Feasibility, Acceptability, and Efficacy of Home-Based Transcranial Direct Current Stimulation on Pain in Older Adults with Alzheimer's Disease and Related Dementias: A Randomized Sham-Controlled Pilot Clinical Trial.

Although transcranial direct current stimulation (tDCS) is emerging as a convenient pain relief modality for several chronic pain conditions, its feasibility, acceptability, and preliminary efficacy on pain in patients with Alzheimer's disease and related dementias (ADRD) have not been investigated. The purpose of this pilot study was to assess the feasibility, acceptability, and preliminary efficacy of 5, 20-min home-based tDCS sessions on chronic pain in older adults with ADRD. We randomly assigned 40 participants to active (n = 20) or sham (n = 20) tDCS. Clinical pain intensity was assessed using a numeric rating scale (NRS) with patients and a proxy measure (MOBID-2) with caregivers. We observed significant reductions of pain intensity for patients in the active tDCS group as reflected by both pain measures (NRS: Cohen's d = 0.69, p-value = 0.02); MOBID-2: Cohen's d = 1.12, p-value = 0.001). Moreover, we found home-based tDCS was feasible and acceptable intervention approach for pain in ADRD. These findings suggest the need for large-scale randomized controlled studies with larger samples and extended versions of tDCS to relieve chronic pain on the long-term for individuals with ADRD.

Effectiveness of Powerful Tools for Caregivers on Caregiver Burden and on Care Recipient Behavioral and Psychological Symptoms of Dementia: A Randomized Controlled Trial.

OBJECTIVE: The aim of this study was to evaluate the effectiveness of a psychoeducational intervention, Powerful Tools for Caregivers (PTC), for family caregivers of individuals with dementia. DESIGN: A pragmatic, 2-arm randomized controlled trial compared the PTC intervention, as delivered in practice, to usual care. Participants randomized to usual care functioned as a control group and then received the PTC intervention. INTERVENTION: PTC is a 6-week manualized program that includes weekly 2-hour classes in a group setting facilitated by 2 trained and certified leaders. The educational program helps caregivers to enhance self-care practices and manage emotional distress. SETTING AND PARTICIPANTS: Two stakeholder organizations delivered the intervention in community settings. Participants were family caregivers of individuals with dementia recruited from the community in Florida. METHODS: Primary outcomes were caregiver burden and behavioral and psychological symptoms of dementia of the care recipient. Secondary outcomes included caregiver depressive symptoms, self-efficacy, self-rated health, and life satisfaction. Measures were collected at baseline (n = 60 participants), postintervention (n = 55), and at 6-week follow-up (n = 44). RESULTS: Intent-to-treat analyses found PTC reduced caregiver burden (d = -0.48) and depressive symptoms (d = -0.53), and increased self-confidence (d = 0.68), but found no significant benefit for behavioral and psychological symptoms of dementia in care recipients. PTC was rated highly by participants and program attrition was low, with 94% of caregivers completing at least 4 of the 6 classes. CONCLUSIONS AND IMPLICATIONS: Although no significant effects were found for behavioral and psychological symptoms of dementia, this trial supports the effectiveness of PTC to improve caregiver outcomes as delivered in the community.

Women's Sexual Health and Aging.

Older women are often sexually active, but physicians caring for older women rarely address sexual concerns. Although women's desire for sex declines with age, a majority of older women rate sex as having importance in their lives. Women identify emotional intimacy as an important reason for engaging in sexual relationships. Women are less likely than men to have an available spousal or intimate partner and more likely to have a partner with sexual difficulties of their own. Up to half of sexually active older women report a distressing sexual problem, with low desire and problems related to genitourinary syndrome (vulvovaginal atrophy) being most common. Difficulty with orgasm in older women is often associated with a partner's erectile dysfunction. Sexually transmitted infections (STIs) are increasingly prevalent in older women. A minority of older women report discussing sexual issues with a physician. Most commonly, the patient initiates discussions. Physicians should ask regularly and proactively about sexual activity and function. Important interventions include offering practical advice to common chronic medical conditions and sexual problems that confront older women; treating vulvovaginal atrophy; and providing STI screening, prevention strategies, and treatment when appropriate.

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.

Antimuscarinic agents: implications and concerns in the management of overactive bladder in the elderly.

BACKGROUND: Overactive bladder (OAB) is a widespread problem that has a negative effect on quality of life, particularly among the elderly. Antimuscarinic agents are the only drug class with broad, accepted efficacy in the treatment of OAB. Their clinical usefulness, however, is limited by dose-dependent adverse effects. In the elderly, the most serious of these is central nervous system (CNS) dysfunction, including cognitive impairment. OBJECTIVE: This article examines currently available antimuscarinic agents for the treatment of OAB in terms of their likelihood of causing CNS dysfunction by crossing the blood-brain barrier (BBB) and blocking muscarinic type 1 (Ml) receptor sites in the brain. METHODS: Pertinent studies were selected from a comprehensive review of the OAB literature with a focus on muscarinic receptor-associated mechanisms leading to CNS adverse effects and their potential impact on elderly patients. MEDLINE was searched for articles published in the past 10 years, and additional articles were obtained from the reference lists of identified publications. Also searched were abstracts of recent meetings of the International Consultation on Incontinence, International Continence Society, American Urological Association, and European Association of Urology. RESULTS: Antimuscarinic agents control involuntary detrusor muscle contractions through cholinergic blockade at the muscarinic receptors. The prevalence of OAB is highest in the elderly, the population most likely to be taking multiple anticholinergic medications and most vulnerable to the CNS adverse effects of these agents. Nonselective antimuscarinic agents that bind to the Ml receptor are most likely to cause significant cognitive adverse effects compared with the more selective antimuscarinic agents for the treatment of OAB. CONCLUSIONS: When considering use of an antimuscarinic agent for the treatment of OAB in elderly patients, prescribers should routinely consider the agent's receptor selectivity and ability to cross the BBB. The medical history should include all current medications that may contribute to the anticholinergic burden and cognitive impairment. Patients and caregivers should be educated to recognize anticholinergic adverse effects.

A collaborative national model to assess competencies for medical students, residents, and other healthcare practitioners in gait and falls risk evaluation.

To ensure that the healthcare workforce is adequately prepared to care for the growing population of older adults, minimum competencies in geriatrics have been published for medical students and primary care residents. Approaches to teaching and assessing these competencies are needed to guide medical schools, residencies, and continuing medical education programs. With sponsorship by the Education Committee and Teachers Section of the American Geriatrics Society (AGS), geriatrics educators from multiple institutions collaborated to develop a model to teach and assess a major domain of student and resident competency: Gait and Falls Risk Evaluation. The model was introduced as a workshop at annual meetings of the AGS and the American College of Physicians in 2011 and 2012. Participants included medical students, residents, geriatrics fellows, practicing physicians, and midlevel practitioners. At both national meetings, participants rated the experience highly and reported statistically significant gains in overall competence in gait and falls risk evaluation. The largest gains were observed for medical students, residents, and practicing physicians (P < .001 for all); geriatrics fellows reported a higher level of baseline competence and therefore had a lower magnitude of improvement, albeit still significant (P = .02). Finally, the majority of participants reported intent to disseminate the model in their institutions. This article describes the design, implementation, and evaluation of this collaborative national model. A number of institutions have used the model, and the goal of this article is to aid in further dissemination of this successful approach to teaching and assessing geriatrics competencies.

What is a geriatrician? American Geriatrics Society and Association of Directors of Geriatric Academic Programs end-of-training entrustable professional activities for geriatric medicine.

Entrustable professional activities (EPAs) describe the core work that constitutes a discipline's specific expertise and provide the framework for faculty to perform meaningful assessment of geriatric fellows. This article describes the collaborative process of developing the end-of-training American Geriatrics Society (AGS) and Association of Directors of Geriatric Academic Programs (ADGAP) EPAs for Geriatric Medicine (AGS/ADGAP EPAs). The geriatrics EPAs describes a geriatrician's fundamental expertise and how geriatricians differ from general internists and family practitioners who care for older adults.

Keeping granny safe on July 1: a consensus on minimum geriatrics competencies for graduating medical students.

Competency-based education prepares trainees to perform tasks occurring within the context of practice. There are currently no geriatrics-specific, competency-based consensus performance standards for medical students.The authors present the results of a systematic, multimethod process to identify and define the minimum geriatrics-specific competencies needed by a new intern to adequately care for older adults. An alpha draft was crafted by geriatricians, identifying measurable performance subtasks associated with accepted standards of evidence-based geriatric care, patient safety, and "do no harm" within the first-year resident's expected scope of practice. The competencies were then assessed for content validity by key stakeholders and informants. Of the 315 respondents, 26% were geriatricians, 21% family physicians, 24% general internists, 6% neurology program directors, 14% surgery program directors, and 9% other. Twenty-four were decanal appointees. Faculty from almost half (44%) of U.S. medical schools and representatives of several major medical education organizations were present at the working conference.The final document consists of 26 competencies nested within eight content domains: Medication Management; Self-Care Capacity; Falls, Balance and Gait Disorders; Hospital Care for Elders; Cognitive and Behavioral Disorders; Atypical Presentation of Disease; Health Care Planning and Promotion; and Palliative Care.Setting minimum geriatric competency standards establishes the performance benchmarks for medical school graduates who as first-year residents will care for geriatric patients. Only half-facetiously, they are referred to as the "Don't Kill Granny" competencies. Achievement of these minimum competencies by medical students, grounded in evidence-based principles of quality care for older adults, will assure that, each year, older patients are in safer hands on July 1.