Lack of patient and primary care physician follow-up in geriatric emergency department patients with head trauma from a fall.

STUDY OBJECTIVE: Falls are the leading cause of injuries in the US for older adults. Follow-up after an ED-related fall visit is essential to initiate preventive strategies in these patients who are at very high risk for recurrent falls. It is currently unclear how frequently follow-up occurs and whether preventive strategies are implemented. Our objective is to determine the rate of follow-up by older adults who sustain a fall related head injury resulting in an ED visit, the rate and type of risk assessment and adoption of preventive strategies. METHODS: This 1-year prospective observational study was conducted at two South Florida hospitals. All older ED patients with an acute head injury due to a fall were identified. Telephone surveys were conducted 14 days after ED presentation asking about PCP follow-up and adoption of fall prevention strategies. Clinical and demographic characteristics were compared between patients with and without follow up. RESULTS: Of 4951 patients with a head injury from a fall, 1527 met inclusion criteria. 905 reported follow-up with their PCP. Of these, 72% reported receiving a fall assessment and 56% adopted a fall prevention strategy. Participants with PCP follow-up were significantly more likely to have a history of cancer or hypertension. CONCLUSION: Only 60% of ED patients with fall-related head injury follow-up with their PCP. Further, 72% received a fall assessment and only 56% adopted a fall prevention strategy. These data indicate an urgent need to promote PCP fall assessment and adoption of prevention strategies in these patients.

Prescribing Benzodiazepines and Opioids and Clinical Characteristics Associated With 30-Day Hospital Return in Patients Aged ≥75 Years: Secondary Data Analysis.

PURPOSE: The current study compared prevalence of opioid or benzodiazepine (BZD) prescription and co-prescription of opioids and BZD at discharge and return to a community hospital within 30 days, as well as identified clinical characteristics associated with hospital return in patients aged ≥75 years. METHOD: A secondary analysis of a database created during implementation of the Safe Transitions for At Risk Patients program at a 400-bed community teaching hospital in south Florida was conducted. Multivariable logistic regression analyses were performed to identify significant demographic and clinical characteristics associated with return to the hospital within 30 days of discharge. RESULTS: A total of 24,262 participants (52.6% women) with a mean age of 85.3 (SD = 6.42) years were included. More than 20% in each central nervous system prescription group (i.e., opioids only, BZD only, opioids and BZD) returned to the hospital within 30 days of discharge. Demographic and chronic conditions (e.g., congestive heart failure, chronic obstructive pulmonary disease, diabetes) and poly-pharmacy were significant factors of a 30-day return to the hospital. CONCLUSION: Findings highlight the importance of hospital nurses' role in identifying high-risk patients, educating patients and caregivers, monitoring them closely, communicating with primary care physicians and specialists, and conducting intensive follow up via telephone to avoid 30-day rehospitalization. [Journal of Gerontological Nursing, 50(4), 25-33.].

Balancing Vision With Pragmatism: The Geriatric Emergency Department Guidelines-Realistic Expectations From Emergency Medicine and Geriatric Medicine.

BACKGROUND: In 2014, the Geriatric Emergency Department (GED) Guidelines were published and endorsed by four major medical organizations. The multidisciplinary GED Guidelines characterized the complex needs of the older emergency department (ED) patient and current best practices, with the goal of promoting more cost-effective and patient-centered care. The recommendations are extensive and most EDs then and now have neither the resources nor the hospital administrative support to provide this additional service. DISCUSSION: At the 2021 American Academy of Emergency Medicine's Scientific Assembly, a panel of emergency physicians and geriatricians discussed the GED Guidelines and the current realities of EDs' capacity to provide best practice and guideline-recommended care of GED patients. This article is a synthesis of the panel's presentation and discussion. With the substantial challenges in providing guideline-recommended care in EDs, this article will explore three high-impact GED clinical conditions to highlight guideline recommendations, challenges, and opportunities, and discuss realistically achievable expectations for non-GED-accredited institutions. CONCLUSIONS: In 2014, the GED Guidelines were published, describing the current best practices for GED patients. Unfortunately, most of the EDs worldwide do not provide the level of service recommended by the GED Guidelines. The GED Guidelines can best be termed aspirational for U.S. EDs at the present time.

Pragmatic trials in long-term care: Research challenges and potential solutions in relation to key areas of care.

As a method of research, pragmatic trials are recommended so as to generate results that are applicable to real-world care. This intent is especially important for the millions of older adults who receive long-term care in thousands of nursing homes and assisted living communities across the country-and many millions more around the globe. This article presents key points raised by experts participating in a conference funded by the National Institute of Aging held at the 2021 conference of the Society for Post-Acute and Long-term Care Medicine. The purpose of the conference was to convene leading clinicians, researchers, and industry partners to address special considerations of pragmatic trials in long-term care. Cross-cutting and unique challenges and solutions to conducting pragmatic trials were discussed focusing on 3 areas of clinical relevance to long-term care: (1) functional care and outcomes, (2) psychosocial care and quality of life, and (3) medical care and outcomes, with a special focus on persons with dementia. Challenges and innovative solutions were organized across the 9 domains of the revised Pragmatic-Explanatory Continuum Indicator Summary (PRECIS) Tool, and future research recommendations for pragmatic trials in long-term care were identified.

Pragmatic trials in long-term care: Challenges, opportunities, recommendations.

Randomized controlled trials are considered the most rigorous research design in efficacy and effectiveness research; however, such trials present numerous challenges that limit their applicability in real-world settings. As a consequence, pragmatic trials are increasingly viewed as a research design that overcomes some of these barriers with the potential to produce data that are more reproducible. Although pragmatic methodology in long-term care is receiving increasing attention as an approach to improve successful dissemination and implementation, pragmatic trials present complexities of their own. To address these complexities and related issues, experts with experience conducting pragmatic trials, developing nursing home policy, participating in advocacy efforts, and providing clinical care in long-term care settings participated in a virtual consensus conference funded by the National Institute on Aging in Spring 2021. Participants recommended 4 cross-cutting principles key to dissemination and implementation of pragmatic trial interventions: (1) engage stakeholders, (2) ensure diversity and inclusion, (3) assess organizational strain and readiness, and (4) learn from adaptations. Specifically related to implementation, participants provided 2 recommendations: (1) integrate interventions into existing workflows and (2) maintain agility and responsiveness. Finally, participants had 3 recommendations specific to dissemination: (1) package the message for the audience, (2) engage diverse audiences, and (3) apply dissemination and diffusion tools. Participants emphasized that implementation processes must be grounded in the perspectives of the people who will ultimately be responsible for implementing the intervention once it is proven to be effective. In addition, messaging must speak to long-term care staff and all others who have a stake in its outcomes. Although our understanding of dissemination and implementation strategies remains underdeveloped, this article is designed to guide long-term care researchers and community providers who are increasingly aware of the need for pragmatism in disseminating and implementing evidence-based care interventions.

Advancing clinical trials in nursing homes: A proposed roadmap to success.

An effective clinical research effort in nursing homes to address prevention and treatment of COVID-19 faced overwhelming challenges. Under the Health Care Systems Research Network-Older Americans Independence Centers AGING Initiative, a multidisciplinary Stakeholder Advisory Panel was convened to develop recommendations to improve the capability of the clinical research enterprise in US nursing homes. The Panel considered the nursing home as a setting for clinical trials, reviewed the current state of clinical trials in nursing homes, and ultimately developed recommendations for the establishment of a nursing home clinical trials research network that would be centrally supported and administered. This report summarizes the Panel's recommendations, which were developed in alignment with the following core principles: build on available research infrastructure where appropriate; leverage existing productive partnerships of researchers with groups of nursing homes and nursing home corporations; encompass both efficacy and effectiveness clinical trials; be responsive to a broad range of stakeholders including nursing home residents and their care partners; be relevant to an expansive range of clinical and health care delivery research questions; be able to pivot as necessary to changing research priorities and circumstances; create a pathway for industry-sponsored research as appropriate; invest in strategies to increase diversity in study populations and the research workforce; and foster the development of the next generation of nursing home researchers.

Influencing Factors Associated with Implementation of INTERACT (Interventions to Reduce Acute Care Transfers) in VA Community Living Centers (CLCs) Using the Consolidated Framework.

Our objective was to identify the influencing factors associated with the implementation of the INTERACT (Interventions to Reduce Acute Care Transfers) Quality Improvement program within a national healthcare system. INTERACT focuses on early identification and management of changes in residents' condition leading to a reduction in potentially preventable hospital transfers. The Consolidated Framework was used to evaluate implementation data from eight VA Community Living Centers. Qualitative implementation data suggest two influencing Consolidated Framework domains had a strong influence: 1) key attributes of the intervention (e.g., adaptability or complexity) and 2) internal organizational factors (e.g., culture or compatibility). Using the Consolidated Framework can assist future adaptations to this and other complex quality improvement initiatives.

INTERACT in VA Community Living Centers (CLCs): Training and Implementation Strategies.

Studies have shown that hospitalizations of nursing home (NH) residents lead to complications and poorer quality of life. The Interventions to Reduce Acute Care Transfers (INTERACT) Quality Improvement (QI) Program assists licensed NH staff in avoiding such hospitalizations. INTERACT aims to improve the management of acute changes in residents' conditions by providing tools to help staff recognize subtle changes in condition, improve communication, and implement QI strategies. INTERACT has been vetted by national clinical leaders and experts in long term care (LTC). Multiple NHs have implemented INTERACT and it has been adopted in Canada, the United Kingdom, and Singapore. QI initiatives involve adaptation to the organizational context in which it is being implemented. We report adaptation of the INTERACT QI program and implementation training into Veteran Affairs (VA) Community Living Centers (CLCs) (VA equivalent NH) and summarize the efforts to introduce and train nursing leadership to integrate the intervention into selected CLCs.

Barriers and Facilitators to Implementing a Change Initiative in Long-Term Care Using the INTERACT® Quality Improvement Program.

Implementation of major organizational change initiatives presents a challenge for long-term care leadership. Implementation of the INTERACT® (Interventions to Reduce Acute Care Transfers) quality improvement program, designed to improve the management of acute changes in condition and reduce unnecessary emergency department visits and hospitalizations of nursing home residents, serves as an example to illustrate the facilitators and barriers to major change in long-term care. As part of a larger study of the impact of INTERACT® on rates of emergency department visits and hospitalizations, staff of 71 nursing homes were called monthly to follow-up on their progress and discuss successful facilitating strategies and any challenges and barriers they encountered during the yearlong implementation period. Themes related to barriers and facilitators were identified. Six major barriers to implementation were identified: the magnitude and complexity of the change (35%), instability of facility leadership (27%), competing demands (40%), stakeholder resistance (49%), scarce resources (86%), and technical problems (31%). Six facilitating strategies were also reported: organization-wide involvement (68%), leadership support (41%), use of administrative authority (14%), adequate training (66%), persistence and oversight on the part of the champion (73%), and unfolding positive results (14%). Successful introduction of a complex change such as the INTERACT® quality improvement program in a long-term care facility requires attention to the facilitators and barriers identified in this report from those at the frontline.

Factor structure of the Arthritis-Related Health Belief instrument in ethnically diverse community-dwelling older adults with chronic pain.

Nonpharmacological treatment of chronic pain in older people can be effective but attitudes and adherence to use of this treatment may differ by ethnicity. This study supports that a modified 14-item instrument based on the modified Health Belief Model-the arthritis-related health belief instrument (AHBI)-can be used across ethnically diverse older adults (i.e., European Americans, Hispanics, African Americans, and Afro-Caribbeans). Confirmatory factor analysis tested the factor structure of the AHBI to eliminate items inappropriate for this population. Structural equation modeling tested expected relationships among four latent variables-severity, susceptibility, barriers, and benefits-across the four ethnic groups. Findings suggest that the modified 14-item AHBI (eliminating two items from the original AHBI) adequately described the four latent factors pertaining to use of nonpharmacological pain therapy in this sample. All items registered substantial loadings (.41-.95) on the hypothesized factors, operating similarly across the four ethnic groups. The modified 14-item AHBI may be useful in (a) assessing how individual perceptions influence access to nonpharmacological pain therapy among ethnically diverse community-dwelling older adults, with the goal to develop and implement effective pain treatment for this population; and (b) measuring the likelihood of using nonpharmacological pain therapy by older adults. The modified 14-item AHBI can help health care providers to provide accurate pain assessment and examine domains that could affect use of nonpharmacological pain therapy by ethnically diverse older adults and guide practice with them by identifying barriers to use of such therapies and providing education to encourage their use.

Health-Related Quality of Life and Pain Intensity Among Ethnically Diverse Community-Dwelling Older Adults.

Chronic pain is highly prevalent in older adults and often negatively associated with health-related quality of life (HRQoL). This study compared HRQoL, including physical health and mental health, in persons of differing ethnicities, and identified factors associated with pain intensity and HRQoL in ethnically diverse older adults. Older adults with chronic pain from four ethnic groups (African Americans, Afro-Caribbeans, Hispanics, and European Americans) were recruited from the Florida Atlantic University Healthy Aging Research Initiative (HARI) registry. The Medical Outcomes Study Short Form-36 (SF-36) was used to evaluate HRQoL, including functional status, emotional well-being, and social functioning. Of 593 persons in the four ethnic groups in the registry, 174 met the inclusion criteria (pain level of four or higher on an 11-point scale, lasting 3 months or longer). Among these 174, African Americans reported the highest level of pain intensity, followed by Afro-Caribbeans, Hispanics, and European Americans. Hispanics reported the highest physical health scores and the lowest mental health scores. In contrast, African Americans reported the highest mental health scores and the lowest physical health scores. Multivariate linear regression analysis revealed that ethnicity, lower physical health scores, and lower mental health scores were significantly (p ≤ .01) associated with pain intensity. Understanding ethnic variations in response to pain intensity may address gaps in knowledge about HRQoL to reduce disparities in optimal care. Health care providers should consider ethnic norms and cultural diversity to provide optimal interventions for this population.

Clinical Burden and Nonpharmacologic Management of Nursing Facility Residents with Overactive Bladder and/or Urinary Incontinence.

OBJECTIVE: To identify clinical characteristics of residents with a diagnosis of overactive bladder (OAB) and/or urinary incontinence (UI) to determine the prevalence of comorbidities, severe mobility impairment (SMI), moderate-to-severe cognitive impairment (MSCI), and a toileting program and the response to that program. DESIGN: Cross-sectional retrospective analysis. SETTING: Skilled nursing facilities. PATIENTS, PARTICIPANTS: Residents with a diagnosis of OAB and/or UI and an age range, and gender frequency-matched 1:1 control cohort without OAB and/or UI. INTERVENTIONS: None. MAIN OUTCOME MEASURE(S): De-identified Minimum Data Set data 3.0 records (October 1, 2010, to September 30, 2012). RESULTS: Of the 175,632 residents, 65% had a diagnosis of UI and 1% had a diagnosis of OAB. Those with UI and/or OAB were more likely to have MSCI (mean Brief Inventory of Mental Status score 10.2 ± 4.5 vs. 12.5 ± 3.6; P = 0.001) and SMI (49.4% vs. 26.4%; P < 0.001), multiple comorbid conditions, falls and falls with injury, hip fractures (5.5% vs. 4.9%; P < 0.001), urinary tract infections (21.4% vs. 16.5%; P = 0.001), and moisture-associated skin damage (5.2% vs. 2.6%; P = 0.001) than the control cohort. Toileting programs were attempted more often (17.0% vs. 5.1%; P < 0.001) in those with UI and/or OAB but were only minimally successful, with 4.2% having decreased wetness and 0.9% being completely dry. CONCLUSION: Residents with UI and/or OAB exhibit a higher burden of MSCI, SMI, and comorbidities than do residents without these diagnoses. Nonpharmacologic therapies such as toileting programs should be a primary focus in the nursing facility.

Effect of fesoterodine in vulnerable elderly subjects with urgency incontinence: a double-blind, placebo controlled trial.

PURPOSE: We evaluated the efficacy and safety of flexible dose fesoterodine in medically complex vulnerable elderly subjects with urgency urinary incontinence. MATERIALS AND METHODS: In this 12-week, randomized, double-blind, flexible dose, placebo controlled trial, subjects were community dwelling men and women 65 years old or older. Subjects had scores of 3 or more on the VES-13 (Vulnerable Elders Survey) and 20 or more on the MMSE (Mini-Mental State Examination), and 2 to 15 urgency urinary incontinence episodes and 8 or more micturitions per 24 hours on 3-day baseline diaries. Subjects randomized to fesoterodine received 4 mg once daily for 4 weeks and could then increase to 8 mg based on discussion with the investigator. Subjects receiving 8 mg could decrease the dose to 4 mg at any time (sham escalation and de-escalation for placebo). The primary outcome measure was change in daily urgency urinary incontinence episodes. Secondary outcomes included changes in other diary variables and patient reported quality of life measures. Safety evaluations included self-reported symptoms and post-void residual volume. RESULTS: A total of 562 patients were randomized (mean age 75 years, 50.4% age 75 years or greater). Subjects had high rates of comorbidities, polypharmacy and functional impairment. At week 12 the fesoterodine group had significantly greater improvements in urgency urinary incontinence episodes per 24 hours (-2.84 vs -2.20, p = 0.002) and most other diary variables and quality of life, as well as a higher diary dry rate (50.8% vs 36.0%, p = 0.002). Adverse effects were generally similar to those of younger populations including risk of urinary retention. CONCLUSIONS: To our knowledge this is the first antimuscarinic study in a community based, significantly older, medically complex elderly population with urgency urinary incontinence. Flexible dose fesoterodine significantly improved urgency urinary incontinence episodes and other outcomes vs placebo, and was generally well tolerated.

Costs associated with recruitment and interviewing of study participants in a diverse population of community-dwelling older adults.

BACKGROUND: America's racial and ethnic composition is changing so rapidly that minority groups are expected to constitute almost half of the U.S. population by 2060. Special efforts are needed to effectively recruit and retain members of racial and ethnic minority groups in health-related research studies, but the information available on time and costs associated with their recruitment is limited. OBJECTIVES: The aim of this study was to describe and compare the time and monetary costs associated with recruiting and interviewing a diverse sample of older adults living in south Florida. METHODS: Men and women aged 60 years and older from four ethnic groups-African American, Afro-Caribbean, Hispanic American, and European American-were recruited to participate in a longitudinal study of healthy aging. Costs for study activities (including recruitment, scheduling sessions, interviewing, file scoring, log updating, blood specimen analysis and storage, data analysis, and monetary compensation to participants) were determined after 100 weeks of data collection. RESULTS: Altogether, 483 participants completed the study in the first 100 weeks. The total cost for each participant ranged from $265 to $576. Each successful enrollment required an average of 1.83 hours for recruitment and scheduling of the interviews. The time to interview African American and Afro-Caribbeans was greater than the time needed to interview Hispanic American and European American participants. DISCUSSION: To develop more accurate budgets for recruitment of minority individuals into research studies and to use the limited resources in an effective way, careful planning and ongoing monitoring of costs are essential.

The value proposition for geriatrics.

In response to some of the challenges that have been articlulated about the future of Geriatrics, we describe a more positive view and value proposition for the field. Health professionals with specific training in Geriatrics are a natural fit for a variety of roles in value-based care (VBC) programs and health systems. These roles include serving as educators for primary care health professionals and specialists in person-centered care of older adults, serving as consultants on geriatric conditions and syndromes in a co-management model of care, becoming effective leaders in VBC programs and health systems, and conducting quality improvement initiatives to build on the evidence-base for the management of common conditions in the older population. We further recommend that VBC programs and systems support Centers of Excellence or Institutes to implement these strategies within and Age-Friendly, learning system approach.

The Florida Geriatric Head Trauma CT Clinical Decision Rule.

BACKGROUND: Several clinical decision rules have been devised to guide head computed tomography (CT) use in patients with minor head injuries, but none have been validated in patients 65 years or older. We aimed to derive and validate a head injury clinical decision rule for older adults. METHODS: We conducted a secondary analysis of an existing dataset of consecutive emergency department (ED) patients >65 years old with blunt head trauma. The main predictive outcomes were significant intracranial injury and Need for Neurosurgical Intervention on CT. The secondary outcomes also considered in the model development and validation were All Injuries and All Intracranial Injuries. Predictor variables were identified using multiple variable logistic regression, and clinical decision rule models were developed in a split-sample derivation cohort and then tested in an independent validation cohort. RESULTS: Of 5776 patients, 233 (4.0%) had significant intracranial injury and an additional 104 (1.8%) met CT criteria for Need for Neurosurgical Intervention. The best performing model, the Florida Geriatric Head Trauma CT Clinical Decision Rule, assigns points based on several clinical variables. If the points totaled 25 or more, a CT scan is indicated. The included predictors were arrival via Emergency Medical Services (+30 points), Glasgow Coma Scale (GCS) <15 (+20 points), GCS <14 (+50 points), antiplatelet medications (+17 points), loss of consciousness (+16 points), signs of basilar skull fracture (+50 points), and headache (+20 points). Utilizing this clinical decision rule in the validation cohort, a point total ≥25 had a sensitivity and specificity of 100.0% (95% CI: 96.0-100) and 12.3% (95% CI: 10.9-13.8), respectively, for significant intracranial injury and Need for Neurosurgical Intervention. CONCLUSIONS: The Florida Geriatric Head Trauma CT Clinical Decision Rule has the potential to reduce unnecessary CT scans in older adults, without compromising safe emergency medicine practice.

Efficacy of adding behavioural treatment or antimuscarinic drug therapy to α-blocker therapy in men with nocturia.

UNLABELLED: WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: Nocturia is a common and bothersome lower urinary tract symptom, particularly in men. Many single drug therapies have limited benefit. For men who have persistent nocturia despite alpha-blocker therapy, the addition of behavioural and exercise therapy is statistically superior to anticholinergic therapy. OBJECTIVE: To compare reductions in nocturia resulting from adding either behavioural treatment or antimuscarinic drug therapy to α-adrenergic antagonist (α-blocker) therapy in men. PATIENTS AND METHODS: Participants were men who had continuing urinary frequency >8 voids/day) and urgency after 4 weeks of α-blocker therapy run-in and who had ≥1 nightly episode of nocturia. Participants received individually titrated drug therapy (extended-release oxybutynin) or multicomponent behavioural treatment (pelvic floor muscle training, delayed voiding and urge suppression techniques). Seven-day bladder diaries were used to calculate reductions in mean nocturia. RESULTS: A total of 127 men aged 42-88 years with ≥1 nocturia episode per night were included in the study. There were 76 men who had a mean of ≥2 nocturia episodes. Among those with ≥1 nocturia episode, behavioural treatment reduced nightly nocturia by a mean of 0.97 episodes and was significantly more effective than drug therapy (mean reduction = 0.56 episodes; P = 0.01). Participants with ≥2 episodes nocturia at baseline also showed larger changes with behavioural treatment compared with antimuscarinic therapy (mean reduction = 1.26 vs 0.61; P = 0.008). CONCLUSIONS: Both behavioural treatment and drug therapy reduced nocturia in men with ≥1 episode of nocturia/night when added to α-blocker therapy. These results were similar even when only those with ≥2 episodes of nocturia were considered. The addition of behavioural treatment was statistically better than bladder-relaxant therapy for nocturia.

Characteristics of older adults rehospitalized within 7 and 30 days of discharge: implications for nursing practice.

Rehospitalization within 30 days consumes a significant portion of health care costs; therefore, interventions aimed at reducing the risk of rehospitalization are needed. A retrospective study was conducted examining rehospitalization rates and diagnoses according to discharge location and comparing characteristics of older adults within 7 and 30 days of discharge from a community hospital. Data on rehospitalization for Medicare fee-for-service patients (75 and older) over a 12-month period were obtained from the information technology department of a not-for-profit community hospital. A total of 6,809 patients were discharged, with 12% rehospitalized within 30 days. Skilled nursing facilities had the highest rehospitalization rates (15%), followed by home with home health care (13%) and then home with self-care (8%). The highest rehospitalization rates were in areas where nursing has a strong presence, suggesting that nurses can play an important role in the development of interventions aimed at reducing rehospitalizations.