Outcomes and provider perspectives on geriatric care by a nurse practitioner-led community paramedicine program.

This study explores the use of a nurse practitioner-led paramedicine program for acute, home-based care of geriatric patients. This case series describes patients, outcomes, and geriatric primary care provider perspectives related to use of this independent paramedicine program. There were 40 patient visits from August 2016-May 2017. We reviewed patient demographics, medical conditions, healthcare utilization, and communication processes and used semi-structured interviews and content analysis to explore staff perspectives. The most commonly treated diagnoses were respiratory conditions, urinary tract infections, and gastrointestinal concerns. Two patients required an immediate transfer to a higher level of care. Six patients had emergency department visits and five patients were hospitalized within two weeks. Geriatric providers identified three themes including: potential benefits to geriatric patients, importance of enhanced care coordination and communication, and considerations for the specific role of nurse practitioner-led community paramedicine programs for geriatric patient care.

Identifying Cognitive Impairment in an Older Adult Using Two Different Screening Tools.

A 78-year-old Hispanic woman presented to an ambulatory care clinic for older adults describing memory impairment and requesting an assessment of her cognitive status. A Mini-Mental State Examination (MMSE) was performed and found to be 29/30 (normal). One year later, the same situation occurred and her MMSE was again found to be 29/30 (normal). However, a Saint Louis University Mental Status (SLUMS) examination administered that same day demonstrated a different result: a score of 19/30 (dementia). Fourteen months later, the patient returned again and scored 26/30 (normal) on the MMSE and 22/30 (mild neurocognitive disorder) on the SLUMS. Our patient case illustrates inherent differences between the MMSE and SLUMS in the ability to detect mild cognitive impairment and dementia, along with the variability that may occur with testing.

Multidisciplinary Approach to Deprescribing Sedative-Hypnotic Medications in Geriatric Primary Care.

INTRODUCTION/OBJECTIVES: Due to the risks associated with sedative hypnotic medications in older adults, our study evaluated the impact of a multidisciplinary approach to deprescribing in geriatric primary care clinics. METHODS: The study was a retrospective review of older adults at 2 academic, geriatric primary care clinics who were prescribed sedative-hypnotic medications. Patients were mailed an education packet of information that included working with the clinical pharmacy team, behavioral health team, or both in order to deprescribe their sedative-hypnotic medication. The study assessed the rate of discontinuation of sedative-hypnotic medications between the different intervention groups. RESULTS: The study included 93 older adults with a mean age of 81.3 years and 39.8% discontinuation rate of their medication. The number of falls decreased in patients who discontinued use compared to when previously using a sedative hypnotic medication. CONCLUSION: Patients are more likely to discontinue their sedative hypnotic medication with a multidisciplinary approach, specifically with primary care provider support.

Disparities in Video and Telephone Visits Among Older Adults During the COVID-19 Pandemic: Cross-Sectional Analysis.

BACKGROUND: Telephone and video telemedicine appointments have been a crucial service delivery method during the COVID-19 pandemic for maintaining access to health care without increasing the risk of exposure. Although studies conducted prior to the pandemic have suggested that telemedicine is an acceptable format for older adults, there is a paucity of data on the practical implementation of telemedicine visits. Due to prior lack of reimbursement for telemedicine visits involving nonrural patients, no studies have compared telephone visits to video visits in geriatric primary care. OBJECTIVE: This study aimed to determine (1) whether video visits had longer durations, more visit diagnoses, and more advance care planning discussions than telephone visits during the rapid implementation of telemedicine in the COVID-19 pandemic, and (2) whether disparities in visit type existed based on patient characteristics. METHODS: We conducted a retrospective, cross-sectional analysis of patients seen at two geriatric clinics from April 23 to May 22, 2020. Approximately 25% of patients who had telephone and video appointments during this time underwent chart review. We analyzed patient characteristics, visit characteristics, duration of visits, number of visit diagnoses, and the presence of advance care planning discussion in clinical documentation. RESULTS: Of the 190 appointments reviewed, 47.4% (n=90) were video visits. Compared to telephone appointments, videoconferencing was, on average, 7 minutes longer (mean 37.3 minutes, SD 10 minutes; P<.001) and had, on average, 1.2 more visit diagnoses (mean 5.7, SD 3; P=.001). Video and telephone visits had similar rates of advance care planning. Furthermore, hearing, vision, and cognitive impairment did not result in different rates of video or telephone appointments. Non-White patients, patients who needed interpreter services, and patients who received Medicaid were less likely to have video visits than White patients, patients who did not need an interpreter, and patients who did not receive Medicaid, respectively (P=.003, P=.01, P<.001, respectively). CONCLUSIONS: Although clinicians spent more time on video visits than telephone visits, more than half of this study's older patients did not use video visits, especially if they were from racial or ethnic minority backgrounds or Medicaid beneficiaries. This potential health care disparity merits greater attention.

Development and economic evaluation of a pharmacist-provided chronic care management service in an ambulatory care geriatrics clinic.

PURPOSE: The implementation and delivery of a pharmacist-led chronic care management (CCM) service in a geriatric primary care clinic are described. METHODS: A CCM service was provided March 1 through December 31, 2016, at the University of Colorado Hospital Seniors Clinic ("Seniors Clinic"). The electronic health record (EHR) team for the University of Colorado Health system developed a patient registry through EPIC Healthy Planet (Epic Systems Corp., Verona, WI) to identify patients at the Seniors Clinic eligible for CCM services. The EHR team constructed a note type and documentation template within the EHR to ensure documentation of all necessary components for billing and to allow individual clinical staff to document the time spent providing CCM care. RESULTS: Overall, 36 elderly patients enrolled in the pharmacist-provided CCM service over the 10 months. Clinical pharmacists spent a total of 156-849 minutes per month providing CCM services, with a mean outreach time of 45.4 minutes per patient. The clinical pharmacists submitted 95 claims, and all but 5 were paid. The total amount reimbursed from the health plans during the 10 months was $2,775.02. CONCLUSION: Medicare patients were successfully enrolled in a CCM service in a geriatrics primary care clinic led by clinical pharmacists and medical providers. The CCM services were more time-consuming than the allotted 20 minutes per patient per month with the CCM Current Procedural Terminology code used during this study.

Hyponatremia after initiation and rechallenge with trimethoprim-sulfamethoxazole in an older adult.

PURPOSE: The purpose of this study is to describe a case report of a patient experiencing hyponatremia from trimethoprim-sulfamethoxazole (TMP-SMX) upon initial use and subsequent rechallenge. SUMMARY: An 82-year-old woman presented to the emergency department with altered mental status thought to be due to complicated cystitis and was treated with TMP-SMX 160 mg/800 mg orally twice daily for 7 days. Her basic metabolic panel prior to initiation of TMP-SMX was within normal limits, with the exception of her serum sodium of 132 mmol/L (range 133-145 mmol/L). The day after completing her 7-day course of TMP-SMX therapy the patient was evaluated by her primary care provider and another basic metabolic panel revealed a reduction in the serum sodium to 121 mmol/L. The patient's serum sodium concentrations increased to baseline 7 days after completion of the TMP-SMX therapy, and remained normal until she was treated in the emergency department several months later for another presumed urinary tract infection. She was again started on TMP-SMX therapy empirically, and within several days her serum sodium concentrations decreased from 138 mmol/L to a low of 129 mmol/L. The TMP-SMX therapy was discontinued upon negative urine culture results and her serum sodium increased to 134 mmol/L upon discharge. Based upon the Naranjo probability scale score of 9, TMP-SMX was the probable cause of the patient's hyponatremia. CONCLUSION: Our patient developed hyponatremia from TMP-SMX therapy upon initial use and rechallenge. Although hyponatremia appears to be rare with TMP-SMX therapy, providers should be aware of this potentially life-threatening adverse event.

Medication management for elderly patients in an academic primary care setting: a quality improvement project.

PURPOSE: Medication reconciliation is a National Patient Safety Goal. Completing medication reconciliation minimizes the risk for preventable adverse drug events (ADEs). The elderly are at greatest risk for ADEs because of their high number of comorbidities and medications usage. The purpose of this quality improvement project was to improve medication management in a geriatric primary care practice. Interventions focused on improving medication reconciliation documentation, improving accuracy of medication lists, reducing inappropriate medication use, and minimizing duplicate medication therapy. DATA SOURCES: A pre/post design was used over a 9-month period. Interventions focused on educating providers, staff, and patients on medication management. Analysis of 1580 manual chart audits and 903 patient questionnaires were completed. CONCLUSIONS: Outcomes improved in all four performance outcomes: medication reconciliation-χ(2) (1, N = 576) = 32.00, p < .0001, V = 0.4; patients bringing medications to clinic-χ(2) (1, N = 277) = 90.46, p < .0001, V = 0.7; reduction in use of specific medications-χ(2) (1, N = 267) = 19.49, p < .0001, V = 0.3; and duplicate therapy was reduced-χ(2) (1, N = 267) = 45.13, p < .0001, V = 0.5. IMPLICATIONS FOR PRACTICE: Improved medication management had a significant impact in patient safety and quality of care in this clinic.

Hepatotoxicity associated with chinese skullcap contained in Move Free Advanced dietary supplement: two case reports and review of the literature.

Move Free Advanced is a widely available dietary supplement in the United States, marketed to comfort sore joints and improve flexibility and mobility. This product contains glucosamine, chondroitin, hyaluronic acid, and Uniflex proprietary extract, which is a combination of Chinese skullcap and black catechu. We describe two patients who developed hepatotoxicity after ingesting a Move Free Advanced product. In both patients, the hepatotoxicity resolved after discontinuation of the supplement. Use of the Naranjo adverse drug reaction probability scale indicated a probable relationship (score of 6 for both patients) between the patients' development of hepatotoxicity and the Move Free Advanced supplement. Based on a review of the literature, the herbal extract Chinese skullcap is the most likely cause of the hepatotoxicity. To our knowledge, these two cases are the first to be published regarding possible hepatotoxicity associated with Move Free Advanced. Patients seeking dietary supplements for osteoarthritis may want to avoid glucosaminechondroitin products such as Move Free Advanced that also contain Chinese skullcap.