Caring for Patients with Functional Impairment in Middle Age: Perspectives from Primary Care Providers and Geriatricians.

BACKGROUND: The prevalence of functional impairment is increasing among middle-aged adults and is associated with adverse health outcomes. Primary care providers (PCPs) and geriatricians may have important insights about optimal approaches to caring for these patients, but little is known about their perspectives. OBJECTIVE: To examine PCPs' and geriatricians' perspectives on clinical needs and optimal approaches to care for middle-aged patients with functional impairment. DESIGN: Qualitative study using semi-structured interviews. PARTICIPANTS: PCPs and geriatricians from outpatient practices in the San Francisco Bay area. APPROACH: Interviews focused on characteristics and care needs of middle-aged patients with functional impairment and models of care to address these needs. We analyzed interviews using hybrid deductive-inductive qualitative thematic analysis. KEY RESULTS: Clinicians (14 PCPs, 15 geriatricians) described distinct characteristics of functional impairment in middle-aged versus older adults, such as different rates of onset, but similar clinical needs. Despite these similar needs, clinicians identified age-specific barriers to delivering optimal care to middle-aged patients. These included system-level challenges such as limited access to insurance and social services; practice- and clinician-level barriers including inadequate clinician training; and patient-level factors including less access to family caregivers and perceptions of stigma. To overcome these challenges, clinicians suggested clinical approaches including addressing health-related social needs within healthcare systems; implementing practice-based models that are multi-disciplinary, team-based, and coordinated; training clinicians to effectively manage functional impairment; and expanding community-based services and supports to help patients navigate the medical system. Identified needs, challenges, and solutions were generally similar across geriatricians and PCPs. CONCLUSIONS: Clinicians face challenges in delivering optimal care to middle-aged patients who have functional impairments similar to their older counterparts but lack access to services and supports available to older people. These findings suggest the importance of increasing access to care models that address functional impairment regardless of age.

Why the UK is vaccinating its older adult population against RSV-what geriatricians should know.

The UK is launching a new free vaccination programme against respiratory syncytial virus (RSV) in adults aged 75 or over. This follows the development of safe and effective vaccines against RSV and the growing realisation of the burden of RSV-related disease in older adults-estimated at circa 8000 deaths and 175 000 GP episodes every year in the UK. It is likely that the full burden of RSV-related illness is under-appreciated and under-reported due to a lack of testing and awareness of its dangers in older adults. Healthcare professionals working with older people should be aware of the evidence base and be in a position to advise patients on the risks and benefits of vaccination and nonvaccination. We briefly review the evidence for the safety and effectiveness of the two licensed vaccines against RSV with a special focus on what geriatricians and others working with frailer, older people need to know.

'Auspicious liaisons'-evaluating the impact of a liaison geriatrician initiative on older adults psychiatric wards.

BACKGROUND: Although liaison services in acute hospitals are now the norm, the reverse is not usually available for patients in mental health trusts. Following the introduction of support from geriatricians to older people's mental health inpatient wards, we wanted to see if this intervention was effective and acceptable to clinicians. METHODS: We performed a retrospective cohort service evaluation on the impact of a liaison geriatrician, using routinely collected data, and assessed acceptability among medical staff by semi-structured interview. INTERVENTION: Our service introduced regular sessions from consultant community geriatricians across older adults psychiatric wards including a mixture of video conference and face-to-face input. RESULTS: There was no significant decrease in emergency transfers but there was a significant reduction in length of stay with an associated cost benefit for the service after the introduction of a liaison geriatrician. There was a significant increase in geriatrician consultations and a decrease in specialty consultations to other specialists. There was no change in discharge prescriptions or destination. There was a significant reduction in falls in the intervention arm but not in falls leading to emergency hospital admissions geriatricians gave confidence to psychiatrists of all grades to treat physical health care issues. CONCLUSIONS: A liaison geriatrician service may be a component in reducing length of stay (although there are many others) and improving continuity of care, although it confers no impact on emergency transfers. The intervention was highly acceptable to clinicians.

New horizons in sepsis management in older patients.

Sepsis is a frequent disease in older people, characterised by an inappropriate systemic inflammatory response following an infection, leading to life-threatening organ dysfunctions. In the very old, sepsis is often difficult to diagnose, given the frequent atypical presentation. While there is no gold standard for the diagnosis of sepsis, new definitions published in 2016, aided by clinical-biological scores, namely Sequential Organ Failure Assessment (SOFA) and quick SOFA scores, allow earlier recognition of septic states at risk of poor outcome. The management of sepsis in itself differs little in older patients compared to younger subjects. However, the key question of whether or not to admit the patient to an intensive care setting has to be anticipated, depending on the sepsis severity but also on patient's comorbidities and wishes. The earliness of acute management in older subjects with decreased immune defences and physiological reserves is an essential prognostic element. The early control of comorbidities is the main plus value of the geriatrician in the acute and post-acute management of older patients with sepsis.

Point-of-care ultrasound in geriatrics: a national survey of VA medical centers.

BACKGROUND: Point-of-care ultrasound (POCUS) can aid geriatricians in caring for complex, older patients. Currently, there is limited literature on POCUS use by geriatricians. We conducted a national survey to assess current POCUS use, training desired, and barriers among Geriatrics and Extended Care ("geriatric") clinics at Veterans Affairs Medical Centers (VAMCs). METHODS: We conducted a prospective observational study of all VAMCs between August 2019 and March 2020 using a web-based survey sent to all VAMC Chiefs of Staff and Chiefs of geriatric clinics. RESULTS: All Chiefs of Staff (n=130) completed the survey (100% response rate). Chiefs of geriatric clinics ("chiefs") at 76 VAMCs were surveyed and 52 completed the survey (68% response rate). Geriatric clinics were located throughout the United States, mostly at high-complexity, urban VAMCs. Only 15% of chiefs responded that there was some POCUS usage in their geriatric clinic, but more than 60% of chiefs would support the implementation of POCUS use. The most common POCUS applications used in geriatric clinics were the evaluation of the bladder and urinary obstruction. Barriers to POCUS use included a lack of trained providers (56%), ultrasound equipment (50%), and funding for training (35%). Additionally, chiefs reported time utilization, clinical indications, and low patient census as barriers. CONCLUSIONS: POCUS has several potential applications for clinicians caring for geriatric patients. Though only 15% of geriatric clinics at VAMCs currently use POCUS, most geriatric chiefs would support implementing POCUS use as a diagnostic tool. The greatest barriers to POCUS implementation in geriatric clinics were a lack of training and ultrasound equipment. Addressing these barriers systematically can facilitate implementation of POCUS use into practice and permit assessment of the impact of POCUS on geriatric care in the future.

Intrinsic Capacity and Active and Healthy Aging Domains Supported by Personalized Digital Coaching: Survey Study Among Geriatricians in Europe and Japan on eHealth Opportunities for Older Adults.

BACKGROUND: The worldwide aging trend requires conceptually new prevention, care, and innovative living solutions to support human-based care using smart technology, and this concerns the whole world. Enabling access to active and healthy aging through personalized digital coaching services like physical activity coaching, cognitive training, emotional well-being, and social connection for older adults in real life could offer valuable advantages to both individuals and societies. A starting point might be the analysis of the perspectives of different professionals (eg, geriatricians) on such technologies. The perspectives of experts in the sector may allow the individualization of areas of improvement of clinical interventions, supporting the positive perspective pointed out by the intrinsic capacity framework. OBJECTIVE: The overall aim of this study was to explore the cross-national perspectives and experiences of different professionals in the field of intrinsic capacity, and how it can be supported by eHealth interventions. To our knowledge, this is the first study to explore geriatric care providers' perspectives about technology-based interventions to support intrinsic capacity. METHODS: A survey involving 20 geriatricians or clinical experts in the fields of intrinsic capacity and active and healthy aging was conducted in Italy, France, Germany, and Japan between August and September 2021. RESULTS: The qualitative findings pointed out relevant domains for eHealth interventions and provided examples for successful practices that support subjective well-being under the intrinsic capacity framework (the benefits offered by personalized interventions, especially by promoting health literacy but avoiding intrusiveness). Moreover, eHealth interventions could be used as a bridge that facilitates and enables social engagement; an instrument that facilitates communication between doctors and patients; and a tool to enrich the monitoring actions of medical staff. CONCLUSIONS: There is an unexplored and significant role for such geriatric perspectives to help the development process and evaluate the evidence-based results on the effectiveness of technologies for older people. This is possible only when clinicians collaborate with data scientists, engineers, and developers in order to match the complex daily needs of older adults.

Effects of a shared decision making intervention for older adults with multiple chronic conditions: the DICO study.

BACKGROUND: To evaluate the effects of a shared decision making (SDM) intervention for older adults with multiple chronic conditions (MCCs). METHODS: A pragmatic trial evaluated the effects of the SDMMCC intervention, existing of SDM training for nine geriatricians in two hospitals and a preparatory tool for patients. A prospective pre-intervention post-intervention multi-center clinical study was conducted in which an usual care group of older patients with MCC and their informal caregivers was included before the implementation of the intervention and a new cohort of patients and informal caregivers after the implementation of the intervention. SDM was observed using the OPTIONMCC during video-recorded consultations. Patient- and caregivers reported outcomes regarding their role in SDM, involvement, perceived SDM and decisional conflict were measured. The differences between groups regarding the level of observed SDM (OPTIONMCC) were analyzed with a mixed model analysis. Dichotomous patient-reported outcomes were analyzed with a logistic mixed model. RESULTS: From two outpatient geriatric clinics 216 patients with MCCs participated. The mean age was 77.3 years, and 56.3% of patients were female. No significant difference was found in the overall level of SDM as measured with the OPTIONMCC or in patient-reported outcomes. However, at item level the items discussing 'goals', 'options', and 'decision making' significantly improved after the intervention. The items discussing 'partnership' and 'evaluating the decision-making process' showed a significant decrease. Fifty-two percent of the patients completed the preparatory tool, but the results were only discussed in 12% of the consultations. CONCLUSION: This study provides scope for improvement of SDM in geriatrics. Engaging older adults with MCCs and informal caregivers in the decision making process should be an essential part of SDM training for geriatricians, beyond the SDM steps of explaining options, benefits and harms. More attention should be paid to the integration of preparatory work in the consultation.

[«He always talked about something else ¼ Alexey Matveyevich Olovnikov and his unusual science.]

In this article, we celebrate the life and scientific contributions of the exceptional theoretical gerontologist Alexey Matveyevich Olovnikov (1936-2022), who is renowned for his visionary hypothesis regarding the role of telomeres in aging. He postulated that the ends of linear chromosomes cannot be completely replicated, which explains the limited potential of somatic cell divisions. He also predicted the presence of a specialized DNA polymerase that lengthens telomeres in germ, cancer, and stem cells. These and other aspects of telomere biology have been confirmed and are now the foundations of modern gerontology. Alexey proposed several hypotheses on aging, biorhythms, morphogenesis and evolution, all of which are striking and extraordinary, much like their author.

[Status and prospects for improving geriatric care in the Russian Federation.]

The data on legal support, resources, structure, staffing of the geriatric service are given. The state of the geriatric service during the COVID-19 pandemic is discussed, as well as plans and directions for development in the post-COVID period. At the end of 2022, the geriatric service in its development reached the following indicators: 1 303 outpatient rooms; 75 geriatric centers; about 2 000 geriatricians trained; 9,2 million citizens older than working age underwent professional examinations; more than 16.0 million citizens older than working age were under dispensary observation; 106,8 thousand citizens older than working age were hospitalized in geriatric beds. It emphasizes the need to organize the provision of multi-level geriatric care and the need to reorganize geriatric care in general.

[Doing vulnerability : The social construction of age(ing) during the COVID-19 pandemic]. / Doing Vulnerability : Soziale Konstruktionen des Alter(n)s während der COVID-19 Pandemie.

BACKGROUND: Since the beginning of the COVID-19 pandemic old age has been "vulnerablilized" in the media by characterizing old age as a vulnerable and risky phase of life. Gerontologists have criticized the age-based definition of risk groups for their underlying agism. OBJECTIVE: From a practice-theoretical perspective the article asks through which social practices a vulnerable age is realized during the COVID-19 pandemic. MATERIAL AND METHODS: The article refers to data from six qualitative interviews with people aged 65 and older. The data was analyzed using fine structure analysis followed by a topic analysis. RESULTS: The results show that during the COVID-19 pandemic doing age was characterized by a not doing or the disappearance of routinized everyday practices. For the respondents this not doing age was connected to experiencing vulnerable ageing, in which they felt physically and temporally vulnerable. DISCUSSION: Practices of aging during the COVID-19 pandemic have developed against the backdrop of a societal discourse that has positioned activity as an indicator of good and positive aging. At the same time few opportunities have been created to maintain activity under the conditions of the COVID-19 pandemic.

Inequities in the care of older adults: Identifying education gaps in geriatric medicine fellowship.

The past year amplified inequities in the care of older adults. Milestones focused on social determinants of health (SDOH) are lacking within Geriatric fellowship training. A virtual learning collaborative GERIAtrics Fellows Learning Online And Together (GERI-A-FLOAT) was developed to connect trainees nationwide. To address gaps in education around SDOH, a needs assessment was conducted to inform a curricular thread. A voluntary, anonymous survey was distributed to fellows through a broad network. We sought to understand prior curricula trainees had that were specifically focused on SDOH and older adults. Respondents prioritized topic areas for the curriculum. Seventy-five respondents completed the survey. More than 50% of participants indicated no training on homelessness, immigration, racism, or LGBTQ+ health at any level of medical training, with more than 70% having no training in sexism or care of formerly incarcerated older adults. The most commonly taught concepts were ableism, ageism, and poverty. Respondents prioritized the topic of racism, ageism, and ableism. There is a lack of consistent SDOH curricula pertaining to older adults across all levels of training. This needs assessment is guiding a curricular thread for GERI-A-FLOAT and ideally larger milestones for fellowships. The time is now to prepare future geriatricians to serve as change agents.

Illustrating a Person-Centered Approach to Financial Capacity Evaluations Through a Case Study.

OBJECTIVES: Although the National Institute of Medicine Social Security committee recommended that a person's financial capacity should be defined and assessed as real-world performance, there has been scant progress on creating methods to translate this idea into reliable methods. The current clinical comment focuses on analyzing actual financial management and decision-making in an evaluation to determine whether the older person needed a conservator. METHODS: A case study is used to illustrate how to take a feasible approach to analyzing financial management and decisions and applying those to financial capacity assessment. RESULTS: By employing a person-centered analysis of checking and credit card statements and using a semi-structured interview, the clinician was able to assess the financial management and decision-making skills of an older adult. CONCLUSIONS: Clinical gerontologists have an ethical prerogative to enhance autonomy where possible. Analyzing a person's actual financial management records as opposed to hypothetical and perhaps unfamiliar financial tasks may represent a step forward in person-centered assessment of financial management and capacity. CLINICAL IMPLICATIONS: Clinical gerontologists are often asked to provide financial capacity assessments. Using a person-centered approach to assessing financial management and financial decision-making offers a new and reliable method of assessing financial capacity.

[Collaborative work between coordinating physicians, geriatric EMGE physicians and emergency physicians]. / Un travail collaboratif entre médecins coordonnateurs, médecins gériatres des EMGE et médecins urgentistes.

The medical summary section (VSM) was formalized in 2011 with its content defined in 2013. In residential facilities for dependent elderly people (Ehpad), the VSM is almost non-existent and is requested by the majority of doctors who have to take medical care of a resident, often in an emergency situation. Following the health crisis and under the aegis of the regional and national associations of coordinating physicians, a working group was set up in 2021 to create a unique VSM that meets the needs of the field. This document was created and tested with very favorable feedback from users. This VSM is currently being deployed in the Ehpad of the Île-de-France region.

[What are the barriers to private practice in geriatrics?] / Quels sont les freins à l'exercice libéral de la gériatrie ?

Liberal geriatrics is not developed in France. However, given the aging of the population and the benefits of specialized care for elderly patients, the increase in this activity could be beneficial. For a liberal activity in geriatrics to be established, it would be necessary to better define the role of the geriatrician in the follow-up of patients, to inform during the studies of this possibility of exercise and that a real adapted nomenclature be put in place.

[The role of private geriatricians in the health care system (2/2): comprehensive qualitative analysis using semi-structured interviews]. / Rôle des gériatres libéraux dans le système de santé (2/2) : analyse qualitative compréhensive par entretiens semi-dirigés.

Private geriatricians report heterogeneous practices, while the specialty as a whole is questioning its model. We conducted semi-structured interviews to understand how private geriatricians viewed their role in the health care system. They report a certain homogeneity in their conception of their role, which corresponds to that of geriatricians as a whole: there seems to be a professional identity for geriatrics.

[Role of private geriatricians in the health care system (1/2): quantitative descriptive analysis by questionnaire]. / Rôle des gériatres libéraux dans le système de santé (1/2) : analyse quantitative descriptive par questionnaire.

Private practice geriatrics is a little known practice modality. We conducted a questionnaire survey to try to describe the role of private geriatricians in the health care system. Although few in number, private geriatricians report very different practices, including their conception of their role. This is the first monograph on the activity of private geriatricians, and the results have motivated us to propose a comprehensive analysis of this role.

[Radical cystectomy in the geriatric population. Tools for screening postoperative complications]. / Cystectomie radicale chez les patients gériatriques. Outils de dépistage des complications postopératoires.

Radical cystectomy is the gold standard for the treatment of muscle-invasive bladder cancer. Advanced age is only a relative criterion when selecting patients eligible for radical cystectomy, and to reduce post-operative complications, the management of an elderly patient requires a multidisciplinary approach. The role of the geriatrician is therefore essential, in collaboration with the urologist, to ensure appropriate follow-up. A series of preoperative screening tests should be used to identify frailer patients who are at high risk of developing complications, so that appropriate follow-up can be carried out.

La cystectomie radicale est le traitement de choix du cancer de la vessie musculo-invasif. L'âge avancé ne représente qu'un critère relatif lors de la sélection des patients éligibles à une cystectomie radicale. Afin de réduire les complications postopératoires, la prise en charge d'un patient âgé nécessite une approche multidisciplinaire. Le rôle du gériatre est donc essentiel, en collaboration avec l'urologue, afin d'assurer un suivi approprié. Une série de tests de dépistage préopératoires identifie les patients plus fragiles, présentant un risque accru de complications, et permet de réaliser un suivi adapté.

Clinical preferences and treatment attitudes among urologists, gynecologists, and geriatricians: An independent online questionnaire survey for comparison of treatment choices in the management of overactive bladder.

OBJECTIVE: Overactive bladder (OAB) is a common clinical problem with associated morbidities both in men and women. Although real-life management strategies have been examined among urologists (URO), treatment choices may differ between different specialties. In the present study, an online survey was conducted to determine and compare the management strategies and clinical preferences of UROs, obstetricians/gynecologists (OB/GYN), and geriatricians (GER) in the treatment of OAB in their daily practices. METHODS: Between December 2020 and February 2021, an online questionnaire was sent to URO, OB/GYN, and GER specialists/residents. Current strategies and attitudes toward treatment of OAB in patients <65 years were compared between URO and OB/GYN, whereas the responses were compared between all three specialties in patients ≥65 years. RESULTS: A total of 733 specialists/physicians (433 URO, 236 OB/GYN, and 64 GER) completed the online survey. Patients with OAB were more likely to present to URO compared to OB/GYN and GER (p = 0.001). A combination of behavioral modification and pharmacotherapy (antimuscarinics and/or beta-3 agonists) were chosen for the initial treatment of patients with OAB in both specialties with a significantly higher proportion by URO than by OB/GYN (51.9% vs. 38.1%; p = 0.001). Antimuscarinics were the most frequently prescribed medications by both the URO and OB/GYN specialties (81.8% vs. 78.4%; p = 0.27). Combination therapy with antimuscarinics was preferred more often by URO (91.5% vs. 77.1%; p = 0.001) when no or an inadequate response after initial treatment occurred. Multiple medication use, comorbidities, and risk of cognitive side effects affected medication preference by all specialists, especially by GER (p = 0.018). CONCLUSIONS: Patients with OAB present to UROs, OB/GYN and GER more frequently compared to other specialities. Although antimuscarinics and beta-3 adrenoceptor agonists are equally recommended as first-line pharmacotherapy for OAB, antimuscarinics were preferred for most patients as the initial molecule by all specialties. Beta-3 agonists are increasingly preferred for elderly patients.

Refashioning the uneasy relationship between older people and geriatric medicine.

A notable feature of most medical specialties is close joint working between patient advocacy groups and specialist societies in furthering improvements in policy and services. While growing old is not a disease, nor too is being a child, and the engagement of advocacy and international bodies such as UNICEF with paediatricians is well established and recognised. Yet almost eight decades after the founding of geriatric medicine, it is clear that this type of relationship does not hold for the advocacy bodies representing those we serve, as well as the wider constituency of older people. Geriatricians are an extraordinary resourceful and imaginative group, and a more effective promotion of our role as guardians of the longevity dividend is vital to a more positive and mutually beneficial relationship with older people and society. This will require a redirection of our focus to a more critical stance on our origins as a discipline, our relationship with ageing across the lifespan and with older people and a fuller engagement with the broader concepts of gerontology in training and research to develop a refreshed articulacy for, the opportunities arising from gerontologically attuned healthcare.

Developing a core outcome set for hospital deprescribing trials for older people under the care of a geriatrician.

BACKGROUND: Half of older people are prescribed unnecessary/inappropriate medications that are not routinely deprescribed in hospital hence there is a need for deprescribing trials. We aimed to develop a Core Outcome Set (COS) for deprescribing trials for older people under the care of a geriatrician during hospital admission. METHODS: We developed a list of potentially relevant outcomes from the literature. Using a two-round Delphi survey of stakeholder groups representing older people and carers, hospital clinicians, hospital managers, and ageing/deprescribing researchers, each outcome was scored according to Grading of Recommendations Assessment, Development and Evaluation, followed by two consensus workshops to finalise the COS. RESULTS: Two hundred people completed Round 1 and 114 completed Round 2. Representing all stakeholder groups, 10 people participated in workshop 1 and 10 in workshop 2. Six outcomes were identified as most important, feasible and acceptable to collect in a trial: number of prescribed medicines stopped; number of prescribed medicines with dosage reduced; quality of life; mortality; adverse drug events and number of hospital stays. Three other outcomes were identified as important, but currently too burdensome to collect: number of potentially inappropriate medicines prescribed; burden from medication routine; and medication-related admissions to hospital. CONCLUSIONS: A COS represents the minimum outcomes that should be collected and reported. Whilst uncommon practice for COS development, the value of considering outcome collection feasibility is demonstrated by the removal of three potential outcomes that, if included, may have compromised COS uptake due to challenges with collecting the data.