 25 content areas essential to the primary care of older adults and attitudes toward aging held by first-yearmedical students and Internal Medicine residents. A survey of 136 medical students and 61 Internal Medicine residents was conducted at an academic health-center. Beliefs were assessed by the 25-item Geriatrics Clinician-Educator Survey. Gap scores reflecting the difference in ratings between self-rated importance and knowledge were calculated. Attitudes toward aging was assessed by the Images of Aging Scale. Students and residents expressed similar beliefs about the importance of content areas, but students provided lower ratings in knowledge. Students reported larger gap scores in areas that reflected general primary care (e.g., chronic conditions, medications), whereas residents reported larger gap scores in areas that reflected specialists' expertise (e.g., driving risk, cognition, psychiatric symptoms). Attitudes toward aging did not differ appreciably between students and residents. Our findings suggest that primary care topics applicable for any age demographic were rated as most important by first-year medical students and Internal Medicine residents. Topics relevant to older populations--particularly those requiring specialists' knowledge of or requiring sensitive discussion with older adults-were rated as less important and were less well-mastered.

Medical Faculty Beliefs: Self-Rated Importance and Confidence in Teaching Geriatrics Primary Care.

OBJECTIVES: To evaluate and contrast 25 content areas essential to the primary care of older adults by medical faculty, thus identifying faculty beliefs and areas of possible improvement. DESIGN: Using measures from the Healthcare Effectiveness Data and Information Set, the Consumer Assessment of Healthcare Providers and Systems, and Healthy People 2020, nine practicing clinical faculty identified 25 content areas essential to the primary care of older adults. SETTING: A large academic health center in southeastern United States. PARTICIPANTS: Eighty-two university medical faculty. MEASUREMENTS: Faculty rated importance, knowledge, and confidence in teaching the 25 content areas on a scale from 1 (low) to 10 (high). Gap scores reflecting the difference in ratings for importance and confidence in teaching were calculated and assessed. The survey had high internal consistency within each of the three domains-Cronbach's α > .94. RESULTS: The most important content areas were being able to explain details about patient's condition and taking medication clearly, followed by taking age-appropriate history. The three largest gaps were: "evaluating sensory impairment," "identifying and counseling at-risk drivers," and "evaluating cognition." The three smallest gaps were: "explaining prescribed medications," "explaining health conditions in easy-to-understand language," and "taking an age-appropriate patient history and performing a physical assessment." CONCLUSION: Medical faculty were comfortable with topics reflecting primary care expertise but expressed less confidence with more specialized topics, such as sensory or cognitive impairment and driving. This may represent key areas for geriatrics training applicable to all those involved in education and training of future healthcare professionals. Integration of specialists (eg, neurologists, psychiatrists) may improve the geriatrics curricula. J Am Geriatr Soc 67:576-580, 2019.

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.

Epidemiology of chronic kidney disease and anemia.

Anemia is a common comorbidity of chronic kidney disease (CKD). As the diseased kidney loses its ability to produce the erythropoietin essential to the production of hemoglobin, anemia ensues. The age-related rise in CKD makes anemia in CKD a problem of increasing prevalence among residents of long-term care facilities. CKD refers to the entire continuum of renal disease that progresses from mildly impaired kidney function (stage 1, glomerular filtration rate [GFR] > or =90 mL/min/1.73 m(2)) to significant deterioration, requiring dialysis or kidney transplant in what is categorized as stage 5 (GFR <15 mL/min/1.73 m(2)). The definition of anemia is controversial. The WHO defines anemia as hemoglobin <13 g/dL for men and <12 g/dL for women. The National Kidney Foundation's Kidney Disease Outcomes Quality Initiative, which is the criteria used for Medicare reimbursement, defines anemia in adult men and postmenopausal women as hemoglobin <12 g/dL, or <11 g/dL in a premenopausal woman.

Decisions for hospice care in patients with advanced cancer.

OBJECTIVES: To identify factors that may influence the decision of whether to enter a hospice program or to continue with a traditional hospital approach in patients with advanced cancer and to understand their decision-making process. DESIGN: Cross-sectional structured interview. SETTING: One community-based hospice and three university-based teaching hospitals. PARTICIPANTS: Two hundred thirty-four adult patients diagnosed with advanced lung, breast, prostate, or colon cancer with a life expectancy of less than 1 year: 173 hospice patients and 61 nonhospice patients receiving traditional hospital care. MEASUREMENTS: Hospice and nonhospice patients' demographic, clinical, and other patient-related characteristics were compared. Multivariate analysis was then conducted to identify variables associated with the hospice care decision in a logistic regression model. Information sources regarding hospice care and people involved in the hospice decision were identified. RESULTS: Patients receiving hospice care were significantly older (average age 69 vs 65 years, P =.009) and less educated (average 11.9 vs 12.9 years, P =.031) and had more people in their households (average 1.66 vs 1.16 persons, P =.019). Hospice patients had more comorbid conditions (1.30 vs 0.93, P =.035) and worse activities of daily living scores (7.01 vs 6.23, P =.030) than nonhospice patients. Hospice patients were more realistic about their disease course than their nonhospice counterparts. Patients' understanding of their prognoses affected their perceptions of the course of their disease. Hospice patients preferred quality of life to length of life. In the multivariate analysis, lower education level and greater number of people in the household were associated with the decision to enter hospice. A healthcare provider first told most of those who entered hospice about hospice. Families largely made the final decision to enter hospice (42%), followed by patients themselves (28%) and physicians (27%). CONCLUSION: The decision to enter hospice is related to demographic, clinical, and other patient-related characteristics. This study suggests that the decision-making process for hospice care in patients with advanced cancer is multidimensional. The healthcare community may better meet the end-of-life care needs of advanced cancer patients through enhanced communication with patients and families, including providing accurate prognoses and better understanding of patients' preferences and values.

Diminished quality of life and physical function in community-dwelling elderly with anemia.

The occurrence of anemia in older adults has been associated with adverse outcomes including functional decline, disability, morbidity, and mortality. It is not clear to what extent these outcomes are the result of the anemia or concurrent illness. We performed a cross-sectional, observational study to determine whether lower hemoglobin concentrations in older adults are associated with reduced health-related quality of life, functional status, depression, disability, and physical strength, independent of chronic disease. Three sites participated in this research: an academic geriatric practice, a hospital-based geriatric outpatient unit, and a community-based multispecialty internal medicine group. Health-related quality of life and functional status were measured using the Short Form-36 Health Survey (SF-36) and the Functional Assessment of Chronic Illness Therapy-Anemia (FACIT-An). Disability and depression were assessed using the Instrumental Activities of Daily Living (IADL) and the Geriatric Depression Scale (GDS) questionnaires, respectively. Handgrip strength was used as a physical performance measure. Anemia was defined as hemoglobin <13 g/dL for men or <12 g/dL for women. The mean SF-36 physical health component summary scores were 38.9 (with anemia) and 44.1 (without anemia) (p<0.001). Anemia was associated with greater fatigue (p < 0.001), lower handgrip strength (p = 0.014), increased number of disabilities (p=0.005), and more depressive symptoms (p = 0.002). Multivariate regression analysis, adjusted for demographic and clinical characteristics, demonstrated strong associations for reduced hemoglobin, even within the "normal" range, and poorer health-related quality of life across multiple domains. Thus, anemia was independently associated with clinically significant impairments in multiple domains of health-related quality of life, especially in measures of functional limitation. Mildly low hemoglobin levels, even when above the World Health Organization (WHO) anemia threshold, were associated with significant declines in quality of life among the elderly.