Supporting Vulnerable Older Adults With Telehealth Through Wellness Calls and Tablet Distribution During COVID-19: Quality Improvement Project.

BACKGROUND: Loneliness, social isolation, and lack of technical literacy are associated with poorer health outcomes. To help improve social connection during the COVID-19 pandemic, Nova Southeastern University's South Florida Geriatric Workforce Enhancement Program partnered with a community-based organization to provide educational resources to promote telehealth services. OBJECTIVE: This study aimed to provide educational resources to older adults with limited resources and promote the use of telehealth services in this population. METHODS: Through this pilot project, we contacted 66 vulnerable older adults who expressed interest in telehealth support through wellness calls, with 44 participants moving on to participate in tablet usage. All tablets were preloaded with educational information on using the device, COVID-19 resources, and accessing telehealth services for patients, caregivers, and families. RESULTS: Feedback from wellness assessments suggested a significant need for telehealth support. Participants used the tablets mainly for telehealth (n=6, 15%), to connect with friends and family (n=10, 26%), and to connect with faith communities (n=3, 8%). CONCLUSIONS: The findings from the pilot project suggest that wellness calls and telehealth education are beneficial to support telehealth usage among older adults.

Integrating 4Ms Assessment through Medicare Annual Wellness Visits: Comparison of Quality Improvement Strategies in Primary Care Clinics.

The Medicare Annual Wellness Visit (AWV), which includes comprehensive preventative assessments and screenings, is associated with improved preventative services, including vaccination and cancer screenings. However, the AWV alone does not promote whole-person care. Integrating the AWV within an Age-Friendly Health System (AFHS) contextualizes AWV services within a comprehensive geriatric care framework that integrates the "4Ms" (mentation, medication, mobility, and what matters). This study describes and evaluates quality improvement initiatives to improve the completion of AWV within two different AFHS-recognized health systems (an academic university clinic and a Federally Qualified Health Center). The results from this evaluation present opportunities that other health systems can consider for leveraging electronic health records (EHRs) and enabling services to complete AWVs within a 4Ms framework. The implementation results also suggest an adaptation of the 4Ms assessment schedule for patients with complex chronic conditions who may suffer from multiple comorbidities and cognitive impairment.

The Growing Role of Technology in the Care of Older Adults With Diabetes.

The integration of technologies such as continuous glucose monitors, insulin pumps, and smart pens into diabetes management has the potential to support the transformation of health care services that provide a higher quality of diabetes care, lower costs and administrative burdens, and greater empowerment for people with diabetes and their caregivers. Among people with diabetes, older adults are a distinct subpopulation in terms of their clinical heterogeneity, care priorities, and technology integration. The scientific evidence and clinical experience with these technologies among older adults are growing but are still modest. In this review, we describe the current knowledge regarding the impact of technology in older adults with diabetes, identify major barriers to the use of existing and emerging technologies, describe areas of care that could be optimized by technology, and identify areas for future research to fulfill the potential promise of evidence-based technology integrated into care for this important population.

Medication Prescribing for Type 2 Diabetes in the US Long-Term Care Setting: Observational Study.

OBJECTIVES: To characterize prescribing of glucose-lowering medication annually and to quantify the annual frequency of hypoglycemia among residents in long-term care (LTC) facilities with type 2 diabetes mellitus (T2DM). DESIGN: Serial cross-sectional study using a deidentified real-world database comprising electronic health records from LTC facilities. SETTING AND PARTICIPANTS: Individuals eligible for this study were ≥65 years old with T2DM and recorded stay of ≥100 days at an LTC facility in the United States in any of 5 study years (2016-2020), excluding individuals receiving palliative or hospice care. METHODS: Drug orders (prescriptions) for glucose-lowering medications for each LTC resident with T2DM in each calendar year were summarized by administration route (oral or injectable) and by drug class as ever-prescribed (ie, multiple prescriptions were included once), overall and stratified by age subgroup, <3 vs ≥3 comorbidities, and obesity status. We calculated the annual percentage of patients ever prescribed glucose-lowering medication each year, overall and by medication category, who experienced ≥1 hypoglycemic events. RESULTS: Among 71,200 to 120,861 LTC residents with T2DM included each year from 2016 to 2020, 68% to 73% (depending on the year) were prescribed ≥1 glucose-lowering medications, among them oral agents for 59% to 62% and injectable agents for 70% to 71%. Metformin was the most commonly prescribed oral agent, followed by sulfonylureas and dipeptidyl peptidase 4 inhibitors; basal plus prandial insulin was the most commonly prescribed injectable regimen. Prescribing patterns remained relatively consistent from 2016 to 2020, both overall and by patient subgroup. During each study year, 35% of LTC residents with T2DM experienced level 1 hypoglycemia (glucose ≥54 to <70 mg/dL), including 10% to 12% of those prescribed only oral agents and ≥44% of those prescribed injectable agents. Overall, 24% to 25% experienced level 2 hypoglycemia (glucose concentration <54 mg/dL). CONCLUSIONS AND IMPLICATIONS: Study findings suggest that opportunities exist for improving diabetes management for LTC residents with T2DM.

Basal Insulin/GLP-1 RA Fixed-Ratio Combinations as an Option for Advancement of Basal Insulin Therapy in Older Adults With Type 2 Diabetes.

The prevalence of type 2 diabetes (T2D) is increasing, and owing to the aging population, the number of older adults with T2D is growing rapidly. By virtue of their age, older adults are likely to have been living with the disease longer than their younger counterparts. This, coupled with differences in T2D pathophysiology between younger and older patients, means that older adults often require advancement of treatment from basal insulin. However, older adults with T2D represent a heterogeneous population, for whom the goals of treatment are complex, and overtreatment can increase the risk of complications. These factors highlight the need for individualized glycemic targets and therapeutic strategies. In this roundtable, the authors discuss the management of older adults with T2D--a large patient population who often require treatment simplification.

Using the 4M framework of the Age-Friendly Health System to improve MIPS documentation in primary care clinics: A quality improvement study.

Age-Friendly Health Systems (AFHS) commit to providing evidence-based, low-risk, coordinated care centered on what matters most to older adults, their families, and caregivers. Nova Southeastern University's South Florida Geriatric Workforce Enhancement Program (NSU SFGWEP) has partnered with primary care clinics to provide AFHS training and support to promote AFHS transformation in Broward and Miami-Dade Counties. NSU SFGWEP provides face-to-face and virtual training for AFHS and Electronic Health Record (EHR) documentation as part of the initiative. This project focuses on a group of primary care clinics in Broward County, Florida. In this paper, we evaluate the progress of AFHS transformation through six e-clinical measures that collectively provide indicators of the 4 M framework of AFHS (What Matters, Medication, Mentation, and Mobility). We used provider feedback and e-clinical measures aligned with the Center for Medicare & Medicaid Services (CMS) Merit-based Incentive Payment System (MIPS) to measure clinic outcomes. From Jan 1- Dec 31, 2019, to Jan 1-Dec 31, 2020, the clinics improved high-risk medication management (0-3.71%), advanced care planning (6.79%-20.74%), and fall risk assessment (no data- 46.72%). Results demonstrate some success and ongoing opportunities to continue and expand AFHS interventions for sustainability.

Hypoglycemia upon hospital admission from long-term care: health care resource use.

OBJECTIVES: Residents with diabetes in long-term care (LTC) settings often have recognized risk factors for developing hypoglycemia, including advanced age, dementia, and polypharmacy; however, data regarding hypoglycemia in LTC and associated hospitalizations are lacking. Our aim was to describe health care resource use and costs for patients with diabetes and hypoglycemia upon hospital admission. STUDY DESIGN: Retrospective, descriptive study using a US hospital billing database, October 2015 through September 2019. METHODS: Eligible patients were those 18 years and older with type 1 or 2 diabetes who (1) were hospitalized with hypoglycemia upon admission from LTC or from home and (2) received insulin during hospitalization. We described the percentages of patients admitted from LTC or from home with hypoglycemia and their characteristics, length of hospitalization, and hospital costs (2019 US$). RESULTS: Of 106,602 patients with diabetes admitted from LTC and 4,315,571 from home, 6609 (6%) and 182,756 (4%), respectively, presented with hypoglycemia on hospital admission. Mean ages of patients admitted with hypoglycemia from LTC and home were 73 and 66 years, respectively. The percentages of patients in LTC and home cohorts with dementia were 34% and 12%, respectively; with renal disease, 60% and 52%; and with type 2 diabetes, 95% and 89%. Mean hospital stays were 8.0 days for patients admitted from LTC and 6.7 days for those admitted from home; mean total hospital costs were $19,800 and $16,800, respectively. CONCLUSIONS: These findings highlight the importance of providing optimal diabetes management for patients in LTC settings to prevent hypoglycemia and potential hospitalizations and costs.

Effectiveness of Mavrilimumab in Viral Infections Including SARS-CoV-2 Infection - A Brief Review.

Hyperinflammation and cytokine storm has been noted as a poor prognostic factor in patients with severe pneumonia related to coronavirus disease 2019 (COVID-19). In COVID-19, pathogenic myeloid cell overactivation is found to be a vital mediator of damage to tissues, hypercoagulability, and the cytokine storm. These cytokines unselectively infiltrate various tissues, such as the lungs and heart, and nervous system. This cytokine storm can hence cause multi-organ dysfunction and life-threatening complications. Mavrilimumab is a monoclonal antibody (mAb) that may be helpful in some cases with COVID-19. During an inflammation, Granulocyte-macrophage colony-stimulating factor (GM-CSF) release is crucial to driving both innate and adaptive immune responses. The GM-CSF immune response is triggered when an antigen attaches to the host cell and induces the signaling pathway. Mavrilimumab antagonizes the action of GM-CSF and decreases the hyperinflammation associated with pneumonia in COVID-19, therefore strengthening the rationale that mavrilimumab when added to the standard protocol of treatment could improve the clinical outcomes in COVID-19 patients, specifically those patients with pneumonia. With this review paper, we aim to demonstrate the inhibitory effect of mavrilimumab on cytokine storms in patients with COVID-19 by reviewing published clinical trials and emphasize the importance of extensive future trials.

Diabetes in ageing: pathways for developing the evidence base for clinical guidance.

Older adults with diabetes are heterogeneous in their medical, functional, and cognitive status, and require careful individualisation of their treatment regimens. However, in the absence of detailed information from clinical trials involving older people with varying characteristics, there is little evidence-based guidance, which is a notable limitation of current approaches to care. It is important to recognise that older people with diabetes might vary in their profiles according to age category, functional health, presence of frailty, and comorbidity profiles. In addition, all older adults with diabetes require an individualised approach to care, ranging from robust individuals to those residing in care homes with a short life expectancy, those requiring palliative care, or those requiring end-of-life management. In this Review, our multidisciplinary team of experts describes the current evidence in several important areas in geriatric diabetes, and outlines key research gaps and research questions in each of these areas with the aim to develop evidence-based recommendations to improve the outcomes of interest in older adults.

Challenges and Strategies for Managing Diabetes in the Elderly in Long-Term Care Settings.

Diabetes affects a large number of patients in the long-term care (LTC) setting, and their care is often complicated because of multimorbidity, diabetes-related complications, disability, dependency on caregivers, and geriatric syndromes, including frailty and cognitive impairment. This population includes patients receiving short-term rehabilitation in skilled nursing facilities, those who are residents in LTC facilities, and those receiving palliative or end-of-life care. An individualized approach to care based on clinical complexity, diabetes trajectory, and patients' preferences and goals is required. Such patients may experience one or more transitions of care and decline in condition. They are also prone to adverse drug events, cardiovascular events, and hypoglycemia. Facility-related challenges include varying staff competencies and practitioner preferences, inconsistent interdisciplinary communication, overly complex medication regimens, and poorly implemented care transitions.

A Structured Tool for Communication and Care Planning in the Era of the COVID-19 Pandemic.

Residents in long-term care settings are particularly vulnerable to COVID-19 infections and, compared to younger adults, are at higher risk of poor outcomes and death. Given the poor prognosis of resuscitation outcomes for COVID-19 in general, the specter of COVID-19 in long-term care residents should prompt revisiting goals of care. Visitor restriction policies enacted to reduce the risk of transmission of COVID-19 to long-term care residents requires advance care planning discussions to be conducted remotely. A structured approach can help guide discussions regarding the diagnosis, expected course, and care of individuals with COVID-19 in long-term care settings. Information should be shared in a transparent and comprehensive manner to allay the increased anxiety that families may feel during this time. To achieve this, we propose an evidence-based COVID-19 Communication and Care Planning Tool that allows for an informed consent process and shared decision making between the clinician, resident, and their family.

Recommendations for Mandatory Influenza Vaccinations for Health Care Personnel From AMDA's Infection Advisory Subcommittee.

Preventing influenza infections is a national health priority, particularly among geriatric and adults with frailty who reside in post-acute and long-term care (PALTC) settings. Older adults account for more than 70% of deaths from influenza, a reflection of decreased vaccine effectiveness in that age group. Annually vaccinating health care personnel (HCP) working with these patients against influenza is critical to reducing influenza morbidity and mortality among patients. PALTC HCP have the lowest influenza vaccination rate when compared to HCP in other settings. The Advisory Committee on Immunization Practices recommends that all HCP receive an annual influenza vaccination, including those who do not have direct patient care responsibilities. Here, we discuss the importance of influenza vaccination for HCP, detail recommendations for influenza vaccination practice and procedures for PALTC settings, and offer support to PALTC settings and their staff on influenza vaccinations.

Challenges of Diabetes Care in Older People With Type 2 Diabetes and the Role of Basal Insulin.

IN BRIEF The use of long-acting basal insulin analogs is a recommended strategy in older people with diabetes because of their lower risk of hypoglycemia compared to intermediate-acting insulins. In this article, we review the results from recent clinical trials of second-generation basal insulin preparations. We conclude that, although these preparations have improved the management of insulin-requiring older people with type 2 diabetes, there is a need for additional and more specific studies to address the complexities of hyperglycemia management in this population.

Predicting medication adherence in older Hispanic patients with type 2 diabetes.

PURPOSE: Potential cognitive and demographic correlates of medication nonadherence in older Hispanic adults with type 2 diabetes were investigated. METHODS: Forty community-dwelling participants 65 years of age or older were recruited. Executive control function (ECF) was assessed using the executive clock drawing task (CLOX 1) test and the 25-item Executive Interview. Self-reported medication adherence was measured on a visual analog scale (VAS); measures of glycemic control included glycosylated hemoglobin (HbA1c) concentration. The primary objective was to determine if ECF performance correlated with medication adherence or glycemic control. RESULTS: Participants' mean ± S.D. age was 74.95 ± 7.07 years, and 73% (n = 29) were female. Lower VAS scores correlated with worse CLOX 1 performance (r = 0.38, p = 0.02) and worse HbA1c status (r = -0.42, p = 0.007). Linear regression modeling indicated significant associations between VAS scores and both CLOX 1 results (beta coefficient [ß] = 0.41, p = 0.01) and educational level (ß = 0.345, p = 0.03). Receiver operating characteristic analysis of CLOX 1 scores (scoring range, 0-15; lower scores indicate greater impairment) showed that a highly sensitive cutoff score for predicting adherence of <90% would be 7, but a cutoff of 10 would provide more specificity. CONCLUSION: Results of an evaluation of a small sample of Hispanic older adults with type 2 diabetes demonstrated a relationship between ECF, as measured by the CLOX 1 instrument, and self-reported medication adherence.

Optimizing insulin delivery for patients with diabetes.

Management of diabetes for residents in long-term care settings is particularly challenging, due to the wide range of physical and mental limitations that bear on efficacy of their medications, as well as practical issues associated with the optimal administration of these medications. Foremost among the practical issues for residents requiring insulin injections, is the need to ensure that it is consistently delivered to the circulation at the target rate and dosage, thereby avoiding life-threatening episodes of hypoglycemia. Recent evidence from a multinational survey has elucidated principles of insulin injection technique, including optimal needle length and site rotation that can greatly improve consistency in delivering insulin to the subcutaneous compartment, while reducing pain, improving patient compliance, and limiting the total daily dosage. The present review consolidates these findings and highlights the most critical take-home messages for healthcare professionals working in this area.

Pilot test of a six-week group delivery caregiver training program to reduce sleep disturbances among older adults with dementia (Innovative practice).

The purpose of the pilot program was to examine the adaptability and feasibility of a modified group-delivery sleep education program (NITE-AD) designed to reduce nocturnal disturbances in community-dwelling older adults with dementia. We recruited seven caregivers of persons with dementia from two adult day care centers in South Florida into a six-week group program at adult day care centers. A trained sleep educator taught caregivers about the impact of aging and dementia on sleep and how non-pharmacological interventions such as increasing light, regular exercise, and sleep hygiene strategies can improve sleep in persons with dementia. The curriculum incorporated ongoing problem solving and goal setting. Results suggest improvement in caregiver depression and persons with dementia sleep problems. Caregivers reported that the program provided them support and valuable strategies that they will continue to apply. Educating caregivers in a group setting about non-pharmacologic strategies for managing sleep may reduce caregiver burden and improve sleep among persons with dementia.

Arm, Leg, and Foot Skin Water in Persons With Diabetes Mellitus (DM) in Relation to HbA1c Assessed by Tissue Dielectric Constant (TDC) Technology Measured at 300 MHz.

BACKGROUND: DM is associated with structural skin changes. However, few studies have investigated changes in dermal water and specifically its relationship to glucose control as measured by HbA1c. Our goal was to test the hypothesis that skin water, assessed by its tissue dielectric constant (TDC), is inversely related to HbA1c. METHODS: Water content of 3 skin sites (forearm, lower leg, and foot dorsum) of 50 persons with DM was estimated by measuring TDC at 300 MHz. TDC is the ratio of tissue dielectric constant to vacuum and depends on free and bound water in the measured volume. TDC was measured in triplicate to 4 depths, 0.5. 1.5, 2.5, and 5.0 mm to include different skin components. RESULTS: At each site increased measurement depth showed (1) a significant decrease in absolute TDC values and (2) a significant increase in foot-to-arm TDC ratios. TDC values at forearm were shown to be greater than at either leg or foot. However, testing of these 50 patients at 3 sites and 4 skin depths did not show any significant relationship between TDC and HbA1c or fasting glucose. CONCLUSIONS: The data indicate no relationship between TDC values, as indices for skin water, and HbA1c or fasting glucose. This implies that skin TDC values to assess skin property features and changes in persons with DM are not sensitive to recent glucose control. Furthermore, the results introduce a newly applied TDC technology useful to assess skin properties of persons with DM.

A GIS Approach to Identifying Socially and Medically Vulnerable Older Adult Populations in South Florida.

Purpose of the Study: We define, map, and analyze geodemographic patterns of socially and medically vulnerable older adults within the tri-county region of South Florida. Design and Methods: We apply principal components analysis (PCA) to a set of previously identified indicators of social and medical vulnerability at the census tract level. We create and map age-stratified vulnerability scores using a geographic information system (GIS), and use spatial analysis techniques to identify patterns and interactions between social and medical vulnerability. Results: Key factors contributing to social vulnerability in areas with higher numbers of older adults include age, large household size, and Hispanic ethnicity. Medical vulnerability in these same areas is driven by disease burden, access to emergency cardiac services, availability of nursing home and hospice beds, access to home health care, and available mental health services. Age-dependent areas of social vulnerability emerge in Broward County, whereas age-dependent areas of medical vulnerability emerge in Palm Beach County. Older-adult social and medical vulnerability interact differently throughout the study area. Implications: Spatial analysis of older adult social and medical vulnerability using PCA and GIS can help identify age-dependent pockets of vulnerability that are not easily identifiable in a populationwide analysis; improve our understanding of the dynamic spatial organization of health care, health care needs, access to care, and outcomes; and ultimately serve as a tool for health care planning.