Are Geriatrics-Focused Primary Care Clinics Better at Diagnosing Dementia Than Traditional Clinics? A Matched Cohort Study.

BACKGROUND: Dementia and mild cognitive impairment (MCI) are prevalent but underdiagnosed. OBJECTIVE: To compare new dementia/MCI diagnosis rates in geriatrics-focused primary care clinics and traditional primary care clinics. DESIGN: Secondary analysis of a prospective matched cohort study that spanned 2017-2021. PARTICIPANTS: Community-dwelling Veterans over 65 receiving primary care in a geriatrics-focused medical home (GeriPACT) or traditional primary care home (PACT) at one of 57 Veterans Affairs sites. We excluded individuals with a documented diagnosis of dementia or MCI in the year prior to enrollment. MAIN MEASURES: Diagnoses obtained from EHR. Cognitive status was assessed using modified Telephone Interview for Cognitive Status (mTICS) tool. KEY RESULTS: The 470 participants included in this analysis were predominantly white, non-Hispanic males with an average age of 80.3 years. 9.4% of participants received a diagnosis of dementia/MCI after 24 months: 11.5% in GeriPACT and 7.2% in PACT. Adjusted OR for dementia/MCI diagnosis based on GeriPACT exposure was 1.47 (95% CI 0.65-3.29). Low mTICS score (≤ 27) (OR 4.89, 95% CI 2.36-10.13) and marital status (married/partnered) (OR 1.89, CI 0.99-3.59) were independent predictors of dementia/MCI diagnosis. When stratified by cognitive status: diagnosis rates were 20.8% in GeriPACT and 16.7% in PACT among those who scored lower on the cognitive assessment (mTICS ≤ 27); 7.4% in GeriPACT and 3.6% in PACT among those who scored higher (mTICS > 27). The OR for new dementia/MCI diagnosis in GeriPACT was 1.19 (95% CI 0.49-2.91) among those with a low mTICS score and 1.85 (95% CI 0.70-4.88) among those with a higher mTICS score. CONCLUSIONS: Observed rates of new dementia/MCI diagnosis were higher in GeriPACT, but with considerable uncertainty around estimates. Geriatrics-focused primary care clinics may be a promising avenue for improving the detection of dementia in older adults, but further larger studies are needed to confirm this relationship.

A systematic review of clinical guidelines on the management of acute, community-acquired CNS infections.

BACKGROUND: The epidemiology of CNS infections in Europe is dynamic, requiring that clinicians have access to up-to-date clinical management guidelines (CMGs) to aid identification of emerging infections and for improving quality and a degree of standardisation in diagnostic and clinical management practices. This paper presents a systematic review of CMGs for community-acquired CNS infections in Europe. METHODS: A systematic review. Databases were searched from October 2004 to January 2019, supplemented by an electronic survey distributed to 115 clinicians in 33 European countries through the CLIN-Net clinical network of the COMBACTE-Net Innovative Medicines Initiative. Two reviewers screened records for inclusion, extracted data and assessed the quality using the AGREE II tool. RESULTS: Twenty-six CMGs were identified, 14 addressing bacterial, ten viral and two both bacterial and viral CNS infections. Ten CMGs were rated high quality, 12 medium and four low. Variations were identified in the definition of clinical case definitions, risk groups, recommendations for differential diagnostics and antimicrobial therapy, particularly for paediatric and elderly populations. CONCLUSION: We identified variations in the quality and recommendations of CMGs for community-acquired CNS infections in use across Europe. A harmonised European "framework-CMG" with adaptation to local epidemiology and risks may improve access to up-to-date CMGs and the early identification and management of (re-)emerging CNS infections with epidemic potential.

Point-of-Care Ultrasound in Post-acute and Long-Term Care: A Scoping Review.

OBJECTIVES: Point-of-care ultrasound (POCUS) is an emerging application of ultrasonography that is being integrated into patient care in many medical specialties. The post-acute and long-term care (PALTC) setting has opportunities to adopt POCUS as a diagnostic aid to improve patient outcomes. We aim (1) to describe the current use of POCUS in PALTC and (2) to examine how the use of POCUS can advance in PALTC settings. DESIGN: Scoping review. SETTING AND PARTICIPANTS: PALTC facilities and residents. METHODS: The MEDLINE, Embase, CINAHL Complete, and Web of Science databases were searched by a medical librarian for studies on the use of POCUS in PALTC. All studies underwent dual, independent review during 2 phases of screening. We included all study designs where POCUS was obtained and interpreted by a provider at the bedside. RESULTS: Six studies met inclusion criteria. Most studies were conducted in the setting of COVID19 outbreaks in nursing homes and communities. The organ systems examined using POCUS were lung and vasculature. Lung ultrasound was shown to have variable diagnostic and prognostic utility in assessing lung injury secondary to COVID19. Ultrasound measurements of the vasculature were not useful for predicting hydration status. CONCLUSION AND IMPLICATIONS: Implementation of POCUS in PALTC is feasible, but current literature is limited to use in only 2 organ systems. These results suggest potential for expanding POCUS in PALTC. Further work is required to ascertain if POCUS use can improve patient outcomes in this health care setting.

Frailty Explains Variation in Emergency Department Use for Older Veterans During the COVID-19 Pandemic.

Introduction: Older adults were critically vulnerable to disruptions in health care during the COVID-19 pandemic, but it is not known if changes in ED utilization varied based on patient characteristics. Using a cohort of older Veterans, we examined changes in ED visit rates based on four characteristics of interest: age, race, area deprivation index, and frailty. Methods: Participants were aged ≥65, with ≥2 visits in primary or geriatric clinics between 02/02/2018-05/07/2019. An adjusted negative binomial regression model was constructed for each characteristic. We report mean counts of all ED visits by quarter for subgroups separately, and report rate ratios to compare ED visits in the first year of the COVID-19 pandemic to the year before. Results: Patients with complete case data numbered 38,871. During the first two quarters, all subgroups had decreased ED visits, with more variation in the third and fourth quarters. The very highly frail, who had the highest mean estimated count of ED visits per person through both pre-COVID and COVID periods, also had a significant decrease in their ED visits during multiple quarters of the pandemic to a greater degree than other frailty subgroups. Conclusion: Stratifying older adults by frailty identified patient subgroups with the greatest variation in ED visits during COVID. Very highly frail patients warrant special attention to understand how variation in ED utilization affects patient outcomes.

Geriatrics Scholarly Concentration Programs Among U.S. Medical Schools.

OBJECTIVES: To identify and describe geriatric scholarly concentration programs (GSCPs) among U.S. medical schools. DESIGN: Survey and interview. SETTING: Allopathic and osteopathic medical schools in the United States. PARTICIPANTS AND METHODS: We used a systematic internet search, forum postings, and word of mouth to identify all U.S. allopathic and osteopathic medical schools with existing GSCPs. GSCP directors completed an online survey. We conducted interviews with key faculty of two representative programs. MEASUREMENTS: GSCP size, goals, duration of activity, requirements, funding sources, and student outcomes. RESULTS: Nine GSCPs were identified, and eight responded to the survey. The number of current medical student participants ranged from 0 to 28, with a mean cohort size of 23. All programs included the following components: formal mentoring, clinical experiences in geriatric medicine beyond the standard medical school curriculum, and research. Half required students to complete an independent research project. GSCPs reported challenges, including low student interest, lack of availability of faculty mentors, and budget constraints; however, student satisfaction was high. Among three programs that reported on the residency matches of their graduates, half matched into a residency with a geriatric subspecialty training option. CONCLUSIONS: Among U.S. medical schools, there are few GSCPs. The GSCP model may help compensate for limited exposure to geriatric competencies in the standard medical school curriculum for a subset of interested students and may increase interest in geriatrics subspecialty training.