Advanced Geriatrics Evaluation Skills.

BACKGROUND AND OBJECTIVES: Older adults are the fastest growing subset of the population and residency training in the basic concepts of care to the older adult is limited. We created a 1-day interactive training program, Advanced Geriatric Evaluation Skills (AGES), to upskill first-year primary care residents in the care of older adults. METHODS: An interprofessional faculty team developed and taught the IRB-approved course to a convenience sample of family medicine and internal medicine interns in 2017, 2018, and 2019. Topics addressed common geriatric presentations seen in the outpatient setting. The faculty provided useful tips and hints for successful workup, diagnosis, and treatment. RESULTS: Over the 3 years, 56 of the 135 (41%) first-year primary care residents participated. Residents reported that the course was well organized, relevant, and well taught, and they appreciated the dedicated time to focus on caring for older adults. During 2019, residents completed a pre- and posttest with 25 multiple-choice questions. The average score on the pretest was 76% and the average on the posttest was 88%. Ninety percent of the residents improved their score from the pre- to the posttest. CONCLUSIONS: The development of an AGES program provided a structured geriatric didactic curriculum for primary care residents. The course was well received by the residents, was reported to be relevant and timely, and resulted in increased knowledge in the care of older adults in the outpatient setting.

Joint AGS-CCEHI Survey Offers Insights into Patient Engagement in Geriatric Clinical Settings.

OBJECTIVES: Many clinical practices and health systems are increasingly interested in adopting structures for consumer engagement to inform organizational policies and programs. These structures can include patient and family advisory committees, patient representation on an organization's board of directors, or inclusion of patients and family members in quality improvement activities. However, to date only limited information has been available on the uptake of patient engagement strategies and structures, and none specific to geriatrics. We surveyed American Geriatrics Society (AGS) members to ascertain how and when consumer engagement is occurring in the clinical settings where AGS members provide care, and to identify opportunities to improve engagement. DESIGN: Descriptive survey. PARTICIPANTS: A total of 20% (829) of eligible AGS members responded to this section of the survey. MEASUREMENTS: Respondents' primary work site, methods and staffing of patient and family engagement, barriers to engagement, and strategies to improve engagement. RESULTS: The most common methods of engagement were through advisory committees (28%), quality improvement and program evaluations (27%), and focus groups (21%). However, more than one-third of respondents (35%) said they were not sure whether their clinical setting had any structures or strategies in place for consumer engagement. Respondents identified barriers to engagement as well as the tools and information that would help improve engagement. CONCLUSION: The survey findings provide insight into what patient engagement looks like in the hospitals, health systems, and other clinical settings where geriatrics health professionals work. Making structures for patient and family engagement more widespread in geriatric practice settings will require addressing the barriers identified by survey respondents including the need for funding and staff time, transportation, and training and supports for participating patients and caregivers. J Am Geriatr Soc 67:1791-1794, 2019.

C9orf72 ablation causes immune dysregulation characterized by leukocyte expansion, autoantibody production, and glomerulonephropathy in mice.

The expansion of a hexanucleotide (GGGGCC) repeat in C9ORF72 is the most common cause of amyotrophic lateral sclerosis (ALS) and frontotemporal dementia (FTD). Both the function of C9ORF72 and the mechanism by which the repeat expansion drives neuropathology are unknown. To examine whether C9ORF72 haploinsufficiency induces neurological disease, we created a C9orf72-deficient mouse line. Null mice developed a robust immune phenotype characterized by myeloid expansion, T cell activation, and increased plasma cells. Mice also presented with elevated autoantibodies and evidence of immune-mediated glomerulonephropathy. Collectively, our data suggest that C9orf72 regulates immune homeostasis and an autoimmune response reminiscent of systemic lupus erythematosus (SLE) occurs in its absence. We further imply that haploinsufficiency is unlikely to be the causative factor in C9ALS/FTD pathology.

Preparing the health care workforce to care for adults with Alzheimer's disease and related dementias.

In the United States, one in nine people ages sixty-five and older and one-third of people ages eighty-five and older have Alzheimer's disease. The number of cases of Alzheimer's disease is projected to triple by 2050, from 5.0 million in 2013 to 13.8 million. This will challenge the health care workforce, which is already inadequate in both size and training. We assessed what is likely to be an increasing shortage of physicians, nurses, and social workers with specialized training in geriatrics and, more specifically, in the care of people with dementia. We highlight the limited training of health care professionals in best practices of dementia care and chronic disease management. To address these shortfalls, we recommend the dissemination of team-based models of care that integrate health and social services; expansion of education loan forgiveness and faculty development programs to attract students into clinician-educator careers focusing on Alzheimer's disease; inclusion of curricula specific to the disease in all health professions training; expansion of federal programs to train existing workers; and increased compensation for the direct care workforce.

Practice patterns, beliefs, and perceived barriers to care regarding dementia: a report from the American Academy of Family Physicians (AAFP) national research network.

PURPOSE: Given the increasing age of the US population, understanding how primary care is delivered surrounding dementia and physicians' perceived barriers and needs associated with this care is essential. METHODS: A 29-item questionnaire was developed by project investigators and family physician consultants and mailed to a random sample of 1500 US members of the American Academy of Family Physicians in 2008; 2 follow-up mailings were sent to nonrespondents. Physicians were queried about sociodemographic characteristics, practice patterns, and beliefs (including challenges, barriers, and needs) about care processes focusing on dementia among older patients. RESULTS: The response rate was 60%, with respondents statistically comparable (P > .05) to the American Academy of Family Physicians physician population. Among physicians, 93% screen and/or conduct diagnostic evaluations for dementia in older patients, whereas 91% provide ongoing primary care for patients with dementia whether or not they screen for or diagnose dementia. Forty percent of physicians refer some patients with suspected dementia to other providers (primarily neurologists) to verify diagnosis, for comanagement, or both. Factors affecting the diagnosis of dementia and the delivery of dementia care included patient behavior challenges (aggressiveness, restlessness, paranoia, wandering); comorbidities (falls, delirium, adverse medication reactions, urinary incontinence); caregiver challenges (fatigue, planning for patient's institutional placement, anger); and structural barriers (clinician time, time required for screening, limited treatment options). Tools needed to provide enhanced dementia care included better assessment tools, community resources, and diagnostic and screening tools. CONCLUSION: Family physicians are highly involved in the assessment and routine care of patients with suspected dementia or diagnosed with dementia, although a relative few are not. This is despite the recognized challenges physicians encounter in the assessment and care processes.

The MLK-related kinase (MRK) is a novel RhoC effector that mediates lysophosphatidic acid (LPA)-stimulated tumor cell invasion.

The small GTPase RhoC is overexpressed in many invasive tumors and is essential for metastasis. Despite its high structural homology to RhoA, RhoC appears to perform functions that are different from those controlled by RhoA. The identity of the signaling components that are differentially regulated by these two GTPases is only beginning to emerge. Here, we show that the MAP3K protein MRK directly binds to the GTP-bound forms of both RhoA and RhoC in vitro. However, siRNA-mediated depletion of MRK in cells phenocopies depletion of RhoC, rather than that of RhoA. MRK depletion, like that of RhoC, inhibits LPA-stimulated cell invasion, while depletion of RhoA increases invasion. We also show that active MRK enhances LPA-stimulated invasion, further supporting a role for MRK in the regulation of invasion. Depletion of either RhoC or MRK causes sustained myosin light chain phosphorylation after LPA stimulation. In addition, activation of MRK causes a reduction in myosin light chain phosphorylation. In contrast, as expected, depletion of RhoA inhibits myosin light chain phosphorylation. We also present evidence that both RhoC and MRK are required for LPA-induced stimulation of the p38 and ERK MAP kinases. In conclusion, we have identified MRK as a novel RhoC effector that controls LPA-stimulated cell invasion at least in part by regulating myosin dynamics, ERK and p38.

Teaching resident physicians chronic disease management: simulating a 10-year longitudinal clinical experience with a standardized dementia patient and caregiver.

BACKGROUND: Education for all physicians should include specialty-specific geriatrics-related and chronic disease-related topics. OBJECTIVE: We describe the development, implementation, and evaluation of a chronic disease/geriatric medicine curriculum designed to teach Accreditation Council for Graduate Medical Education core competencies and geriatric medicine competencies to residents by using longitudinal encounters with a standardized dementia patient and her caregiver daughter. INTERVENTION: Over 3 half-day sessions, the unfolding standardized patient (SP) case portrays the progressive course of dementia and simulates a 10-year longitudinal clinical experience between residents and a patient with dementia and her daughter. A total of 134 residents participated in the University of Cincinnati-based curriculum during 2007-2010, 72% of whom were from internal medicine (79) or family medicine (17) residency programs. Seventy-five percent of participants (100) said they intended to provide primary care to older adults in future practice, yet 54% (73) had little or no experience providing medical care to older adults with dementia. RESULTS: Significant improvements in resident proficiency were observed for all self-reported skill items. SPs' evaluations revealed that residents' use of patient-centered language and professionalism significantly improved over the 3 weekly visits. Nearly all participants agreed that the experience enhanced clinical competency in the care of older adults and rated the program as "excellent" or "above average" compared to other learning activities. CONCLUSIONS: Residents found this SP-based curriculum using a longitudinal dementia case realistic and valuable. Residents improved in both self-perceived knowledge of dementia and the use of patient-centered language and professionalism.

The development of academic geriatric medicine in the United States 2005 to 2010: an essential resource for improving the medical care of older adults.

Academic geriatric medicine programs are critical for training the physician workforce to care effectively for aging Americans. This article updates the progress made by U.S. medical schools from 2005 to 2010 in developing these programs. Academic leaders in geriatrics in accredited allopathic and osteopathic medical schools were surveyed in the winter of 2010 (60% response rate), and results were compared with findings from a similar 2005 survey (68% response rate). Physician faculty in geriatrics increased from 9.6 (mean) full-time equivalents (FTEs) in 2005 to 11.2 by 2010. In 2010, faculty and staff effort was mostly devoted to clinical practice (mean = 37%) and education (mean = 33%), with only seven responding schools devoting more than 40% of faculty effort to research. Schools that have been designated as Centers of Excellence had a median 20 FTE physician faculty, compared with seven at the other schools (P < .001). In 2010, 27% of medical schools required a geriatrics clerkship, and 87% (n = 83) had an elective geriatric clerkship. In summary, more fellows and faculty were recruited and trained in 2010 than in 2005, and some academic programs have emerged with strong education, research, and clinical initiatives. Medical student exposure to geriatrics curriculum has increased, but few academic geriatricians are pursuing research careers, and the number of practicing geriatricians is declining. New approaches to training the entire physician workforce to care for older adults will be required to ensure adequate medical care for aging Americans.

Role of a DNA damage checkpoint pathway in ionizing radiation-induced glioblastoma cell migration and invasion.

Ionizing radiation (IR) induces a DNA damage response that includes activation of cell cycle checkpoints, leading to cell cycle arrest. In addition, IR enhances cell invasiveness of glioblastoma cells, among other tumor cell types. Using RNA interference, we found that the protein kinase MRK, previously implicated in the DNA damage response to IR, also inhibits IR-induced cell migration and invasion of glioblastoma cells. We showed that MRK activation by IR requires the checkpoint protein Nbs1 and that Nbs1 is also required for IR-stimulated migration. In addition, we show that MRK acts upstream of Chk2 and that Chk2 is also required for IR-stimulated migration and invasion. Thus, we have identified Nbs1, MRK, and Chk2 as elements of a novel signaling pathway that mediates IR-stimulated cell migration and invasion. Interestingly, we found that inhibition of cell cycle progression, either with the CDK1/2 inhibitor CGP74514A or by downregulation of the CDC25A protein phosphatase, restores IR-induced migration and invasion in cells depleted of MRK or Chk2. These data indicate that cell cycle progression, at least in the context of IR, exerts a negative control on the invasive properties of glioblastoma cells and that checkpoint proteins mediate IR-induced invasive behavior by controlling cell cycle arrest.

The Donald W. Reynolds Consortium for Faculty Development to Advance Geriatrics Education (FD~AGE): a model for dissemination of subspecialty educational expertise.

PURPOSE: Most U.S. medical schools and training programs lack sufficient faculty expertise in geriatrics to train future physicians to care for the growing population of older adults. Thus, to reach clinician-educators at institutions and programs that have limited resources for enhancing geriatrics curricula, the Donald W. Reynolds Foundation launched the Faculty Development to Advance Geriatrics Education (FD~AGE) program. This consortium of four medical schools disseminates expertise in geriatrics education through support and training of clinician-educators. The authors conducted this study to measure the effects of FD~AGE. METHOD: Program leaders developed a three-pronged strategy to meet program goals: FD~AGE offers (1) advanced fellowships in clinical education for geriatricians who have completed clinical training, (2) mini-fellowships and intensive courses for faculty in geriatrics, teaching skills, and curriculum development, and (3) on-site consultations to assist institutions with reviewing and redesigning geriatrics education programs. FD~AGE evaluators tracked the number and type of participants and conducted interviews and follow-up surveys to gauge effects on learners and institutions. RESULTS: Over six years (2004-2010), FD~AGE trained 82 fellows as clinician-educators, hosted 899 faculty scholars in mini-fellowships and intensive courses, and conducted 65 site visits. Participants taught thousands of students, developed innovative curricula, and assumed leadership roles. Participants cited as especially important to program success expanded knowledge, improved teaching skills, mentoring, and advocacy. CONCLUSIONS: The FD~AGE program represents a unique model for extending concentrated expertise in geriatrics education to a broad group of faculty and institutions to accelerate progress in training future physicians.

National survey of geriatric psychiatry fellowship programs: comparing findings in 2006/07 and 2001/02 from the American Geriatrics Society and Association of Directors of Geriatric Academic Programs' Geriatrics Workforce Policy Studies Center.

OBJECTIVE: : To document the development of geriatric psychiatry (GP) fellowship training in the United States through 2008. METHODS: : A cross-sectional survey of the 56 U.S. GP fellowship programs was conducted in summer 2007. Longitudinal data from the American Medical Association and the Association of American Medical Colleges' National Graduate Medical Education Census and data from the Accreditation Council for Graduate Medical Education were also analyzed. RESULTS: : Thirty-seven (66%) of 56 program directors responded. The number of fellowship programs has decreased over the past 7 years. During 2006/07, 72 fellows were in training, as compared with 94 fellows in 2001/02. Application rates declined significantly with a mean of 4.3 applications per program in 2006/07 as compared with the mean of 10 applications per program in 2001/02. The fill rate for first-year GP fellowship positions dropped from 61% in 2001/02 to 48% in 2006/07. During 2006/07, 67% of programs reported having two or fewer first-year fellows and 16% had no first-year fellows. Seventeen programs reported having no United States medical school graduates as first-year fellows. CONCLUSION: : The number of GP fellows in training has declined by 23% from 2001/02 to 2006/07. This decline has occurred at the same time when the number of older adults continues to expand rapidly. It is critical that an adequate number of geriatric psychiatrists be trained to support and educate general psychiatrists in the care of the elderly. Specific strategies need to be developed urgently to stimulate interest in careers in clinical and academic GP.

Paul B. Beeson career development awards in aging research and U.S. medical schools aging and geriatric medicine programs.

Established in 1995, the Paul B. Beeson Career Development program provides faculty development awards to outstanding junior and midcareer faculty committed to academic careers in aging-related research, training, and practice. This study evaluated the effect of 134 Beeson Scholars on their medical schools' aging and geriatric medicine programs and on the field of aging research from 1995 to 2007. Quantitative and qualitative survey data from multiple sources, including the American Geriatrics Society/Association of Directors of Geriatric Academic Programs' Geriatrics Workforce Policy Studies Center, National Institutes of Health (NIH) rankings of research funding, and other governmental databases were used to compare 36 medical schools with Beeson Scholars with 34 similar medical schools without Beeson scholars and to examine the influence of Beeson Scholars on the field of geriatrics and aging. Most Beeson Scholars remained at the institution where they trained during their Beeson award, and 89% are still practicing or conducting research in the field of geriatrics and aging. Twenty-six (19.4%) of the scholars have led institutional research mentoring awards, 51 (39%) report leadership roles in institutional program project grants, and 13 (10%) report leadership roles in the Clinical and Translational Science Award programs at their institutions. Beeson Scholars are more likely than a matched sample of non-Beeson NIH K awardees to study important geriatric syndromes such as falls, cognitive impairment, adverse drug events, osteoporosis, and functional recovery from illness. Total Beeson Impact Years (the total number of years all Beeson Scholars have worked at each school) is positively correlated with more geriatrics research faculty, after controlling for NIH funding rank (P=.02). Beeson Scholars have made positive contributions to the development of academic geriatrics research programs at U.S. medical schools.

Rural-urban distribution of the U.S. Geriatrics physician workforce.

OBJECTIVES: To determine the distribution of geriatricians across the rural-urban continuum from 2000 to 2008 and to compare with primary care physicians in 2008. DESIGN: County-level analysis of physician data from the American Medical Association Physician Masterfile for 2000, 2004, and 2008 merged with U.S. Census data on the number of older (≥65) county residents. Descriptive statistics for each year were stratified according to 2003 Rural Urban Continuum Codes (RUCCs). SETTING: United States. PARTICIPANTS: Physicians in the United States. MEASUREMENTS: Number of physicians per county elderly population. RESULTS: The number of self-identified geriatricians nationwide increased from 5,157 to 7,412 from 2000 to 2008. The number of geriatricians increased in each RUCC level, with nearly 90% of geriatricians residing in urban areas in all years. In 2008, the number of geriatricians per 10,000 older adults declined as rurality increased (from 1.48 in the most-urban areas to 0.80 in the most rural). General internal medicine physicians are more plentiful in urban counties and declined as rurality increased (from 27.29 to 3.85 per 10,000 older adults in 2008). In contrast, family physicians were more evenly distributed with the elderly population across the rural-urban continuum (22.02 to 14.27 per 10,000 older adults in 2008). CONCLUSION: Small numbers of geriatricians combined with a growing elderly population poses a challenge and an opportunity. Healthcare systems and policy-makers will need to modify care models to better use the skill of geriatricians in concert with other providers to provide quality care for older rural and urban Americans.

National survey of geriatric medicine fellowship programs: comparing findings in 2006/07 and 2001/02 from the American Geriatrics Society and Association of Directors of Geriatric Academic Programs Geriatrics Workforce Policy Studies Center.

This article documents the development of geriatric medicine fellowship training in the United States through 2009. Results from a national cross-sectional survey of all geriatric medicine fellowship training programs conducted in 2007 is compared with results from a similar survey in 2002. Secondary data sources were used to supplement the survey results. The 2007 survey response rate was 71%. Sixty-seven percent of responding programs directors have completed formal geriatric medicine fellowship training and are board certified in geriatrics, and 29% are board certified through the practice pathway. The number of Accreditation Council for Graduate Medical Education-accredited fellowship programs has slowly increased, from 120 (23 family medicine (FM) and 97 internal medicine (IM)) in 2001/02 to 145 in 2008/09 (40 FM and 105 IM), resulting in a 21% increase in fellowship programs and a 13% increase in the number of first-year fellows (259 to 293). In 2008/09, the growth in programs and first-year slots, combined with the weak demand for geriatrics training, resulted in more than one-third of first-year fellow positions being unfilled. The number of advanced fellows decreased slightly from 72 in 2001/00 to 65 in 2006/07. In 2006/07, 55% of the advanced fellows were enrolled at four training programs. In 2008/09, 66% of fellows were international medical school graduates. The small numbers of graduating geriatric medicine fellows are insufficient to care for the expanding population of older frail patients, train other disciples in the care of complex older adults, conduct research in aging, and be leaders in the field.

Community physician education in geriatrics: applying the assessing care of vulnerable elders model with a multisite primary care group.

Providing practicing physicians with effective education that leads to better patient outcomes remains challenging. In 2003, the University of Cincinnati College of Medicine developed a comprehensive program to enhance practicing physician geriatric medicine education based on the Assessing the Care of Vulnerable Elders model. The program was implemented with a large, multisite primary care group based in the greater Cincinnati area and was designed to increase physicians' clinical skills and assist them in implementing new office and system strategies that could improve the quality of care for their older patients. Four topic areas were chosen: medication management, falls and mobility, urinary incontinence, and dementia. A multifaceted physician education program was developed for each topic area, with lunch-time, in-office, geriatrician-led presentations as the primary intervention. Over a 4-year period (2004-2007), more than 60 physicians in 16 primary care practices attended 107 teaching sessions. The value of the presentation content, quality of the presentations, and perception of meeting the primary care physicians' (PCPs') educational needs were each rated at 3.8 or above (4=excellent). Between 80% and 92% of the PCPs planned to make a change in their practice behavior as a result of the training, but only two offices initiated formal quality improvement projects. During the teaching sessions, the PCPs were provided with screening tools to identify "at risk" patients, assessment chart templates, and community resource and patient education materials. The application of a modified version of the ACOVE model to reach a large group of primary care physicians is possible and may be one strategy to improve the assessment and management of geriatric syndromes.

Geriatrics education in psychiatric residencies: a national survey of program directors.

OBJECTIVE: The authors describe the current characteristics of geriatrics training within general psychiatry training programs. METHODS: In the fall of 2006, a survey was mailed and made available online to all U.S. psychiatric residency program directors (N=181). RESULTS: The response rate was 54% (n=97). Of the responding psychiatry programs, 96% (n=93) required a clinical experience in geriatrics, with a mean of 54.9 half days of required clinical training. The predominant training sites were inpatient geriatric psychiatry acute care units, ambulatory care experiences precepted by one or more geriatric psychiatrists, and outpatient geriatric psychiatry assessment centers. The mean number of physician faculty per residency program available to teach geriatrics was 2.8 full-time equivalents, and the mean number of physicians certified in geriatric psychiatry was 3.2 per program. Conflicting time demands with other curricula was ranked as the most significant barrier to expanding geriatrics training. CONCLUSION: Variability in the amount of time devoted to geriatrics training exists across general psychiatric residency programs. Some residents spend very little time in specific required geriatric psychiatry clinical experiences and have limited exposure to well-trained geriatric psychiatrists. Therefore, some psychiatrists who will take care of older patients in the future may be ill prepared to do so.

Medicine in the 21st century: recommended essential geriatrics competencies for internal medicine and family medicine residents.

BACKGROUND: Physician workforce projections by the Institute of Medicine require enhanced training in geriatrics for all primary care and subspecialty physicians. Defining essential geriatrics competencies for internal medicine and family medicine residents would improve training for primary care and subspecialty physicians. The objectives of this study were to (1) define essential geriatrics competencies common to internal medicine and family medicine residents that build on established national geriatrics competencies for medical students, are feasible within current residency programs, are assessable, and address the Accreditation Council for Graduate Medical Education competencies; and (2) involve key stakeholder organizations in their development and implementation. METHODS: Initial candidate competencies were defined through small group meetings and a survey of more than 100 experts, followed by detailed item review by 26 program directors and residency clinical educators from key professional organizations. Throughout, an 8-member working group made revisions to maintain consistency and compatibility among the competencies. Support and participation by key stakeholder organizations were secured throughout the project. RESULTS: The process identified 26 competencies in 7 domains: Medication Management; Cognitive, Affective, and Behavioral Health; Complex or Chronic Illness(es) in Older Adults; Palliative and End-of-Life Care; Hospital Patient Safety; Transitions of Care; and Ambulatory Care. The competencies map directly onto the medical student geriatric competencies and the 6 Accreditation Council for Graduate Medical Education Competencies. CONCLUSIONS: Through a consensus-building process that included leadership and members of key stakeholder organizations, a concise set of essential geriatrics competencies for internal medicine and family medicine residencies has been developed. These competencies are well aligned with concerns for residency training raised in a recent Medicare Payment Advisory Commission report to Congress. Work is underway through stakeholder organizations to disseminate and assess the competencies among internal medicine and family medicine residency programs.