Geriatric care physicians' perspectives on providing virtual care: a reflexive thematic synthesis of their online survey responses from Ontario, Canada.

BACKGROUND: During the COVID-19 pandemic, telemedicine was widely implemented to minimise viral spread. However, its use in the older adult patient population was not well understood. OBJECTIVE: To understand the perspectives of geriatric care providers on using telemedicine with older adults through telephone, videoconferencing and eConsults. DESIGN: Qualitative online survey study. SETTING AND PARTICIPANTS: We recruited geriatric care physicians, defined as those certified in Geriatric Medicine, Care of the Elderly (family physicians with enhanced skills training) or who were the most responsible physician in a long-term care home, in Ontario, Canada between 22 December 2020 and 30 April 2021. METHODS: We collected participants' perspectives on using telemedicine with older adults in their practice using an online survey. Two researchers jointly analysed free-text responses using the 6-phase reflexive thematic analysis. RESULTS: We recruited 29 participants. Participants identified difficulty using technology, patient sensory impairment, lack of hospital support and pre-existing high patient volumes as barriers against using telemedicine, whereas the presence of a caregiver and administrative support were facilitators. Perceived benefits of telemedicine included improved time efficiency, reduced travel, and provision of visual information through videoconferencing. Ultimately, participants felt telemedicine served various purposes in geriatric care, including improving accessibility of care, providing follow-up and obtaining collateral history. Main limitations are the absence of, or incomplete physical exams and cognitive testing. CONCLUSIONS: Geriatric care physicians identify a role for virtual care in their practice but acknowledge its limitations. Further work is required to ensure equitable access to virtual care for older adults.

Geriatric Specialists' Perspectives on Telemedicine during the COVID-19 Pandemic: a Concurrent Triangulation Mixed-Methods Study.

During the COVID-19 pandemic, physicians provided virtual care to minimize viral transmission. This concurrent triangulation mixed-methods study assesses the use of synchronous telephone and video visits with patients and asynchronous eConsults by geriatric providers, and explores their perspectives on telemedicine use during the pandemic. Participants included physicians practicing in Ontario, Canada who were certified in Geriatric Medicine, or Care of the Elderly, or who were the most responsible physician in a long-term care for at least 10 patients. Participants' perspectives were solicited using an online survey and themes were generated through a reflexive thematic analysis of survey responses. We assessed the current use of each telemedicine tool and compared the proportion of participants using telemedicine before the pandemic with self-predicted use after the pandemic. We received 29 surveys from eligible respondents (87.9% completion rate), with 75.9% being geriatricians. The telephone was most used (96.6%), followed by video (86.2%) and eConsults (64%). Most participants using telephone and video visits had newly implemented them during the pandemic and intend to continue using these tools post-pandemic. Our thematic analysis revealed that telemedicine plays an important role in the continuity of care during the pandemic, with increased self-reported positive perspectives and openness towards use of virtual care tools, although limited by inadequate physical exams or cognitive testing. Its ongoing use depends on the availability of continued remuneration.

Assessing the Accuracy of International Classification of Diseases (ICD) Coding for Delirium.

OBJECTIVE: We assessed the accuracy of the ICD-10 code for delirium (F05) and its relationship with delirium discharge summary documentation. METHODS: We performed a retrospective chart review at three academic hospitals. The Chart-based Delirium Identification Instrument (CHART-DEL) was used to identify 108 hospitalized patients aged ≥65 years with delirium, and 758 patients without delirium as controls. We assessed the proportion of patients who received the F05 code and calculated the sensitivity and specificity. We compared the rates of F05 code received between patients with and without "delirium" documented in the discharge summary. RESULTS: Among delirious patients, 46.3% received a F05 code, which has a sensitivity of 46.3% and specificity of 99.6% for delirium. Of charts with "delirium" in the discharge summary (n = 67), 67.2% were appropriately coded. CONCLUSIONS: Current ICD-10 data inadequately capture delirium. Delirium documentation in the discharge summary is associated with improved delirium coding.

The frequency and quality of delirium documentation in discharge summaries.

BACKGROUND: The National Institute for Health and Care Excellence recommends documenting all delirium episodes in the discharge summary using the term "delirium". Previous studies demonstrate poor delirium documentation rates in discharge summaries and no studies have assessed delirium documentation quality. The aim of this study was to determine the frequency and quality of delirium documentation in discharge summaries and explore differences between medical and surgical services. METHODS: This was a multi-center retrospective chart review. We included 110 patients aged ≥ 65 years identified to have delirium during their hospitalization using the Chart-based Delirium Identification Instrument (CHART-DEL). We assessed the frequency of any delirium documentation in discharge summaries, and more specifically, for the term "delirium". We evaluated the quality of delirium discharge documentation using the Joint Commission on Accreditation of Healthcare Organization's framework for quality discharge summaries. Comparisons were made between medical and surgical services. Secondary outcomes included assessing factors influencing the frequency of "delirium" being documented in the discharge summary. RESULTS: We identified 110 patients with sufficient chart documentation to identify delirium and 80.9 % of patients had delirium documented in their discharge summary ("delirium" or other acceptable term). The specific term "delirium" was reported in 63.6 % of all delirious patients and more often by surgical than medical specialties (76.5 % vs. 52.5 %, p = 0.02). Documentation quality was significantly lower by surgical specialties in reporting delirium as a diagnosis (23.5 % vs. 57.6 %, p < 0.001), documenting delirium workup (23.4 % vs. 57.6 %, p = 0.001), etiology (43.3 % vs. 70.4 %, p = 0.03), treatment (36.7 % vs. 66.7 %, p = 0.02), medication changes (44.4 % vs. 100 %, p = 0.002) and follow-up (36.4 % vs. 88.2 %, p = 0.01). CONCLUSIONS: The frequency of delirium documentation is higher than previously reported but remains subpar. Medical services document delirium with higher quality, but surgical specialties document the term "delirium" more frequently. The documentation of delirium in discharge summaries must improve to meet quality standards.

A mixed methods evaluation of a 4-week geriatrics curriculum in strengthening knowledge and comfort among orthopaedic surgery residents.

BACKGROUND: In 2014, the University of Toronto Faculty of Medicine implemented a 4-week "Orthogeriatrics" rotation for orthopaedic surgery residents. We sought to assess the rotation's impact on trainees' knowledge, attitudes, and behaviours toward caring for older adults, and explore areas for improvement. METHODS: We used a mixed methods concurrent triangulation design. The Geriatrics Clinical Decision-Making Assessment (GCDMA) and Geriatric Attitudes Scale (GAS) compared knowledge, attitudes, and behaviours between trainees who were or were not exposed to the curriculum. Rotation evaluations and semi-structured interviews with trainees and key informants explored learning experiences and the curriculum's impact on resident physician growth and development in geriatric competencies. RESULTS: Among trainees who completed the GCDMA (n = 19), those exposed to the rotation scored higher in knowledge compared to the unexposed cohort (14.4 ± 2.1 vs. 11.3 ± 2.0, p < 0.01). The following themes emerged from the qualitative analysis of 29 stakeholders: Increased awareness and comfort regarding geriatric medicine competencies, appreciation of the value of orthogeriatric collaboration, and suggestions for curriculum improvement. CONCLUSIONS: These results suggest that the Orthogeriatrics curriculum strengthens knowledge, behaviour, and comfort towards caring for older adults. Our study aims to inform further curriculum development and facilitate dissemination of geriatric education in surgical training programs across Canada and the world.

GABA Cells in the Central Nucleus of the Amygdala Promote Cataplexy.

Cataplexy is a hallmark of narcolepsy characterized by the sudden uncontrollable onset of muscle weakness or paralysis during wakefulness. It can occur spontaneously, but is typically triggered by positive emotions such as laughter. Although cataplexy was identified >130 years ago, its neural mechanism remains unclear. Here, we show that a newly identified GABA circuit within the central nucleus of the amygdala (CeA) promotes cataplexy. We used behavioral, electrophysiological, immunohistochemical, and chemogenetic strategies to target and manipulate CeA activity selectively in narcoleptic (orexin-/-) mice to determine its functional role in controlling cataplexy. First, we show that chemogenetic activation of the entire CeA produces a marked increase in cataplexy attacks. Then, we show that GABA cells within the CeA are responsible for mediating this effect. To manipulate GABA cells specifically, we developed a new mouse line that enables genetic targeting of GABA cells in orexin-/- mice. We found that chemogenetic activation of GABA CeA cells triggered a 253% increase in the number of cataplexy attacks without affecting their duration, suggesting that GABA cells play a functional role in initiating but not maintaining cataplexy. We show that GABA cell activation only promotes cataplexy attacks associated with emotionally rewarding stimuli, not those occurring spontaneously. However, we found that chemogenetic inhibition of GABA CeA cells does not prevent cataplexy, suggesting these cells are not required for initiating cataplexy attacks. Our results indicate that the CeA promotes cataplexy onset and that emotionally rewarding stimuli may trigger cataplexy by activating GABA cells in the CeA.SIGNIFICANCE STATEMENT Although cataplexy has been closely linked to positive emotions for >130 years, the neural circuitry that underlies this relationship is poorly understood. Recent work suggests that the amygdala, a brain area important for processing emotion, may be part of this circuit. This study provides the first functional evidence to implicate GABA cells in the amygdala as regulators of cataplexy triggered by positive emotions and identifies the amygdala as the brain region important more for gating the entrance into rather than the exit from cataplexy. We also generated a new mouse model for studying GABA neurons in narcoleptic mice, which could serve as a useful tool for studying the neurobiological underpinnings of narcolepsy.