Clinical presentation of COVID-19 and association with outcomes among hospitalized older adults.

BACKGROUND: Older adults from racial and ethnic minority groups are at higher risk for worse outcomes with COVID-19. This study sought to characterize the symptomatology of COVID-19 and the association of symptoms with all-cause in-hospital mortality and respiratory failure in a cohort of older, predominantly African American adults admitted to a tertiary hospital. METHODS: A retrospective chart review of all hospitalized patients 65 and older with a positive SARS-CoV-2 test was conducted in a 953-bed academic, urban hospital. Measurements included demographics, symptoms, laboratory findings, and outcomes. The primary outcome was in-hospital mortality, and the secondary outcome was respiratory failure. RESULTS: A total of 134 patients with a mean age of 76.4 years were studied. Fifty-six percent were men and 90% were African American. Of these, 108 patients presented with typical symptoms, among whom 89.8% had co-existing geriatric syndromes. Only 10.2% presented with typical symptoms alone. The most common typical symptoms were fever (57%), shortness of breath (SOB) (51.2%), and cough (48.8%). Atypical symptoms were present in 68 (51%) patients, of whom 83.8% had co-existing typical symptoms and 76.5% had co-existing geriatric syndromes. Only 17.2% of patients presented with atypical symptoms alone. Atypical symptoms identified were anorexia (43%), dizziness (12.4%), and syncope (7.4%). Geriatric syndromes were identified in 102 (76%) patients, including altered mental status (71.1%), weakness (26.4%), and falls (24.8%). Respiratory failure occurred in 65.8% of patients, with 35.4% requiring ventilators while 22.3% of patients died. Age, male gender, SOB, sepsis, and certain laboratory values were associated with outcomes. CONCLUSION: Hospitalized older adults infected with SARS-CoV-2 may present with a range of symptoms encompassing typical, atypical, and geriatric syndromes. Early testing for COVID-19 should be considered in hospitalized older adults.

Detecting Cognitive Impairment and Dementia in the Emergency Department: A Scoping Review.

OBJECTIVES: To identify research and practice gaps to establish future research priorities to advance the detection of cognitive impairment and dementia in the emergency department (ED). DESIGN: Literature review and consensus-based rankings by a transdisciplinary, stakeholder task force of experts, persons living with dementia, and care partners. SETTING AND PARTICIPANTS: Scoping reviews focused on adult ED patients. METHODS: Two systematic scoping reviews of 7 medical research databases focusing on best tools and approaches for detecting cognitive impairment and dementia in the ED in terms of (1) most accurate and (2) most pragmatic to implement. The results were screened, reviewed, and abstracted for relevant information and presented at the stakeholder consensus conference for discussion and ranked prioritization. RESULTS: We identified a total of 1464 publications and included 45 to review for accurate tools and approaches for detecting cognitive impairment and dementia. Twenty-seven different assessments and instruments have been studied in the ED setting to evaluate cognitive impairment and dementia, with many focusing on sensitivity and specificity of instruments to screen for cognitive impairment. For pragmatic tools, we identified a total of 2166 publications and included 66 in the review. Most extensively studied tools included the Ottawa 3DY and Six-Item Screener (SIS). The SIS was the shortest to administer (1 minute). Instruments with the highest negative predictive value were the SIS (vs MMSE) and the 4 A's Test (vs expert diagnosis). The GEAR 2.0 Advancing Dementia Care Consensus conference ranked research priorities that included the need for more approaches to recognize more effectively and efficiently persons who may be at risk for cognitive impairment and dementia, while balancing the importance of equitable screening, purpose, and consequences of differentiating various forms of cognitive impairment. CONCLUSIONS AND IMPLICATIONS: The scoping review and consensus process identified gaps in clinical care that should be prioritized for research efforts to detect cognitive impairment and dementia in the ED setting. These gaps will be addressed as future GEAR 2.0 research funding priorities.

An integrated model of care utilizing community health workers to promote safe transitions of care.

BACKGROUND/OBJECTIVES: Healthcare systems' adoption and sustenance of successful transitional care models (TCMs) have been limited by cost-prohibitive resource needs. Cost-effective TCMs that improve patient outcomes are needed to promote adoption by healthcare systems and sustainability. This study evaluated the effectiveness of a TCM utilizing community health workers (CHWs) in reducing inappropriate healthcare utilization and costs. DESIGN: A cohort study with a pre-post intervention evaluation of the intervention group. SETTING: A 953-bed academic urban safety-net hospital. PARTICIPANTS: Eligible participants (N = 154) were hospitalized or had repeated emergency room (ER) visits, identified to be at high risk for readmission. INTERVENTION: Promotion of self-management skills acquisition and care coordination by CHWs achieved through predischarge interdisciplinary team meetings, regular home visits and phone contact, accompaniment to primary care physicians' (PCP) appointments, support with transportation, medications, and self-management education. MEASUREMENTS: Outcome measures were readmissions, ER visits, and PCP establishment. RESULTS: Mean age of participants was 67, 65% were male, 92% African American. There was a significant reduction in overall number of readmissions (Z = 9.6, p < 0.001), also observed at 30-day (Z = 5.5, p < 0.001), 3-month (Z = 4.3, p < 0.001), 6-month (Z = 4.0, p = 0.001), and 1-year (Z = 5.4, p < 0.001) post-intervention. There was a significant reduction in the overall number of ER visits (Z = 5.5, p < 0.001), also seen at 3-month (Z = 3.3, p < 0.001), 6-month (Z = 3.0, p < 0.001), and 1-year (Z = 4.0, p < 0.001) intervals. Care with a PCP was established in 86.6% of participants. Utilization costs were significantly lower post-intervention ($11,530,376.39 vs $4,017,493.17, p < 0.001). CONCLUSION: Use of CHWs during transitions of care may be a cost-effective approach to reducing healthcare utilization and costs and may promote adoption and sustainability within healthcare systems.

Deprescribing Medications Among Older People to Reduce Polypharmacy at a Comprehensive Academic Medical Center.

OBJECTIVE: To evaluate deprescribing of select high-risk medications (HRMs) in an Acute Care for the Elderly (ACE) unit with pharmacist involvement compared with usual care in older people. DESIGN: Retrospective, single-center case-control study. SETTING: Medical-surgical units at an urban academic medical center. PARTICIPANTS: Patients 65 years of age and older admitted April-June 2019, with 1 or more of the following target HRMs prior to admission were included in the study: acid suppressants, antipsychotics, or insulin. Patients admitted to the ACE unit were included in the case group; all other patients were randomly matched by HRMs in a 2:1 ratio into the control group. INTERVENTIONS: The Acute Care for the Elderly pharmacist reviewed patients' medications to identify and deprescribe select HRMs. Deprescribing was defined as discontinuation, dose or frequency reduction. RESULTS: A total of 47 patients with 56 HRMs and 89 patients with 126 HRMs were included in the case and control groups, respectively. The primary outcome of HRMs deprescribed were similar between the case and control groups (21.4% and 25.4%; P = 0.56). Among the HRMs deprescribed (discontinued, dose or frequency reduced), 83.2% were complete discontinuations in case patients and 34.4% were complete discontinuations in control patients.

Atypical Presentations among Older Adults with COVID-19 Disease: A Need for Broadening the Differential Diagnosis.

Typical presenting symptoms of COVID-19 have been reported to be common in older adults. Current guidelines by the World Health Organization (WHO) and Centers for Disease Control (CDC) for testing and diagnosis are based on the presence of these typical symptoms. Several older adults seen at our hospital have presented atypically with symptoms such as delirium, falls, increasing the need for attention to diagnostic protocols since this has significant implications for early detection and patient outcomes, infection control and promotion of safety among healthcare providers. With the increased risk of fatality among older adults with COVID-19, appropriate diagnostic protocols are needed to ensure early diagnosis and management. Recognizing these atypical presentations in nursing homes would also facilitate early screening and cohorting in these congregate living facilities where older adults have had disproportionately high morbidity and mortality rates. We present two patients who presented with delirium and falls, found to have COVID-19 infection.

Delirium Prevention, Detection, and Treatment in Emergency Medicine Settings: A Geriatric Emergency Care Applied Research (GEAR) Network Scoping Review and Consensus Statement.

BACKGROUND: Older adult delirium is often unrecognized in the emergency department (ED), yet the most compelling research questions to overcome knowledge-to-practice deficits remain undefined. The Geriatric Emergency care Applied Research (GEAR) Network was organized to identify and prioritize delirium clinical questions. METHODS: GEAR identified and engaged 49 transdisciplinary stakeholders including emergency physicians, geriatricians, nurses, social workers, pharmacists, and patient advocates. Adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews, clinical questions were derived, medical librarian electronic searches were conducted, and applicable research evidence was synthesized for ED delirium detection, prevention, and management. The scoping review served as the foundation for a consensus conference to identify the highest priority research foci. RESULTS: In the scoping review, 27 delirium detection "instruments" were described in 48 ED studies and used variable criterion standards with the result of delirium prevalence ranging from 6% to 38%. Clinician gestalt was the most common "instrument" evaluated with sensitivity ranging from 0% to 81% and specificity from 65% to 100%. For delirium management, 15 relevant studies were identified, including one randomized controlled trial. Some intervention studies targeted clinicians via education and others used clinical pathways. Three medications were evaluated to reduce or prevent ED delirium. No intervention consistently prevented or treated delirium. After reviewing the scoping review results, the GEAR stakeholders identified ED delirium prevention interventions not reliant on additional nurse or physician effort as the highest priority research. CONCLUSIONS: Transdisciplinary stakeholders prioritize ED delirium prevention studies that are not reliant on health care worker tasks instead of alternative research directions such as defining etiologic delirium phenotypes to target prevention or intervention strategies.

Towards Patient Safety: Evaluation of Care Transitions Training Needs Among Key Providers Involved in Patient Care Transitions.

Significant morbidity, mortality, and increased healthcare costs of up to 20.1 billion dollars annually occur as a result of poorly executed patient care transitions. The critical role of providers in ensuring patient safety at discharge requires provider knowledge of required care transitions processes to ensure optimal execution of transitions of care. The present study was designed to determine provider perception of their care transitions training, curriculum content, and self-identified care transitions knowledge gaps. A cross-sectional survey was conducted among key healthcare providers at the Grady Memorial Hospital, a 953 bed urban safety net hospital. Of these, 131 participants completed the surveys including 73 internal medicine residents, 51 nurses, and 7 social workers. Among participants, 13% reported that they had never had any formal training on care transitions. Of these, 88.2% were medical residents, while 11.8% were bedside nurses. Among participants who had received care transitions training, only 40% received their training prior to graduation. Healthcare providers across disciplines were least exposed to training on discharge settings of care, determining the most appropriate next level of care for patients at discharge, and communication and coordination with post-acute care facilities. Providers made recommendations regarding topics they considered important to be included in care transitions training. Defining the full discharge process and responsibilities of various healthcare providers were topics recommended by most providers as important to be included in care transitions training. This study has highlighted the extent of exposure to formal care transitions training among providers from multiple disciplines involved in various aspects of discharge care. It has demonstrated a paucity of formal care transitions training at the health professional school level. It has also highlighted self-identified care transitions training needs and will form a foundation for design of care transitions curricula for a broad range of healthcare professionals.

Meeting American Geriatrics Society Competencies: Are Residents Meeting Expectations for Quality Care of Older Adults?

In order to determine how often internal medicine and family medicine residents performed specific actions related to the geriatric competencies established by the American Geriatrics Society (AGS) when caring for older hospitalized adults, a cross-sectional anonymous survey of residents at the University of North Carolina, University of Washington, Wake Forest University, Duke University, and Emory University was undertaken. Data on frequency of self-reported behaviors were analyzed, with comparisons made for different levels of training, institution, and program. A total of 375 residents responded for an overall response rate of 48%. Residents reported that they often do not demonstrate all of the AGS recommended core competencies when caring for older adults in the hospital setting. Residents report more frequently performing activities that are routinely integrated into hospital systems such as reviewing medication lists, working with an interdisciplinary team, evaluating for inappropriate bladder catheters, and evaluating for pressure ulcers. There were no consistent differences between institutions and only minor differences noted between Family Medicine and Internal Medicine residents. Operationalizing core competencies by integrating them into hospital systems' quality process indicators may prompt more consistent high-quality care and ensure systems support residents' competence.

Implementation of a care transitions model for low-income older adults: a high-risk, vulnerable population.

Low-income older adults are particularly vulnerable during care transitions. The present study evaluated the effectiveness of a transitional care model in this population. A quasi-experimental design was used to compare outcomes in the intervention group with historical controls at 30, 90, 180, and 365 days after discharge, along with a pre-postintervention evaluation of the intervention group. Eligible individuals were age 60 and older hospitalized between June 2008 and January 2009. Main outcome measures were readmissions, emergency department (ED) visits, and primary care services use. Of 121 participants, 55% were female and 90% African American, with a mean age of 69. Readmission rates were generally but not significantly lower in the intervention group than in controls (Day 30, 9.6% vs 17.3%; Day 90, 28.9% vs 25.0%; Day 180, 32.7% vs 36.5%; Day 365, 44.2% vs 53.9%; P > .05), as were ED visit rates (Day 30, 17.3% vs 15.4%; Day 90, 32.7% vs 34.6%; Day 180, 38.5% vs 40.4%; Day 365, 50.0% vs 55.8%; P > .05). Primary care service utilization rates were significantly higher in the intervention group than in controls at Day 30 (40.4% vs 19.2%, P < .001), 90 (74.9% vs 32.7%, P < .001), and 180 (65.4% vs 32.7%, P < .001). The lack of statistically significant reduction in readmissions and ED visits with the intervention, may suggest the need for additional assistance during care transitions for this vulnerable population.

Barriers to occupational and environmental medicine services in the southeastern United States.

OBJECTIVES: We sought to determine whether low-income and minority populations in the Southeast face barriers to access to occupational and environmental medicine (OEM) services. METHODS: Access to OEM services was defined as the presence of an OEM physician in a county or the proximity of a clinic in the Association of Occupational and Environmental Clinics network to a county. RESULTS: Counties with higher percentages of low-income, all non-white minority, and African-American populations in South Carolina, Georgia, Alabama, and Mississippi were more likely to be farther away from an AOEC clinic. Counties with higher percentages of low-income populations were less likely to have an OEM physician. However, the percentages of minority and African-American populations in these counties were not associated with the presence of an OEM physician. CONCLUSION: Both low-income and minority populations in the Southeast face barriers to OEM services.