Human Immunodeficiency Virus in Older Adults.

As people with HIV live longer, they can experience increased incidence and earlier onset of chronic conditions and geriatric syndromes. Older people are also at substantially increased risk of delayed diagnosis and treatment for HIV. Increasing provider awareness of this is pivotal in ensuring adequate consideration of HIV testing and earlier screening for chronic conditions. In addition, evaluating patients for common geriatric syndromes such as polypharmacy, frailty, falls, and cognitive impairment should be contextualized based on how they present.

Using Mind Mapping in Family Meetings to Support Shared Decision Making with Pediatric and Geriatric Patients.

INTRODUCTION: Divergent objectives and narratives among members of a healthcare team may lead to suffering, underscoring the need to align patient care with the patient's self-identified priorities and goals. Shared decision making (SDM) with patients who may not be able to make healthcare decisions for themselves presents a unique challenge to healthcare providers, caregivers, and patients. Children and the elderly are two such groups where substituted decision making is often required. Family meetings, wherein stakeholders in a patient's care are gathered, present opportunities to align expectations and clinical goals. There is a clear need for a technique exploring all facets of the patient's story within the context of the biopsychosocial-spiritual model. We sought to promote narrative equity among stakeholders and maintain patient focus during family meetings. We describe the use of Mind Mapping in the family meeting to meet these objectives. METHODS: Using two clinical scenarios, one involving a geriatric patient and another involving a pediatric patient, we describe the stepwise development of Mind Maps and how their use informed discussions among stakeholders in the family meeting. RESULTS: Stakeholders found the Mind Maps easy to draw and helpful in eliciting their own priorities and preferences. Group exploration and refinement of the Mind Maps helped stakeholders to appreciate others' sometimes divergent perspectives, to ensure that the patient's voice was heard, and to ensure that care decisions were patient focused. DISCUSSION: Mind Mapping was easily performed in two clinical scenarios, allowing the patient, family, and medical team to explore the biopsychosocial-spiritual model extensively, to appreciate each stakeholder's priorities, and to identify areas for further development. We have found that Mind Mapping helps define the 'topography' of relationships, prioritizes team discussions, finds shared interests in seemingly divergent objectives, and identifies which team member may best lead a discussion on a particular topic. CONCLUSION: Mind Mapping may be a useful tool for family meetings, particularly for geriatric and pediatric patients with multiple stakeholders involved.

Patient-focused healthcare, which prioritizes the needs and desires of the patient when creating a plan of care, relies on the patient's voice being clearly and accurately heard. This is especially important when the patient cannot make medical decisions alone, as may be the case for elderly patients or children. Unfortunately, there are times when the patient's voice may be 'drowned out' by family members, friends, or members of the healthcare team. Family meetings offer an opportunity for all parties involved in the patient's care to gather together to ensure agreement on treatment goals and next steps. In this manuscript, we explore the technique of Mind Mapping as a tool to encourage all family meeting participants to speak and be heard. Using two clinical scenarios, one involving an elderly patient and the other a pediatric patient, we describe in a stepwise fashion how to perform Mind Mapping, what was done in these two cases, and how the Mind Maps changed how health care was delivered. We have found Mind Mapping effective in planning for family meetings, encouraging all persons involved in the patient's care to share their perspectives, ensuring that the patient's story is heard, and confirming that care plans reflect the patient's desires and needs.

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.

Latent Tuberculosis Infection Testing Practices in Long-Term Care Facilities, Boston, Massachusetts.

OBJECTIVES: To describe latent tuberculosis infection (LTBI) testing practices in long-term care facilities (LTCFs). DESIGN: Retrospective cohort study. SETTING: Three Boston-area LTCFs. PARTICIPANTS: Residents admitted between January 1 and December 31, 2011. MEASUREMENTS: Resident demographic characteristics, comorbidities, LTCF stay, and LTBI testing and treatment. RESULTS: Data for 291 LTCF residents admitted in 2011 were reviewed. Of the 257 without a history of LTBI and with documentation of testing, 162 (63%) were tested; 114 of 186 (61%) with a stay less than 90 days and 48 of 71 (68%) with a stay of 90 days or longer were tested. Of 196 residents with data on prior LTBI testing, 39 (19.9%) had LTBI; 12 of these (30.8%) were diagnosed at the LTCF. Hispanic participants were more likely than black participants to undergo LTBI testing (adjusted odds ratio (aOR) = 2.4, P = .003). Having a length of stay of less than 90 days (aOR = 0.7, P < .001) and history of illicit drug use (aOR = 0.7, P < .001) were associated with lower odds of LTBI testing. CONCLUSION: One-fifth of LTCF residents had LTBI, but testing was not always performed. The high prevalence of LTBI in older adults combined with the risk of an outbreak if a case of tuberculosis occurs in a LTCF make LTBI testing and treatment an important prevention opportunity. The importance of LTBI testing in LTCFs needs to be reinforced.

Multisite geriatrics clerkship for fourth-year medical students: a successful model for teaching the Association of American Medical Colleges' core competencies.

As the population ages, it is important that graduating medical students be properly prepared to treat older adults, regardless of their chosen specialty. To this end, the Association of American Medical Colleges (AAMC) and the John A. Hartford Foundation convened a consensus conference to establish core competencies in geriatrics for all graduating medical students. An ambulatory geriatric clerkship for fourth-year medical students that successfully teaches 24 of the 26 AAMC core competencies using an interdisciplinary, team-based approach is reported here. Graduating students (N=158) reported that the clerkship was successful at teaching the core competencies, as evidenced by positive responses on the AAMC Graduation Questionnaire (GQ). More than three-quarters (80-93%) of students agreed or strongly agreed that they learned the seven geriatrics concepts asked about on the GQ, which cover 14 of the 26 core competencies. This successful model for a geriatrics clerkship can be used in many institutions to teach the core competencies and in any constellation of geriatric ambulatory care sites that are already available to the faculty.